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 HOWKINS & BOURNE
SHAW'S TEXTBOOK OF GYNAECOLOGY
 HOWKINS & BOURNE
SHAW'S TEXTBOOK
OF GYNAECOLOGY
Edited by

Sunesh Kumar, MD (AIIMS)

Professor and Chief Gynae Oncdlogj Services,
Depa rtment of Obstetr-lc.;:s ancJ Gynaecology,
All India lnstitut f ed1cal Sciences,
New Delhi

eritus Editars

S, FRCOG (LOND)
edor Professor and Head,
bstetrics and Gynaecology
ge Medica l College, New Delhi

Shirish N ry, , DGO, FICS, FIC, FICOG

er-i us Professor, Formerly Dean and Med1cal Advisor,
Nowrosjee Wadia Ma terni ty Hospi ta l, Mumbai
Past Presiden t, FOGSI

ELSEVIER
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Shaw's Textbook of Gynecology, 17e, Sunesh Kumar, VG Padubidri, and Shirish N Daftary

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Dedicated to my teachers, esfJecially Late Pmf Vera Hingomni
Preface to the 1 7th Edition
Sevemeenth Edition of this popular book "Shaw's Textbook of
O)"wecology" is in your hands. Writing prefuce tO this new
edition brings me t11e nosta lgic memo•) ' of my studem days
when all t11e studenlS read t11is book and when each word
wriuen in the book was like a statemem from experLS. Last
sixty years since first edition of t11e book has seen lot
of adva nceme nt in t11c speciali ty of gynaecology. fVF and
Endoscopic sw·ge•y arc two ve•) ' im porta nt advances which
has made speciali ty of gynaecology challe nging with a
bright fullt re.
I have made best effo rLS to update most of th e topics.
Such a n e ndeavo ur was possible o nly wit11 ac tive support
of Ill)' colleagues, reside nts and other staff. My special
t11anks are due to Dr. Ans hu Yadav, Dr. Aa nhi S Jayraj,
Dr. Ro hitha C and OLhe r Reside nts in my department for
VI
helping me reviewing the text, video recording and collect-
ing photographs. P•·ofessor San deep Mathur of Pat110logy at
AIIMS, New Delhi pr-ovided excellent coloured photomicro-
graphs.
l do not have enough words to express my t11anks to my
secreta•)', Ms. Sapna Gulati for doing w•·iting, editing and
correction work in t11e textbook in a p rofessio nal manne1·.
Special thanks are due to Ms. Shi va ni Pal and Ms. Sheenam
Agarwal of Elsevier Ind ia for their pa ti e nce and persistence.
Reali zing ex tre me hardshi p faced by students befo re
final examinatio ns a new secti on of Audi o-vis ual presenta-
tion o n important topics has bee n added.
Do se nd )'Our comm ents fo r im provingfuu.tre p ublications.
Smush Kwrwr
 Preface to the 16th Edition
\>\'e, the editors of Huwkins and Bounu Shaw's Textbook of
OynaecolQ(Jj) are pleased to acknowledge that this book has
continued tO provide basic foundation of this speciality
since 1936. Keeping in view of the popularity of the book,
tl1e first Lndian edition ( I 0'" edition) was published in
1989. Since then, tl1e book has been updated ft·om time to
tim e in tl1e ligh t of the adva nces made in tl1is speciality.
T he 15th editio n was revised in 20 10. O ur comm itm en t to
tl1 e swd enLS to improve a nd upda te the quali ty of th e
boo k, and provide th e m wi tl1 th e adva nced kn owledge
p ro mp ted us to b ri ng o ut the 16'" ed ition.
Ln tl1 is editio n, not o nly we have added the latest knowl-
edge o n tl1e subject, but also inse n ed mo re illustra tio ns,
flowc harts and tab les to make the read ing easie r and under-
standable. We have added mo re MRI, CT, and man y other
wherever req uired.
Considering the high associated morbid ity and mortali ty
of gynaecological malignancies, we have approached the
topic of genital tract cancers more exhaustively in tl1is edi-
tion. Emphasis has also been laid on the gynaecological prob-
lems amongst adolescents and menopausal women. Minimal
invasive surgel} for the benign conditions is now being re-
placed b) non-surgical tl1emp) such as ablative
tllerapy without the need for hospitaliation. Hopefully ti1ese
procedures willwrn safe and effective in near future.
A website of the book has been created for more infor-
mation on tlle in the form of video clips, online
testing and MCQs for enu-ance tests and tile latest updates
on tlle subject.
We owe our special thanks to the entire staff of Elsevier
for tl1eir wholeheaned support and en couragement. We will
fail in o ur duty if we did not make a special reference lO
Shabina Nasim with whom we interact o n a daily basis and
also Re nu Rawa L. We appreciate their p rofessional atti tude
and the ir knowledge towards th e prqjec t, tl1e ir effi cie ncy
and enorm o us patience to bring o ut the best for th is
p roject.
Ou r veqr special tlHt nks and gra tiu.tde go lO Mr YR
Chadh a, Pub lis hi ng Cons ult.'llll, Bl Ch urchill Livingsto ne,
New Delhi, who in itiated and gu ided us in tile Firs t Indian
Edition in 1989, witho ut whose pers uasion and enco umge-
ment tl1is book wo uld not have seen tile day. There
are many others who have worked behind tile scene, we
acknowledge our thanks to them.
Last. but not ti1e least, we thank our readers and tl1e
student communiL) for their unstinted suppon over
the last 25 ) ears.
VG Padubidri
Shirish N Dajlary
VII
Preface to the 1Oth Edition
Ever since Ttxtbook of C,•IWI'COiog)• a ppeared in Lhe
United Kingdom in 1936, it has maintained iLS popularity
with teachers, exa miners and th e student community.
ll has gone through several editions. The nimh edit.ion,
edited by Dr J ohn Howkins and Dr Gordon Bourne, was
brought out in 197 1, and its populat·ity in India has
remained undiminished. It is th erefo re timely and oppor-
tune tha t this standa rd textbook should be revised by
Indian teachers of gynaecology to meet th e requirements
of o ur unde rgraduate stude nts. We consider o urselves
fortunate for having bee n assigned thi s challe nging task b)'
th e publishers.
In revising tl1 e boo k we have e ndeavoured to upda te the
comenLS to include new metJ1ods of investigations and treat-
me nt. In recent advances in tlte physiology of
me nsu·uatio n and iLS hormonal co ntrol, carcinoma of the
cervix and related preve nLive meas ures, e ndo meuiosis, and
tlte management of wbe rculosis o f the genital u·act have
VIII
been incorporated. In additi on , the latest metl1ods of birtlt
control and a separate chapter on Medical Tennination of
Pregnancy have been added to equip our studenLS wilh Lhe
knowledge re qui•·ed to pr·o mote India's fa mil y welfare pro-
gramme.
We have also tded to make tlte text more concise by
deleting informati o n that we fell was unnecessa ry for tl1e
Indian undergradua te stude nt, witl10ut substamiall y chang-
ing the original style.
We are indebted to Mr YR Chad ha, Publis hing Director
of Bl Churchill Li vingsto ne, New Delhi for his constant e n-
couragement and inva luable suggesti ons in tl1 e preparation
of tl1 is edition. Since re thanks are exte nded to Ch urchill
Livingstone, Edinburgh, fo r Lheir assistance in making this
edition possible.
VG P(Ulubidri
Shirish N Daftary•
 Table of Content

Preface to the 17th Edition, vi SECTION 3 COMMON CONDITIONS

Preface to the 16th Edition, vii IN GYNAECOLOGY, 201
Preface to the 1Oth Edition, viii

:
16 Infertility- Male and Female, 202
Approach to a Gynaecological Patient,
0 How to toke Pop Smeor
17 Ectopic Gestation, 22 8
0 VIA ond VILU 0 Ectopic pregnancy

18 Acute and Chronic Pelvic Pain, 245

SECTION 1 ANATOMY, PHYSIOLOGY AND
DEVELOPMENT OF FEMALE 19 Temporary and Permanent M ethods of
REPRODUCTIVE ORGANS, 12 Contraception, 252
2 Anatomy of Female Genital Tract, 13
0 Loporoscopic tubol sterilization

0Bartholin's Abscess 0 Mini lop tubol sterilization

3 Normal Histology of Ovary and 20 Medical Termination of Pregnancy, 279

Endometrium, 37
SECTION 4 BENIGN CONDITIONS IN
4 Physiology of Ovulation and Menstruation, 48 GYNAECOLOGY, 285

5 Development of Female Reproductive Organs 21 Genital 286

and Related Disorders, 61
22 Displacements of the Uterus, 302
6 Puberty, Adolescence and Related
Gynaecological Problems, 75 23 Diseases of the Broad ligament, Fallopian Tubes
and Parametrium, 308
7 Menopause and Related Problems, 86
24 Benign Diseases of the Ovary, 3 12
8 Breast and Gynaecologist, 99
25 Benign Diseases of the Vulva, 3 19
9 Sexual Development and Disorders of Sexual
Development, 106 26 Benign Diseases of the Vagina, 326

SECTION 2 DISORDERS OF SECTION 5 INFECTIONS IN

MENSTRUATION, 121 GYNAECOLOGY, 336

-
27 Pelvic Inflammatory Disease, 337

I
10 Common Disorders of M enstruation, 122

11 Abnormal Uterine Bleeding (AUB) 111!1 , 128 28 Tuberculosis of the Female Gen ital Tract, 347

12 Primary and Secondary Amenorrhoea, 141 29 Sexually Transmitted Diseases Including HIV
Infection, 356
13 Fibroid Uterus 155

14 Endometriosis and Adenomyosis, 174

15 Hormonal Therapy in Gynaecology, 188

IX
x TABLE OF CONTENT

SECTION 6 URINARY AND INTESTINAL TRACT 39 Radiation Therapy, Chemotherapy and Palliative
IN GYNAECOLOGY, 371 Core for Gynaecological Cancers, 494

30 Diseases of the Urinary Tract, 372 SECTION 8 IMAGING MODALITIES,

ENDOSCOPIC PROCEDURES AND
31 Urinary Fistula and Stress Urinary MAJOR AND MINOR OPERATIONS
Incontinence, 379
IN GYNAECOLOGY, 506
32 Injuries of the Genital Tract and Intestinal
40 Imaging M odalities in Gynaecology, 507
Tract, 396
41 Endoscopy in Gynaecology, 519
SECTION 7 GYNAECOLOGICAL 0 Diagnostic laparoscopy
MALIGNANCIES, 407
0 Diagnostic hysteroscopy

E
33 Preinvasive and Invasive Carcinoma
of Cervix l3,
408 42 Major and Minor Operations in
Gynoecology, 532
0 Colposcopy
0
0 HPV testing
0
Cervical biopsy-<:onisation
Total abdom inal hysterectomy
34 Cancer of the Body of the Uterus I!], 43 2 0 Vaginal hysterectomy for prolapse uterus
35 Pathology of Ovarian Tumours and Benign 43 Obesity and its Significance in
Ovarian Tumours, 44 1 Gynoecology, 54 1
36 Ovarian Malignancies, 459 44 Instruments Used in Gynaecology I!J, 545
37 Vulval and Vaginal Cancer, 472 Index 551
38 Gestational Trophoblastic Diseases, 481

To access th e vid eo:; and lecture PPT•, .can the •rmbols 0 and E prodded in the chapters.
 Approach to a Gynaecological
Patient
History Investigations 6
Physical Examination 3 Key Points 11
Gynaecological Examination 4 Self-Assessment 11
T he term gynaecology (from th e Gree k, gynae meanin g
wo man and logos mea ns discou rse) pe11_ains tO th e diseases
of women and is ge nerally llsed for disea es re laLed LO the
fe male gen iLal organs.
Th e interac ti on of a p ati ent with a p hysician can ofte n be
an a nxi ety-produ cing event, p articul arly so in Lhe prac ti ce
of gynaecology because of t he sensitive naLure of th e p rob-
le ms tha Lneed LO be disc ussed; he nce, th e o bserva nce of the
hig hes t standards of e thical and profession al be haviow· is
req uired to establish rapport, while no L creaLing a host.li e
enviro nm enL in which Lhe p aLi em fee ls embarrassed or t in-
comfo n able LO allow a meaningful assessmem of h er under-
lyin g medica l p roble m.
The fo llowin g fou r ethi cal principl es must be nt -
graLed into t he ca re and n amre of se rvices offered L
pa Lient.
1. Privacy and respect: Nowadays, co unsel-ling on s an
importa nL aspec t of consul tat.i o n. T he
aeco logical ail ment, reason fo r a
a nd iLS predi ct.i ve va lHe h ould b ms
sion on treatme nt options witif h ir d eritS a nd m er-
its will enable a wo ma n tO lOOS 1.h e treatment she
co ns iders besL for he1: The gy 1 co logist sh o11ld, h ow-
ever, guide her in ma king th e right decision. T he clini-
cia n mu.st respect the pa ti em as an individual. Re me m-
be r tha t th e pati e m has th e righL LO make dec ision
abo ut h er health care. lt is n ot eLhi cally or m orally right
to en force Lhe ph ysician 's opinion on the patien t. T l-lis
wil! safeguard agains t any ch arge of n egligen ce, if a
medi colegal problem arise a t a later date. T he records
should be prop erly main tain ed and th e doc umen rs
should be preserved. T h e pa tie nt should fee l assured at
a ll tim es a bout ' privacy and confidenti ali L)" . Talkin g
sofLly a nd pa t.i e ntly lisLening are of a great help .
2. Beneficence: The medical aLLendant must be vi gil ant
LO ensure that th e thera peutic advi ce re ndered to Lhe
pa ti ent should be in ' good faith '. It sh ould be aimed at
be nefiting her. Al l m edical m easu res a dopte d du ring the
course of medical u·eaune nt should be guided and evalu-
ated on the basis of th e principle of the cosL/ benefit
ra ti o acc ruing out of th e m edical advice given.
3. Justice: T his is r en th e ph ysician ma kes
access LO care, · re, the a ttention provided
and t.h e cost to the needs of the paLiem .
4. Avoiding · · dern Lim es, it is imporLant LO
avoid in eatm em which may lead to p os-
sible - · . For a d eLailed desc riptio n it is
a . oipt.i onsgiven by Ley P, Lipkin Mjt~
man R, Lewan M, Todd AD, Fish er S.
J-Sical examination constitute the ftmda men-
h rest th e tentaLive diagn osis, the tests to be
and th e treatm em to be recommended (Table 1.1 ).
Careful histo ry and p hysical examina Lion for m the basis
of pati ent evaluati on, clini cal diagn os is a nd manage ment.
lnvestigaLio n are ma de LO confi rm the di agnosis a nd for
th e fo ll ow-up of u·eatm enL
lt L~ advisable LO ask Lhe pati ent to desc ribe h e r main com-
plainL in her ovm words and take her own Lime narrating the
evo lution of the problem, the aggravating and re lieving fac tors
and the investigations and treatment she has already 1.mder-
gone. Good and patie m listening is essenti al to obtain maxi-
mum coop eraLion during th e sub.sequem pelvic examination.
Hist0ry begin with th e recording of th e basic informa-
tio n abo uL t11 e paLient as sh own in the samp le p roforma in
Table 1.1.
PRESENT ILLNESS
T h e clini cian must record th e patie m ' co mplainrs in th e
sequence in whi ch Lhey occ urred , no t.ing Lhe ir dura ti o n,
th eir aggravating a nd relieving fa ctors and th e ir relati o n to
m enstruation , micturiti on a nd defecati on. T he investiga-
tions pe rform ed and th e resp o nse to treatm ent given so far
sh ould be noLed.
PAST AND PERSONAL HISTORY
Pas Lm edical and surgica l p roblems may have a bearing o n
th e present complaints. For example, a history of di abetes
2 SHAW'S TEXTBOOK OF GYN AECOLOGY

Table 1.1 1 History: Gynaecological Case Record Fonn FAMILY HISTORY

Name
Presenting complaints:
Menstrual History:
Last menstrual period (LMP)
Present menstrual cycles
Previous menstrual cycles
Age at menarchae
Age at Menopause
Previous Obstetric History:
Full term deliveries
Preterm deliveries
Abortions (Spontaneous/
Induced)
Ectopic pregnancy
Living Issues
Contraception used:
Marital Status Cenain problems run in families, e.g. menstrual patterns
Married/Single/ tend to be similar amongst members of 1J1e family. Prema-
Age Unmarried tLtre menopause, menorrhagia and dysmenorrhoea may
in more than one member in a family. Similarly, fe-
male members of some families are more prone to cancer
of the oval'), uterus and breasL Diabetes, hypertension, tlly-
roid disorders, allel'gic diathesis and functional disorders
are often familial in nalllre. Genetic and hereditary disor-
ders affect more than one member in tlle family, e.g. thal-
assaemia. Tuberculosis may affect many members in the
family.
MARITAL AND SEXUAL HISTORY
Note tJ1e details of h er marital life such as the frequency of
coitus, dyspareunia, frigid it)', ac hieve ment of orgasm, libido,
use of contracepLives and the me thod used. T he releva nce
of dyspareunia to infe ttili t)' sho ul d be no ted.

Past Medical History: MENSTRUAL HISTORY

Diabetes
Hypertension
Thyroid disorders
Tuberculosis
Any surgery
Family History:
History of cancers In family
members
History of OM/hypertension
Personal History:
Smoklng
Addictions
Drugs
may suggest that pruritus vulva may be due to gen ital candi-
diasis, and history of sexuall y u·ansm iued disease (STO)
may have a direct bearing on future infertili ty.
History of pelvic inflammatory disease ( PID) or puer-
peral sepsis may be assoc iated with menstrual d isturbances,
lower abdom inal pain, co ngestive dysmenorrhoea and
inferti lity. T ube rculosis ma)' lead to oli go menorrhoea and
infertility. HistOr)' of e ndocrinopathy may affec t her sexual
fun ctions. Medi cal d iseases such as h)'pe n ension, cardiac
disease, anaemia, d iabetes, asthma and Lh e li ke will require
to be controlled before a plann ed st.u·gety Previo us b lood
u·ansfusion and drug a llergy should be noted. This has
special reference to H IV and hepatitis B infection.
Previous abdominal surgery such as caesarean section,
removal of tJ1e appendix and e xcisio n for ovarian cyst may
lead to pelvic adhesions, which may be t11e cause of ab-
dominal pain. backache, retroverted fixed uterus, infertili ty
and menstrual diswrbances. Dyspareunia is often tJ1e result
of pelvic adhesions.
Allergies to an> drug, Cll tTent medication, use of alcohol,
smoking, ch-ug abuse and lifest) le have relevance in t11e
management.
Normal menarche and me nstrua l cycle have been described
in Chapter 4.
The term me1wrrlwgill denotes excessive blood loss (in-
crease in duration ofbleeding/ heavie rblood flow) witho ut
any change in tJ1e cycle length. The term menorrhagia is
now replaced by 'abnormal uterine bleeding' (AU B) and
will be addressed in this chapter. The tenn pdymerwrrhoetl
or epimenorrlwea refers to frequent menstrual cycles as a
resuiL of shortening of the C) cle length. Sometimes women
suffer from a menstrual disorder characteriLed by a shorter
duration of the qcles coupled with a heavier flow or pro-
longation in tJ1e duration of the flow; this condition is
termed as po!Jmtllorrlwgill. The se,e,·ity of AUB can be
assessed by taking into account the number of sanitary pads
required per day, history of passing blood clotS, the pres-
ence of anaemia and evaluating the presence of accompa-
nying symptotns such as fatigue, palpitation, dizziness,
breathlessness on exertion and tJ1e presence of pallor.
Menorrhagia and polymenorrhagia are frequemly present
in women with m)'Oillas, adenomyosis and PI D in women
wearin g intrauterine co ntracep tive devices ( IUCDs) and
also due to hormonal imbalance ca using dysfunc ti o nal
uterine bleeding (DUB) in pcrimenopausa l women. AUB
now rep laces the wo rd DUB.
Oligomenorrlwea is the term used to describe infrequent
menses. ln this condition, the cycle lengtJt is prolonged
without affec ting the d uration and amount of flow. Hyj)(J-
me,wrrlwea refers to tJ1 e condition in which Lhe cycle length
remains unaltered; however, the duration of b leeding or the
amoLLnt of blood loss, or both are substantially red uced.
When the complete cessation of menstruation occurs, tlte
condition is described as amenorrhoea. The problems of
oligrmumorrlwea and h)1JOriU!1Wrrlwe(l are enco untered in con-
ditions such as pol)'l)llic uvamm di.S!XlSI! (PCOD), llyperprvlacti-
ntutmill and (jlmiuiltuberrulrui.s, in women on oral contracep-
Live pills, in association with certain neoplastns of tlle
pituitlll')' or ovary, in functional h) pothalamic disorders
and in ps)chiau·ic disorders. Ot·ugs may occasionally be
implicated. Oligomen01·rhoea and h) pomenorrhoea may
 CHAPTER I - APPROACH TO A GYNAECOLOGICAL PATIENT 3

occasionally progress to ame norrhoea. Amenorrhoea is

physiological during pregnancy, lactation, before puberty
and after menopause. Metrvrrlwgict (now addressed as inter-
menstrual bleeding) means the occurrence of intermen-
strual bleeding, and it rna> occur in association with ovula-
tion (mittelschmer£); however, it is commonly associated
with the presence of neoplasms such as uterine polyps, car-
cinoma cen ix and uterine and lower genital tract malig-
nallC)'· It may occur "ith conditions such as vascular ero-
sions, using intrauterine devices or breakthrough bleeding
in oral pill users. However, this S)lnptom calls for thorough
investigation because of a possible malignam cause. Some-
times the patient may present with the complaint of continu-
O!Ll bleffling, so that the normal pauem can no longer be
distinguished. Sud1 episodes may be of functional origin
due to h ormonal disturbances often willlessed as puberty
bleeding and perimenopausal bleeding disorders ( DUB).
However, during the chil dbearing years, co nditions due to
complications of earl)' pregnancy such as ec topic pregnancy
and abonion often present in this manner. Geni tal tract
neop lasms s uch as sub muco us polyps and ge nital malignan-
cies may present with co ntinuous bleeding. Postme1wpausal
bleeding is often re la ted to genital malignancy in 30%-40%;
hence, this S)'mpto m sho uld not be treated light!)', it sho uld
be evaluated carefulI)' and all efforts made to exclude such
a possibilit)'· Postcoita l b leeding often suggests cervical
lesion, i.e. erosion, polyp and cancer.
The presence of dysmenorrhoea and dyspareunia may
have orga11ic cause in the pelvis, i.e. endometriosis, fibroid
a11d PLD.
Vaginal discharge is common in lower genital u-act
infections.
OBSTETRIC HISTORY
Record the details of e'e•1' conception and its ultimate out-
come, the number of living children, the age of the young-
est child and the details of any obsteu·ic complications
encoume•·ed, e.g. puerpe1-al or postabo•·tal sepsis, postpar-
tum haemo•,·hage (PP H), obsteu·ical ime1ventions, soft
tissue injuries such as cervical tear, an incompetent cervical
os and repeated abortions, genital fistulae, complete peri-
nea l tear and genital prolapse, su·ess urinary inconti nence
and chronic backache. Severe PPH and obsteu·ic sh ock may
lead to pilllita•1' necrosis and 'Sheehan syndrome'. T hus,
man y a gynaecological proble m has its beginni ngs rooted in
earli er inadeq ua te obsteui c ca re.
Medical termination of pregnancy and spontaneous
abortions should also be enquired.
Abdominal pain: Abdom inal pain is a complain t in pelvic
tuberculosis, PID and endometriosis. Ac ute lower abdom i-
nal pain occurs in ectopic pregnancy, torsion or rupture of
all ovariall cyst and chocolate cysL
PHYSICAL EXAMINATION
Physical examination (Table 1.2) includes general exalnina-
tion, S)Stemic examination and gynaecological examination
"ith a female auendam presem to assist the patiem alld reas-
sw·e her, particularly so when t11e attending clinician is a
male doctor.
Table 1.2 Physical Exa mination
General Physical Examination
Height Weight
Pulse BP
Pal or Lymphadenopathy
Thyroid Breast
Systemic Examination
cardiovascular System
Respiratory System
Abdominal Examination
Inspection
Palpation
Percussion
Pelvic Examination
External Genitalia
Per Speculum Examination
Per Vaginal Examination
Per-rectal Examination
Provisional Diagnosis
GENERAL EXAMINATION
General examination includes data mentioned in the pro
forma (Table 1.2). Pallor of the mucous membranes, tl1e
tongue and conjunctivae toget11er witl1 pale appearance
ofthe skin and nails is high I) suggestive of anaemia, fullness
of the neck is suggestive of a thyroid enlargemem a11d
enlal·ged I) mph nodes are indicative of chronic infection,
tuberculosis or metastasis following malignancy. Bilateral
oedema of the feeL ma> be found in women witl1 lal·ge
abdominal tumours, and unilate•-al non pitting oedema is
highly suggesti,·e of malignant growth involving the lpn-
phatics. B•·east examination should be included in general
examination. Hi rsutism is a feature of PCOD. Breast secre-
tion is noted in hyperp•·olactinaemia, an importam feature
in amenon·hoea.
SYSTEMIC EXAMINATION
All gynae patients must be exa mined as a whole. This in-
cludes the examination of the ca rdiovascula r and I-espira-
tory systems. The p resence of any ne urological sy mptoms
calls for a de tailed ne uro logical evaluation, o t11 erwise test-
ing of tl1 e reflexes shoul d generally suffice. Li ve r s ho uld be
palpated in suspected maligna ncy for metastasis.
ABDOMINAL EXAMINATION
INSPECTION
Man y gynaecologicalwmours arising out of the pelvis grow
upwards into tl1e abdominal cavity. They cause enlargement
of the abdomen, particular!) the lower abdomen below tl1e
LUnbilicus. a11d their upper and lateral margins are often
apparent on inspection. Howe,er, very large wmours Call
give rise to a diffuse enlargement of the entire abdomen.
Pseudomucinous CJIIluletwma.s of the ovary can enlal·ge LO
malnmoth proportions, sometimes to an extent of causing
cardiorespiratory distress. E'ersion of the umbilicus Call
4 SHAW'S TEXTBOOK OF GYNAECOLOGY
occur as a resu lt of raised inu·aabdomina l pressure and is
observed with large wmours, ascites and pregnancy. The
mobility of the abdominal wall with breathing should be
observed carefully. In case of an intraabdominal tLLmOLLr,
the abdominal wall moves over the tumour during breath-
ing so that its upper margin is appare ntly altered. ln case of
pelvic pe •·ito n iLis. t11 e movements of t11 e lower abdomen
below the umbilicus are ofte n restricted. The presence of
striae is seen in parous women, pregnam women, in obese
suqjects and in women harbouring large tumours.
PALPATION
'•\lith the clinician standing on the •ight side of tl1e patient,
it is desirable LO palpate t11e liver, spleen and kidneys ,,;th the
right hand, and LO use t11e sensitive ulnar border of the left
hand from above downwards to palpate swellings a•·ising
from the pelvis. The upper and lateral margins of such swell-
ings can be felt, but t11 e lower border ca nnot be reached.
Myo mas feel firm and have a smooth surface, unless they
are mu ltip le, whe n tile)' present a bossed surface. Ovarian
neop lasms often feel cysti c, and may be flucwant. T he upper
margin oftheseswelli ngs is often we ll fe lt, unless the swelli ng
is too large. The pregnant uterus soft and is known to
harden intermiuen tly during th e Brax to n Hicks contrac-
tion s; this is characte•istic of pregnanC)'· The fu ll b ladder
bulges in tl1e lower abdomen and feel5 tense and tende1:
£xu·eme tenderness on palpation below the umbi lict.LS is sug-
gestive of peritoneal irrit.ation , seen in women witl1 ectOpic
pregnancy, PLD, twisted ovarian cyst, a mptured corpLLS lu-
tewn haemaLOma or red degeneration in a fibroid often as-
sociated wilh pregnanC). In women witl1 an acute smgical
condition. guarding in th e lower abdomen and •igidity on
attempting deep palpation a re noted.
PERCUSSION
Ute•·ine m)•omas a nd ova•·ian C)SLS are dull tO percussion,
but the flanks a•·e resonanL Dullness in t11e flanks and shift-
ing dullness indicate t11e presence of a free fluid in the
peritoneal cavity. Ascites may be associated with tuberculous
peritonitis, malignancy or pseuclo-Meig S)'ndrome.
AUSCULTATION
This reveals peristalti c bowel sounds, fetal heart sounds in
pregnancy, souffle in vascular neoplasms and pregnant uterus.
Hyperperistalsis may indicate bowel obsuuction; feeble or
absent peristalsis indicates ileus, calli ng for aggressive atten-
tion. Retw·n of peristalti c so unds follo,,ing pelvic surgery is a
welcome sign of recovery and an ind ication to stan oral feeds.
GYNAECOLOGICAL EXAMINATION
Most prefer dorsal position, so that bimanual examination
of the pelvic organs can be concluctecl following abdominal
examination without changing t11e position. Some may pre-
fer left lateral (Sims' position). Verbal consent should be
obtained for bimanual examination.
EXAMINATION OF EXTERNAL GENITAUA
lt is a good practice LO inspect the external genitalia under
a good lighL otice the disu·ibution of pubic hair. Nonnal
pubic hair is distributed in an inverted u·iangle, with the
base cenu·ed over the mons pubis. The extension of the hair
line upwards in tl1e midline along t11 e linea nigra up to tl1e
tunbilictLS is seen in about 25% of women, especially in
women who are hirsute or mild!) androgenic as in PCOD.
Witl1 the patient in lithotOm) and he r thighs well paned,
note t11e variolLS su·ucwres of th e vulva. Look for the
presence of an) discharge or blood. Ask the patient to bear
down and obsen•e for any p•·oU'LLSion due tO pol) p or genital
descent such as cystocele, rectocele, ute•·ine descent or
procidentia. Separate t11e labia wide apart and examine
the fourcheue to see whether it is intact or reveals an old
healed tear.
SPECULUM EXAMINATION
Speculum examination should ideall y precede bimanual
vaginal examination especiall y when the Papanicolaou
( Pap) smear and vaginal smear need to be taken.
A bivalve self-retaining spec ulum such as spec ulum
is ideal for an office exa mination (Figs 1.1 and 1.2). It allows
satisfactory inspection of t11e ce rvix, ta king of a Pap smear,
colleCLion of the vaginal discharge from t11e posterior fornix
for hanging drop/KOI I smear and colposcopic examination.
Sims' vagina l spec ulum (Fig. 1.3) wi tl1 an anterior vagi-
nal wa ll retractor can be used for the above examination. lt
permits an assessment of Lhe vaginal wall for cystocele and
rectocele. However, an assistant is required to help the clini-
cian dttring this examination and t11e woman needs to be
brought to tl1e edge of the table. Stress-incontinence sho uld
be looked for especiall) in t11e presence of vaginal prolapse.
ln tl1is case. tl1e patient is e xamined with a full bladder.
BIMANUAL EXAMINATION
After separating the labia \\ith t11e tluunb and index fingers
of the left hand, two fingers of the •ight hand (index and
forefinger), after lubrication, are gradually introduced
be)ond the introitus to reach the fornices. If the fingers
encounter tl1e anterior lip of the ce•vix first, it denotes the
cervix is pointing dowmvards and back tOwards tl1e poste-
rior vaginal wall, and that t11e uterus is in tl1e antevened
position, conve•'Sely whe n t11e posterior li p of tl1e cervi.x is
encountered fi1'S4 it is indicative of a retroverted uterus.
Flgure 1.1 Cusco's speculum.
 CHAPTER I - APPROACH TO A GYNAECOLOGICAL PATIENT 5

Rgure 1.2 Speculum examination of the cervix. The patient is lying

in the dorsal position and a Cusco's speculum has been inserted into
the vagina. (Source: Mike Hughey, MD, President, Brookside Associ-
ates, Ltd.)

Rgure 1.4 Bimanual examination of the pelvis In the female. Two

fing ers of the right hand are Introduced Into the vagina and the left
hand is placed well above the symphysis pubi s. (Source: Swartz MH:
Textbook of Physical Diagnosis. Phiadelphia, WB Saunders, 1989,
p 405, Copyright Cl 2007 Saunders, An lmprnt of Elsevier.)

Flgure 1.3 Sims' speculum.

The clinician next observes the consistency of the cervix: it

is soft during pregnancy and firm in the nonpregnant state.
Observe whether the movementS of the cervi.x du•·ing the
examination cause pain; this is seen in an ectopic preg-
nancy, as also in women with acute salpingo-oophoritis. The
examining finge r'S now li ft. up th e cervix and th ereby ele-
vate the uterus towards th e left hand, which is placed over
t11e lower abdomen and bro ught be hind it (Fig. 1.4). T he
uten.rs can thus be brought within reac h of the abdo min al
hand and palpated fo r position, size, shape, mobility,
tenderness and t11e prese nce of any uterine pat11ology, e.g.
fibroids (Fig. 1.5).
ln case of tl1 e retroverted uterus, it will be felt through Rgure 1.5 Bimanual exam ination In the case of mult iple uterine
tlle posterior fornix. myomas. Note how the external hand Is placed high In the abdomen,
Thereafter, the cli nician directS the tips of the examin- well above the level of the tumour. Movements are transmitted
ing fingers in t11e vagina into eac h of the lateral fomices between the two hands directly through the tumour.
and, by lifting it up towards the abdominal hand, attemptS
to feel for masses in the lateral pan of the pelvis between The appendages are normally not palpable unless they
t11e two examining han cis. Should t11 is reveal t11e presence are swollen and enlarged. The ovary is not easily palpable;
of a swelling separate from t11e uterus, t11en t11e presence of however. when palpated, it evinces a peculiar painful sensa-
some adnexal patJ\OIOg) is confirmed. The common swell- Lion t11at makes the patient to wince. ext in tum is tlle
ings identified include ovarian C)St (Fig. 1.6) or neoplasm, palpation of tlle poster·ior fornix. This enables the palpa-
a paraovarian cyst, e.g. fimbr·ial cyst, masses tion of tlle contents of the pouch of Douglas. The most
(Fig. 1.7), h)drosalpinx, and swelling in chronic ectopic common swelling is the loaded rectum, panicularly if she
pregnancy. is constipated. Otllers in order of diminishing frequency
6 SHAW'S TEXTBOOK Of GYNAECOLOGY
Figure 1.6 Bimanual exam ination in the case of an ovarian cyst. The
nature of the tumour is determined on bimanual examination because
the uterus can be Identified apart from the abdominal tumour. Com pare
Fig . 1.5. In some cases the pedicle can be distinguished If the fingers
In the vagina are p laced high up in the posterior fornix. Movements of
the abdominal tumour are clearly not transmitted to the cervix.
Figure 1.7 Bimanual examination in the case of a pyosalpinx. Note
that the uterus Is displaced to the opposite side. The fingers in the
vagina are moved to one side of the cervl x, and they feel the lower
pole of the swelling.
include a reLroverted uterus, ovaries prolapsed into the
pouch of Douglas, uterine fibroid, ovarian neoplasm, choco-
late cyst of the ovary, endomeu·iotic nodules, pehic inflam-
matOt')' masses resulting from the adhesions of LUbo-ovarian
masses to the postet·ior surfuce of the uterus and the floor of
the pouch of Douglas, pelvic abscess pointing in the posterior
pouch and pelvic haematocele common!)' associated with a
ntptured ec topic pregnancy. To recogni:te the uterus from
ll1e ad nexal mass, push the cervix upwards, and if th is is trans-
milled to the swelling it is ll1e utems. Alternate!)', p ushing
down t11e ute ms causes the cervix to move down. Adnexal
mass does not move with cervical or uterine movement.
RECTAL EXAMINATION
ln virgins, a 'oaginal examination is avoided. Instead a well-
lubt·icated finger insened into the rectum can be used for a
bimanual assessment of the pelvic structures. No"oada)'S, pt-ac-
tically all gynaecologistS prefer ultrasonic scanning tO recta l
examination, which , apart from being unpleasa nt, is not that
accurate. A rectal examination is a very useful add itional ex-
amination whenever ll1ere is any palpable pathology in the
pouch of Douglas. It often allows the ovaries to be more easily
identified. In parameuitis and endomeu·iosis, t11e uterosacral
ligamentS are often thickened, nodular and tender. It con-
finns t11e swelling to be amerior to the rectum, and if the
rectum is ad herem to that swelling. This is important in case
of carcinoma of t11e ce tYix to detennine the extent of itS pos-
terior spread. A rectal examination is manclatOt')' in women
having rectal symptoms. This should begin by inspecting the
anus in a good light, when lesions such as fissures, fistula-
in-ano, polyps and piles may come to ligl1 L Introduction of
a well-lubricated proctoscope to inspect the rec wm and
anal canal helps to complete the examination. Ulu·asound
nowada)'S has reduced ll1e importance of rect.al exa mination
except in cancer of the cervix and pelvic endomeu·iosis.
INVESTIGATIONS
Detailed history and clinical examination often clinch the
diagnosis or reduce ll1e differential diagnosis to a few pos-
sibilities. However, investigations may be necessary to con-
finn ll1e diagnosis, to assess the extent of t11e disease, tO
establish a baseline for future comparison regarding the
response to a therapy and finall y tO de te rmine t11 e patiem's
fi mess tO undergo surgery.
Common disorders: Age re lated (see table 1.3 )
Table 1.3 Common Gynaecological Disorders-
Age Related
I. Adolescent and Prepubertal Girls
Vaginal d ischarge
Disorders of growth
Precocious puberty
Delayed p uberty
Sexually transm ltted diseases
Tumors of ovary, vagina and vulva
II. Reproductive Age
Disorder of menstruation
Ectopic pregnancy
Abnormal uterine bleeding
Contraception related issues
Infertility
Pelvic inflammatory diseases
Malignancies: GTN, Garcinoma Cervix, Ovarian Tumors
Ill. Menopause and Post Menopausal Age
Menopause related problems
Prolapse of uterus
Post menopausal bleeding
Malignancies: Cancer Cervix, Carcinoma Endometrium,
Carcinoma Ovary and Vulval Cancer
 CHAPTER I - APPROACH TO A GYNAECOLOGICAL PATIENT
Preoperative investigaLions are described in the chapter
on preoperative and posLOperative care. Special investiga-
tions are discussed as follows.
Special investigations:
• Special tests such as LUmour markers: CA-125 in sus-
pected adenocarcinoma of the ovary; carcinoembryonic
amigen (Cf.A), oc-fetoproteins and in suspected
ov;uian teratoma and other germ cell tumours of ovary.
• Bacterial examinations of th e genital tract. These include
the following: (a) examination of the vaginal dischru-ge
for trichomoniasis; (b) 10% KO H-treated smear for de-
tecting candida; (c) I% b•illian t creS)'I violet for staining
trichomonad, but not the other bacte•ia and leucocytes;
(d) platinum loop for collection of discha•·ge (in sus-
pected gonon·hoea) from the urethra, ducts of Bartholin
and the endocervical secretio n fo r cul tu re on chocolate
(e) immunofluo rescent examination of the dis-
charge of endocervical cells for suspected chl amydia!
infec tion; and (f) mi croscopic exa minati on of the clue
cells for diagnosis of bacte rial vaginosis (Chapter 9) .
Feinberg-Whi tti ngton mediu m is used for u·icho mo nad
and Nickerson-Sabouraud for candiasis. T he presence of
cl ue cells ind icates bacte•ial vaginosis.
Pol>•merase chain reacLion (PC R) staining has been
extensively utilized in the of various infections.
SPECIAL TESTS
HANGING DROP PREPARATION
ln women complaining leucon·hoea, the discharge collected
from the postel'ior fornix on the blade of the speculum
should be suspended in saline and submitted to microscopic
ex;unination. ormal 'oaginal discharge shows the presence
of exfoliated 'oaginal epithelial cells and the presence of
large rod-like lacLObacilli known as Doderlein's bacilli. A
fresh suspension of the discharge may reveal the motile flag-
ellated o•-ganisms known as TridwmQIWS vagina.l.is. Another
common cause of \'llginal infection is fungal infection or
vll{,riual this can also be detected f•·om a micro-
scopic examination of the vaginal discharge. To the suspen-
sion of the vaginal discharge, add an eq ua l amount of 10%
KOH soluti on. Place a drop of the mi xtu re o n a slide, cover
it with a cover sli p, wa nn the slide and exa mine it under the
low power of the microscope. T he KO H dissolves all cellular
debris, leaving be hi nd the mo re resista nt yeast-like organ-
isms. Typical h)•p hae o r m>•celia and b udding spores can
be easil)' detec ted. Many C<'lses of vagi nitis are attrib uted to
bacterial (nonspecific vaginiLis); also known as
Garrlnendla voginalil. The vis ua liz.1tion of 'clue cells' seen
preferably in a stained smear of the vaginal d isc harge is
high ly suggestive of the infection. Vaginal infections have
been discussed later in detail in Chapter 9.
PAPANICOLAOU TEST
Screening for Cancer
First described b) Papanicolaou and Traut in 1943, this
screening test is often •·efen·ed to as the 'Pap test' or a sur-
fuce biopsy or exfoliative C) tology (C) to logy is a Greek
word, meaning swdy of cells). It forms a pan of the routine
gynaecological examination in women. All sexually active
7
women older than 2 1 years should undergo an ann ual
check-up witl1 three yearly Pap test. Aside from premalig-
nant and malignant changes, otJ1er local conditions can
oft.en be recognized b) the cytologist. The Pap smear is
only a screening test. Positive test (abnormal cells) requires
further investigations such as colposcop)'• cervical biopsy
and fractional curettage. Unfonunately, the Pap test cru1
detect on I> about60%-70% of precancer and cance•· of the
and less than 70% of endomeu·ial cance•: Reliability
of the repon depends on the slide preparation and tl1e skiU
of the C) LOiogist. Although a single test yields as much as
10%-15% false-negathe reading, it is reduced to only 1%
with repeated tests. A false-positive finding is reponed in
the presence of infection. A yearly negative Pap sme;u· for
3 years is assuring, and thereafter 5-yearly test is adequate.
Th e Pap smear should be obtained before vaginal
examination, because the nngers may remove tl1 e desqua-
mated cervical cells and give a false-negative repo rt, lubri-
ca m may prevent de tec ti o n of orga nisms a nd a ny vaginal
bleedin g during exa min atio n may preclude a prope r visu-
a li zati o n of th e ce rvix. T he patient s ho uld no t have inte r-
co urse or to uch fo r 24 ho urs befo re the Pap test. T he bes t
time to do Pap smear is a ro und ov ulatio n, b ut any other
time can a lso do. T he patient is placed in th e do rsal posi-
tion, with the lab ia parted, and Cusco's self- retaining
spec ulu m is gemly introd uced witho ut the use of lubrican t
or jelly. The cervix is exposed; the sq uamoco lu mnar ju nc-
tion is now scraped with Ayre's spatula by rotating tl1e
spatula all around (Fig. 1.8 0). The scrapings are evenly
spread onto a glass slide and immediately fixed by dipping
the slide in the jar containing equal parts of 95% ethyl
alcohol and ether. After fixing it for 30 minutes, the slide
is air-d•;ed and stained with Pap or shon stain. The slide is
considered satisfact011, if endocen'ical cells are seen. To
improve the predictive valve, endocen'ix is also scraped
with a brush and added to the slide. owadays, a fixative
spray (cytospray) is a\oailable and can be used conveniently
in an office set-up. For honnonal cytological evaluation,
the scrapings are taken from the upper lateral pan of the
vaginal walls; tlwee types of cells are found in the normal
smear: (i) the basal and pa•-abasal cells are small, •·otmded
and basophilic wi th la •-ge nuclei; (ii) the cells from th e
mi ddle layer are squamous cells, tra nsparent a nd baso-
philic witl1 vesicular nuclei; a nd (iii) th e cells from th e
s uperficial la>•e •· are acidop hilic with charac teris ti c p yk-
noti c nuc lei. ln add ition, endome tri al cells, histiocytes,
blood cells a nd bacteri a ca n be seen . Malignant cells a re
hyperc hro ma ti c with a great increase in c hro matin co n-
te nt. Th e n uclei va11' in size a nd th e re is usua lly o nly a
s ma ll amo unt of C)'top lasm in the un d iffe re miatecl malig-
n am cell (Figs 1.9 and 1.1 0). T he nucle us/cytoplasmic
ratio is increased in malignant cells.
Papru1icolaou classincation:
Grade l Nonnal cells (Fig. 1.9)
Grade ll Slightl) abnonnal, suggestive of inflamma-
tOI") change; repeat smear after treating
tl1e infection
Grade Ill A more se•ious t} pe of abnonnality, usu-
all> indicative of the need for biopsy
Grade IV Distinctly abnonnal, possibly malignruu
and dennitely requi•·ing biopsy
Grade V Malignant cells seen (Fig. 1.1 0)
8 SHAW'S TEXTBOOK OF GYN AECOLOGY

R gure 1.8 (A) Papanicolaou sampling devices. Left to right: Cervix -Brush, Cytobrush, wooden spatula, plastic spatula, tongue blade and
cotton swab applicator. (B) Pap smear with a brush. (Source for (A): From Agure 16, Pre-prooedure. Prooedure ConsUlt. Pap Smear. Editors: Michael
L Tuggy and Jorge Garcia; Source tor (B): From Figure 1, Pre-prooedure. Procedure Consult. Papanicolaou Testing. Editors: Todd W Thomsen and

,,
Gary S Setnik.)
0 Scan to play How to take pap smear

f"T

·l
"
.. ..
•.
_,:..\...:
. :·.. '
' 1.;
·"o"
.

1.
' .
fl .'
B
J
.. - .. (,· ..
Rgure 1.9 Normal cervical smear showing superficial (pink) and intermediate (blue/green) exfoliated cervical cells (low power magnification).
(Source: From Agure 20·5, ian Symonds Sab.,.-atnam Arul<umaran: Essential Obstetrics and Gynaecology, 5th Ed. Elsevier, 2013.)

A newer classification (Tahlc I . I) describes the cytology
smears as follows:
1. Normal cyto logy
2. lnflam ma tOr)' smea r
3. Cervical inu·aepitJle lial neoplasia (CLN l) or mi ld dysplasia
4. Cl N ll, Ill and carcinoma in situ nuclear abno rma lities
5. MalignanL cells and tadpole wiLit nuclear abnor-
ma lities
lt is reasonable LO e nquire abo ut the percentage of
Lmsuspected cancers, including carc inoma in situ, that
are likely to be diagnosed on routine cytology. The In-
dian Council of Medical Researc h (LCMR). ew Delhi,
screened the population of women o lder L11an 30 years
and found 5-15 smears to be abnormal per 1000 women
examined. The incidence of d)Splasia reponed at Llle All
india l nsliune of Medical Sciences, ew Delhi, was
16/ 1000 patients screened. In a posunenopausal woman,
if the squamocolumnar junction is indrawn due to
oestrogen defici e ncy, a 10-day co urse of oestrogen cream
exposes th e squamocolumnar j un ction better a nd yields
a n acc urate resu lt. Pos trad iatio n cytology is d ifficu lt to
samp le because of sca rring and atrop hy of th e vagina.
T he cells are often e n larged, vacuo lated with mu ltip le
nucleation and nuc lea r wrinkling. InflammatOry cells
ma)' be present (Tab le 1.5 ).
C)>tology us ing a thin preparation is s upe-
rior to Pap smear (Fig. I. II ). T he liq uid is used to screen
for papilloma virus. Cervical ca ncer screening is described
in Fig. 1.12. This is described in detail in Chapter 33.
Outer metJ1ocls of cervical screening are also described in
Chapter 33.
VISUAL INSPECTION AFTER ACETIC ACID APPLICATION
(VIA)
Gross inspection of cen·ix after application of 3% or 5%
acetic acid for I minute helps in detecting acetowhite area
which may harbour Cl / neoplasia.
 CHAPTER 1 - APPROACH TO A GYNAECOLOGICAL PATIENT 9

Table 1.5 Bethesda Classification

Sample-adequate, unsatisfactory
Squamous cell abnonnalities
Atypical squamous cells (ASC)
• Atypical squamous cells of undetermined significance
ASCUS
• ASC-cannot exclude high grade lesion ASC-H
• Low- grade squamous intraepithell al lesion (LSIL)
• Hlghijrade squamous intraepithellal lesion (HSIL)
• Squamous cell carcinoma
Adenocarcinoma

S01.rce: Bethesda G.Jideines.

Rgur e 1.10 Illustration of pathological grades of epidennoid cells in

the squamocolumnar junction of the cervix. Cells arising in this loca-
Figure 1.11 Liquid -based cytology classified as epithelial cell
tion were produced by a unifonn cell- scraping technique. Classifica-
abnormality, IOWiJrade squamous lntraeplt hellal lesion (LSiL) . Note
tion of cell types is based upon thorough study, eval uation of cell
particularly the cells in the centre. They have enlarged nuclei
characteristics and pathological features and Is final ly correlated wit h
compared with those in the cell s to the left and below. This feature is
corresponding histological studies of t he tissue. No attempt is made
required for a diagnosis of LSIL. The nuclear contours are irregular.
to classify cell s exfoliated from other tissue areas, such as the endo-
One cell to the right of centre is binucleated, a common feature in
metrium. The squamocolumnar junction Is a vital zone to the female
LSIL. (Source: From Figtre 12-1, Barbara S Apgar, Gregory L Brotzman
because this is the focal point where cancer arises. Grading of
and Mar1< Spczer: Copoooopy: Prnc.,les and Practice, 2nd Ed.
depends upon knowledge of origin of cell sample, on securing a rich
Saunders Else>Aer, 2008.)
concentration of cells, and of greatest importance, correct correlation
with histological fi ndings.

PAP smear (liquid-based cytology with

HPV testing), start with sexual activity
at 30 years or any time after 2 1 years

Table 1.4 Comparison of Different Classification

System for Pre-Invasive Lesion
Papsm e ar Dysplasia CIN Bethesda

II

Ill M ild LS IL

IV Moderate II HSIL

v Severe Ill HSIL

L, low; H, high; SIL, squamous lntraepithellal lesion.

Figure 1.12 Cervical cancer screening.

10 SHAW'S TEXTBOOK OF GYN AECOLOGY

SCHIUER TEST (VISUAL INSPEOION AFTER LUGOL'S

IODINE APPLICATION - VIU)
0 Scan to play VIA and VILI
This test detects tl1e presence of glycoge n in the superficial
cells of tl1e vaginal epitJ1elium. The vagi nal wall is stained
wilh Ltago l's iodine (Lugol's iodine contains 5% iodine and
10% potassium iodide in water [l g iodine + 2g KI]). The
vaginal epiilielium takes mahogan) brown colour in Lhe
presence of gl)cogen. Unstained areas (nega tive LesL) are
abnormal and require biopsy for hisLological exa mination.

CYTOHORMONAL EVALUATION
The ovarian hormones oesu·ogen and progesterone influence
ilie vagin al mucosa; thus, the epitltelial cells exfoliaLed in the
vagina reflect the influence of the pt"C\'<liling dominam hor-
mone in the system at that Li me. The oestrogen-dominated
smear appear-s clea n and shows tl1e p r-esence of discreLe corni-
fied polygona l sq ua mes. The progesLerone-dom inaLed smear
appears cUny and reveals tlt e predom inance of in termed iate
cells. During p regnancy, t11e cytology smea r shows interme-
diate cells and navic ul ar cells. After Lhe menopause due to
tlte deficiency of u1e ova ri an ho rmo nes, tlte vaginal mucosa
tltins down and Ule exfo liated cells are predominantly para-
basal and basal t)•pes. In human papilloma virus (HPV)
infection, one can recognize ko ilocyLes with perinuclear
halo and peripheral conde nsatio n of cytoplasm. The
nucleus is irregular and hype rchroma tic (Fig. 1.10).
Karyopyknotic Index or KPI (Maturation Index)
11. is u1e ratio of mature squamous cells over tl1e imennedi-
aLe and basal cells. It is more tl1an 25% in proliferative
(oes u·ogenic) phase (Fig. 1.1 3) and low in secrewry
(progestational) phase (Fig. 1. 11) a nd during pregnancy.
During pregnanC)', a ratio of more tl1an 10% indicaLes
progesterone deficiency. onnally, a peak value of KPI
is reached on Ute day of ovulation (2 days after serum
E..! peak).
UTERINE ASPIRATION CYTOLOGY
Perimenopausal a nd posu11enopa usal women on a h or-
mone therapy are now being screened for endometYial
cancer. T he uterine aspiration syainge o r brush is fo und to
Figure 1.13 Hi stology of proliferative phase. (Courtesy: Dr Sandeep
Mathur, AIIMS.)
be sa ti sfactory for obta ining adeq uaLe sa mp les. lL can be
uti lized as an office p roced ure; abo ut 90% acc uracy with no
false-positi ve findings is cla imed with this proced ure .
COLPOSCOPY
T he colposcope is a b inocular microscope giving a 10-
20 times magnificatio n. It is useful in loca ting abnorma l
areas and accurately obtaining directed biopsy from tlte
suspicious areas on the cervix and vagina in women witlt
positive Pap smears. This wa> the frequency of false-negative
biopsy is reduced. so also the need for con iLaLio n, a proce-
dure Lhat is accompanied witJ1 considerable amoum of
bleeding and morbid it) (Chapter 18).
ENDOMETRIAL BIOPSY (Fig. 1.14A and B)
An office or outpatient procedure was aLone Lime very popu-
lat· in ilie investigations of the female panner for infea·LiliLy. 11.
is performed in Ute premenstrual phase. A fine cureue is in-
troduced into Ul e uterine cavity to obtain a small su·ip ofthe
endometrial lining for histopat11ological examination, sene-
tory endomeuium denotes ovulaLOry cycle. Witlt t11e avail-
abili ty of uluasoamd, a noninvasive method for tlte detection
of ovul ati on, U1is procedure is now generall y not employed.

A
Figure 1.14 (A) Histology of secretory phase. (B) Midsecretory endometrium. (Source for (A): Copyright 2009 by the Unillllrsity of Aorida)
 CHAPTER I - APPROACH TO A GYNAECOLOGICAL PATIENT
It is still used if tubercular endomeu·itis is suspected. It is
useful in the d iagnosis of co•-pus luteal phase defecL
HORMONAL ASSAYS
In presen t-day practi ce, it is possible to swdy the levels of
several hormo nes using radioimmun <><"1Ssays and/o r the
£ LISA tests. T he co mmo nly assayed ho m1 o nes include FSH,
LJ I, PRL, ACTH, T 3, T 4, TSH, p rogestero ne, oestradiol,
testosterone, cortisol, aldosterone, hCG, dehyd roepia nd ros-
terone and androstenedione. These ass;1ys are used in the
(Uagnosis of menopause, PCOD and prolactinomas, and for
monitoring treaunem regimes in induction of ovulation
and in assisted reproduction.
ULTRASONOGRAPHY
Ultrasonography is a simple noninvasive 11nd painless diag-
nostic procedure that has the advantage of being devoid of
any rad iatio n hazard. T he pelvis and the lower abdomen are
sca nned in bo th the lo ngitudinal and tra nsve rse planes.
Generally, th is scan is do ne when the pati e nt's b ladder is full
as it he lps to e levate th e uterus o ut of the pelvis, and dis-
places the gas-fi lled bowel loops away, thus provid ing the
sonologist with a window to image the pelvic organs. ln
most cases, a transvaginal probe can be tLSefully employed to
obtain finer details of the pelvic organs. The bladder need
not be full , if the vaginal probe is tLSed. The scan can
coll<lborate the clin ical impression or uncover a hitheno
tmsuspected pathology. Lately, •·ectal and perineal routes
are 11lso 11vailable. 0 3 ultraSound is now capable of provid-
ing three-dime nsional images of the pelvic o rga ns and is
recent! )' ava ilable especiall y to de tect ge ni tal trac t malfo r-
mati ons and is less costly than MRI. Ultraso un d is also used
in certa in tlterape utic procedu res such as in vitro fertiliza-
tion and asp iratio n of a C)'St or pelvic abscess.
OTHER IMAGING MODALITIES
Radiological investigation such as h)SterosalpingQgJ-aphy is
utilited for stud)ing the patency of the fallopian tubes in an
infertile patient. CT scan and MRI are advanced investiga·
tions that detenn ine the extent of tumours and their
spre<1d. For details, refer to Chapter 40. Sonosalpingog•-a·
ph y is employed in women with infe rti lity and wh en uterine
poi)'P is suspected.
GYNAECOLOGICAL ENDOSCOPY
Botlt diagnostic laparoscopy and hysteroscopy are estab Ushed
use ful tools in the armamentarium of t11e gynaecologist. For
details, refer to Chapter 41 (Endoscop) in Gynaecology).
11
PREGNANCY TEST
The first morning sample of urine is used in a •-apid immu-
nologi cal test to confirm pregnanC)\ by detecting the
presen ce of human cl1o1·ionic honnone. The pregnancy test
becomes positive by the begi nning of 6th week, from th e
last me nsu·ual period. With modem kits, any sample of
urine ca n be used, and it may beco me positi ve with in
1-2 da)'S after missing tl1 e pe riods.
KEY POINTS
• Most mnaecological diseases can be diagnosed by a
proper and detai led histor) and peh ic examination.
• While approaching a female patient, utmost care should
be taken to respect her feeUngs, ensure p•·hoacy and us-
ing simple words LO know details of her sexual hisLO•) ',
contraCeptive used, abortions and u·eaunenL
• A wide range of investigati o ns are now able with
Ute g)•naecologisLS which finall y co nfi rm the diagno-
sis, detec t the extent of th e d isease a nd help in plan-
ning tlt e managemenL
• Pap smear is now an established scree ning proced ure
in carcinoma cervix.
• Ulu·asound examinations have simplified gynaeco-
logical diagnosis.
• Seleahe ID naecological endoscop) helps defin itive
diagnosis.
• Honnonal assars are necessary in infertilitywork up, in
viu·o ferti litation and v:u·ious hormonal disturbances.
• Cr and MRJ have added to the imaging modalities
and are useful when diagnosis is in do ubt o n the basis
of ph)•Sical exa mina tio n.
SELF-ASSESSMENT
I. List t11e simple steps in history taking of a gynaecological
patient.
2. Describe the imponance of Pap smears in clinical practice.
3. WhaL is t11e role of imaging and endoscopy in the clinical
practice of gynaecolom•?
SUGGESTED READING
Ley P. Commun ications with Patient$. London, Croom I !elm, 1988.
Lipkin M .J r. The me dical interview and related skills. In BrdnCh "WT
(ed). Office Practice ofMedidne. Philadelphia. WB Saunders, 1987;
1287-306.
SirnpM>n M , Buck1nan R. Ste,.lart ct al. Doctor paticnl communica-
tion. ThcTor<>nto consensus statcrnem. B:.tj 1991; 30!l: 1386-7.
Todd AD, Fi>hcr S. The Social Orgdnir.ation of Doctor-P:otienL Com-
munication, 2nd ed. Ablex Publi>hing, 199!l; 243-65.
 ANATOMY, PHYSIOLOGY
AND DEVELOPMENT OF FEMALE
REPRODUCTIVE ORGANS

2 Anatomy of Female Genital Tract 6 Puberty, Adolescence and Related

3 Normal Histology of Ovary and
Endometrium
4 Physiology of Ovulation and
Menstruation
5 Development of Female Reproductive
Organs and Related Disorders
Gynaecological Problems
7 Menopause and Related Problems
8 Breast and Gynaecologist
9 Sexual Development and Development
Disorders of Sexual Development

12
 Anatomy of Female
Genital Tract

The Vulva 13 The Pelv ic Musculature 25

The Vagina 15 The Pelv ic Cellular Tissue 28
The Uterus 18 The Pelvic Blood Vessels 29
The Uterine Appendages 2 1 The Lymphatic System 3 1
Fallopian Tubes 21
The Ovaries 23
The Nerve Supply 33
Applied Anatomy and its Clinical 0
The Urethra 23
The Bladder 24
The Ureters 24
The Rectum and Anal Canal 25
Significance 33
Key Points 35
Self-Assessment 35 0
The anat0m ica! knowl edge of th e female genital organ the labia majora are hairless and the skin of
(Fig. 2. 1) and th eir relation to th e neighbouring structures t I area ·s ofter, moister and pinker th an over th e omer
help in the diagnosis of various gynaecological dise.ases~ ----,~ ( Fig. 2.2). T he labia majora are covered wiL11 squa-
and in interpreting the findings of u ltraso und , computed 1 11.s epithelium and contain sebaceous g lands, sweat
LOmography (CT) and magnetic resonance imaging ( glands and ha ir follicles. There are also certa in speci alized
scanning. During gynaeco logical surgery, di ronlons of the sweat glands call ed apocrine glands, which produce a cha r•
pe lvic organs are beuer appreciated and de.alt a d ac terislic aroma and from which th e rare tumour of hidrad-
grave inj1 11• to the sm.1 ctures uch as bladd enoma of the vu lva Ls derived. T he secre ti on in creases
rectum is avoided. Th e understanding of the l)Un hatic during sexual excitement.
drainage of the pelvic o rgans is necessa.i~ 1 rn~·ng arious The presence of all these su·u ctures in the labia majora
gen ital tract malignanc ies and in their ut ical d ssection. renders th em liable LO common skin lesions such as folliculitis,
boils and sebaceou cysLS (Fig. 2.3). LLS masculine coun terpart
i the scrotum.
THE VULVA

T he vulva is an ill-defined area which in gynaecological

practice comprises th e who le of the external gen itali a and
conveniently includes lhe perineum. It is, therefore,
bounded anteriorly by the mons veneris (pubis), laterally by
tl,e labia majora and posteriorly by the perine um.
LABIAMAJORA
T he labia majora pass from the mons veneris tO end poste-
1iorly in the skin over the perinea! body. T h e}' consist of
fo lds of skin which en dose a vairiable amount of fa Land are
best developed in the ch ildb earing period of life. ln chil-
dren before tl1 e age of puberty and in posunenopausal
women, the amo um of s ubcutaneous fa t in the labia majora
is relative!>• camy, and the cleft between the labia is there-
fore conspicuous. At puberty, pudenda! hair appear o n the
mons veneri , the outer surface of the labia majora and in
some cases on th e skin of the perine t:Lm as well. T h e inner
LABIA MINORA
Th e labia minora are thin folds of skin which encl ose ve ins
an d e lastic tissue and lie on the inner aspect of the labia
majora. T he vasc ular labia minora are erec tile during sexual
activity; they do not contain any sebaceotts glands or hair
follicles (Fig. 2.4). Ameriorly, they enclose the cliLOris to
fo rm the prepuce on the upper surface and the frenulum
on iL~ und ersurface. Posteriorly, they join tO form the fo 111~
chette. The fourc h ette is a tlli n fold of skin, iden tified when
th e labia are separated, and it is often rorn during parturi-
tion. The fossa navicnlaris is the small hollow between th e
hyme n and the fo urchette. Labia minora is homologous
with the ven u·a l aspect of the penis.
The clitoris is an erec tile organ and consists of a glans,
covered by tl,e frenulum and prepuce , an d a body whi ch is
ubcutaneous; it corresponds to th e penis and Ls attached LO
the und ersurface of the symph}•sis pubis by th e suspenso11•
ligament. ormally, the clitoris is 1- 11/1 cm long and 5 mm
13
14 SHAW'S TEXTBOOK OF GYN AECOLOGY

Uterus

Ovary
Rgure 2.1 General view of internal genital organs showing t he
normal uterus and ovaries.

Figure 2.3 Hi stological section of the labium majus showing squa-

Mons pubis
mous epit helium with hair follicle and sebaceous gland {X 55).
(wneris)

Prepuce
Frenum Clitoris
Vestibule _ ,._,1---,f+.- Labium majus
Labium minus l.!l--1+-+1'- External urethral
orific.e
Vaginal introitus -..,.-+--1--SI
Opening of
Bartholin's duct
Hymen
1-+- -- - Perineum

Figure 2.4 Histological section of the labium minus showing squa-

8 Virginal Septate Cribriform Parous mous epithelium. Note complete absence of hair follicles and sebaceous
Rgure 2.2 (A) Anatomy of the vulva. (B) Variations of the hymen. and sweat glands.

in width. Clitoris o f more than 3.5 on in le ngth and I em
in width is called clitoro megaly, and occurs in virilism due to
excess o f androge n ho nno ne. The clitoris is well supplied
with nerve endings and is e xu·emely sensitive . Dlll·ing coiLUs,
it becomes e rect a nd pla)S a conside rable pan in inducing
orgasm in the female. The clito•·is is highl)' vascular. An in-
jury to the clitoris causes profuse bleeding and can be very
painful.
The is the space I) ing be twee n the anterio r and
the inner aspects of the labia minora a nd is bounded poste-
rioliy by the vaginal in troitus. The I'Xf t'rrUllurintt ')' 11U!lt iLIS iies
immediatel) posterio r to the clito •is. The vaginal orifice lies
poste,;or to th e meatus and is surrounded by the hp nen.
In virgins, the h)lne n is re p•-esellled b)• a thin membra ne
cove red o n each surface by sq uamous e pithelium. It gener-
a lly has a small eccenu·ic opening, which is usua lly not wide

enough to admit the fin gertip. Coitus resul ts in the rupture
of tl1e hymen; the resulting lace rations are radially arranged
and are multiple. Occasionally, coital n.apwre can cause a
brisk hae mo rrhage. During childbirtll, further lacerations
occur: tl1e h)lnen is wide!) SU'etched and subsequently is
represe nted b) the tags of skin kn own as the carunculae
myrtiformes. \\'ith the populaait) of tll e use of intemal sani-
tal")' tampons, the loss of in tegait) of tlle hpnen is no longer
an evide nce of loss of virginity.
The ' 'ulval tissues respond to ho nn ones, especially oestrO-
gen , during m e childbeaa·ing)ears. After menopause, auophy
due to oestrogen deficiency m akes me vulval skin tl1inner and
drier, and this m ay lead to atrophi c and itching. Mons
jJUbiJ is an at·ea which overl aps the symphysis pubis and con-
tains f.n. At puberty, abundant hair grow over it.
BARTHOLIN'S GlAND
Bartl1oli n 's gland li es posterolaterall y in relatio n to the vagi nal
otifice, deep to the b ul bospongiosus m uscle and supe rficial to
tl1e o uter layer of tJ1e u·iangu lar ligament. It is e mbedded
in the erec til e tissue of tJ1e vestib ular b ulb at its posterior
ex u·em it)'· It is norma lly impa lpable when healtl1y, but can be
readil)' palpated be twee n the finger and the tl1U mb when
en larged b)' inflammation. Its vascu lar bed accounts for me
brisk bleeding, which always accompan ies its removal. Its
duct passes forwards and inwards to open, external to the
hymen, on tl1e inne r side of the labium minus. The gland
measures about 10 mm in di.'lmeter and lies near tllejunction
of the middle and posterior thirds of tlle labium majus. The
duct of the gland is about 25 mm lo ng and a min mucous
secretio n can be expressed from it by pressure upon me
gland. Barth olin's gland and its duct are infected in acute
gonorrhoea, when the a·eddened mo urn of the duct can easily
be disti nguished on tl1e inner surface of m e labiwn minus to
one side of tl1e vaginal o aifice below the level of tl1e hpnen.
Bat·tllolin's gland is a compound racemose gland and its acini
are lined by low columnar epitllelium (Fig. 2.50 ) . The epi-
theliwn of the duct is cubical near the acini, but becomes
Rgure 2.5 Bartholin's gland. Low-power view showing the structure
of a oompound racemose gland with acini lined by low columnar
epithelium (x92).
0 Scan to play Barthol in's abscess
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 15
u·ansitional and finally squamo us near tl1e mouth oftl1e d uct.
The function of tl1e gland is to sec rete lubricating mucous
dwing coitus. The labia majora j o in at the posterior commis-
Sttre and merge imperceptibl) into tl1e peainea.un.
THE VAGINA
The vagina is a fibronnLSCular passage mat connects tl1e
Lllerus to me introitLLS. The lower end of the vagina lies at
the level of the h) men a nd of the inu·oitus \'llginae. It is sur-
rounded at tllis point by tl1e erectile tissue of tl1e bulb, which
corresponds to tl1e corpus spongiosum of the male. The
direction of the \':!gina is approxim ately parallel tO me
plane of tl1 e brim of tl1e u·ue pelvis; the vagina is slightl y
curved forwards from above downwards, and its anterior
and postetior walls lie in a close co nta ct. It is notofun ifotm
cali bre, being nea rly twi ce as capacious in upper part and
somewhat flask shaped. T he vaginal ponio n of the cervix
projects into its upper e nd and leads to the fo rma tio n of th e
poste ri or and latera l forn ices. T he dep th of th e
forn ices depends upon the deve lopmen t of the portio vagi-
na lis of the cervix. In girls before pube r1.)' and in e lderly
women in whom the ute nts has undergone postmenopausal
atroph)', me fornices are shallow whe reas in women wim
congenital elongation of the portio vaginalis of tl1e cervix,
the fornices are deep. The vagina is attached to the cervix
at a higher leve l posteriorly than elsewhere, and this makes
the posterior fornix the deepest o f the fo rnices and tl1e
posterior \':!gina! wall lo nger than tl1e anterio r. The poste-
rior wall is 4.5 inch ( 11.5 em) lo ng, whereas Ll1e antet;or
wall measures 3.5 in ch (9 em). Transve rse folds which are
present in m e \'3ginal walls of nulliparae a llow the \':!gi na to
stretch and dilate during coitLLS and pat1.ut·itio n. These folds
are pa 11.ly o bliterated in women who have bome ma ny
children. In the a nteri or \':lgi nal wall, tllree sulci caa1 be
disting uished. One lies immediately above the meatus aa1d
is called ( Fig. 2.6). About 35 mm above this
Rgure 2.6 A case of prolapse In which the cervix has been drawn
down. Parameatal recess, hymen, submeatal sulcus, paraurethral
recess, oblique vaginal fold , transverse sulcus of the anterior vaginal
wall, arched rugae of the vaginal wall and bladder sulcus.
16 SHAW'S TEXTBOOK OF GYN AECOLOGY
sulcus in tl1e ameli or vaginal wa ll is a second sulc us, known
as the transver:.e vaginal sulws, which corresponds approxi-
mately to the junction of the urethra and the bladder.
fLLrtller upwards is tl1e bltuhkr sulcus, indicating tl1e junction
of tl1e bladder to tl1e an tetior vaginal wall.
The vaginal mucosa is lined by nonkeratized squamous
epithelium which consists of a basal layer of cuboidal cells,
a middle la)er of prickle cells and a superficial layer of
comified cells (Fig. 2. 7). In the newborn, the epitheliwn
is almost transitional in t)pe and cornified cells are scanty
until puberty is reached. No glands open into the vagina,
and the \'3ginal secretion is derived partly from tl1e mu-
cous discharge of the ce•vix and partly from transudation
through tl1e vaginal epithelium. The subepithelial layer is
Epithelium
Submucous
Smooth muscle
(inner circular
and outer
longitudinal)
- } External
fibrous layer
-- (endopelvic
tascia)
Rgure 2. 7 (A) Low-power {X36) microscopic appea-ance of the
vaginal wall showing the corrugated squamous epithelium and
bundles of plain muscle cells subjacent to the vascular subepithelial
layer. (B) Structure of the vaginal wall. (Courtesy for (A): Dr Sardeep
Mathur, AJIMS.)
vasc ular and contains much erectile tissue. A muscle
layer consisting of a complex interlac ing lattice of plain
muscle lies external to the subepithelial layer, whereas
the large vessels lie in the connective tissues surrounding
the vagina. If the female fews is exposed LO diethylstil-
boestrol (DES) taken b) the mother during pregnancy,
columnar epithelium appears in the upper two-thirds of
vaginal mucosa, which can develop vaginal adenosis
and vaginal cancer during adolescence. The keratiniza-
tion of vaginal mucosa occurs in prolapse due to the
exposure of vagina to the outside and ulcer may form
over the \'3ginal mucosa (decubitus ulcer). The keratized
mucosa appears skin-like and brown. Menopause causes
atrophy of tl1e vagina.
The vagiual is small in amount in healthy
women and consists of white coagulated material. Wh en it
is examined under a microscope, sq uamous cells sh ed from
the vaginal epi thelium and Doderlein's bacilli alo ne are
fo und. !Jacillt.t.l is a large Gra m-positive rod-
s haped organism, whi ch grows a nae robicall y on ac id me-
dia. T he vaginal sec retion is ac id ic cl ue to tl1e presence of
lac tic ac id, and tl1is ac id it)' inhi b its th e growth of pa ul o-
ge nic organ isms. T he pl-1 of th e vagina ave rages abo ut
4.5 du ring reprod ucti ve life. T he ac id it)', which is undo ub t-
ed!)' oestrogen dependent, fa lls afte r me nopause to ne utt·a t
or even a lkaline. Before pubert)', the pH abo ut 7. This
high p l-1 before puberty and after menopause explains the
tendency for the development of mi xed organism infec-
tions in these age groups.
The synthesis of lactic acid is probably influenced by
either enzrme or bacterial activit) {Doderlein 's) on the
glycogen of the epithelial cells, which itself is dependem
on the presence of oestrogen, so that its deficiem activity
can be boosted b) the administration of oral or local
oestrogen. During the pue•·pe•·ium and also in cases of
leucorrhoea, tl1e acidity of the \'llgina is reduced and
pathogenic organisms are then able to survive. The squa-
mous cells of the vagina and cervix stain a deep brown
colour after being painted with iodine solution, owi ng to
the presence of glycogen in healthy cells (positive Schil-
ler's test). Ln a posUllenopausal woma n, because of tl1e
absence of or low glycogen-conta ini ng superficial cells,
Schiller's test becomes negative.
T he vagina l epithelium is under tl1 e ova rian hormo nal
infl ue nces of oestrogen and progestero ne. Oesu-ogen pro-
liferates the gl)'cogen-containing supe rficial cells and pro-
gestero ne causes prolife ratio n of ime rm ediate cells. Lack of
these ho rm ones in a me nopa usal woman leaves only the
basal cells with a thi n vagina l mucosa.
T he abno•mal and malignant cells also do no t con tain
gi)'COgen and do not take up lhe stain. Similarly, these
abnormal cells turn wh ite with acetic ac id d ue tO coagula-
tion of protein. These areas are selected for biopsy in the
detection of cancer.
RELATIONS OF VAGINA
ANTERIOR RELATION
In its lower half. the vagina is close!) related tO tl1e urethra
and the paraurethral glands {Skene's wbules), so closely in
faCL tl1at the urethr0\'3ginal fascia is a fused struCLure and
only separable by a sharp dissection. In its upper half, tl1e

vagina is related to the b ladder in the region of the u·igone,
and here the vesical and vaginal fasc iae are easily separable
by a blunt dissection via the vesicovaginal space. There is a
considerable vasc ular and lymph atic imercommunication
between the vesical and the vaginal vessels, a sinister rela-
tionship having a bearing on Lhe surgery of a malignam
disease of Lh is area.
POSTERIOR RELATIONS
The lower third of the \'llgina is re lated 1.0 Lhe perineal
body, the middle third 1.0 the ampulla of the reCLum
and the upper third to the anterior \\'llll of the pouch of
Douglas, which comains la•·ge and small bowel loops. This
partition dividing the vagina from the pe•·itOneal cavity is
tl1e thinnest a•·ea in the whole pe•·itOneal surface and,
tl1erefore, a site of election for poim ing and opening of
pelvic abscess or th e productio n of a h ernia or enterocele.
T his is also an ideal site for colpocem esis in th e d iagn osis
of ectOpic pregnancy.
Pouch of Douglas (Fig. 2.8) is a pe rito neal cul-de-sac in
the rec tovaginal space in the pelvis. IL is bo unded anterio rl)'
by the peritone um cove rin g the pos te rio r vaginal wall and
posLerio rl )' b)' tl1e peritone um covering the sigmoid colon
and the recwm. Laterall y, th e uterosacral ligame nts limi t
its bo undary whereas th e floor is Lhe reflection of the
peritoneum o f the pe rito neal cavity.
The endometriotic nod ules and metasmtic growth of
an ovarian cance r are fe lt in tl1 e pouch of Douglas, so
also pelvic inflammatOI') mass. The u1.erosacral ligaments
are thickened and become nodular in advanced cancer
cervix.
LATERAL RELATIONS
The la1.eral relations f•·om below upwa rds are the cavern-
ous tissue of the vestibule; the supe •·ficia l muscles of the
pe•·ineum; the u·iangu lar liga ment and at about 2.5 em
from the inu·oitus t11 e Je,>aLOr ani, lateral tO which is tl1e
ischio•·ectal fossa. Above the levator lies the endopelvic
cellular tissue, and its condensation , called Mackenrodt's
ligament, on tl1 e either side. The ureter traverses this
Uterosacral ligament Pouch of Douglas
Figure 2.8 Pouch of Douglas showing uterosacral ligaments as
upper border.
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 17
tissue in the urete ric ca na l and is abou t 12 mm anterolat-
eral to the lateral fo rnix.
SUPERIOR RELATIONS
1l1e cervix with its four fornices - amerior, posterior and
two lateral- are related to tl1 e uLerine vessels, Mackenrodt's
ligament and the PosLe•io rl), surrounding the pouch
of Douglas lie the uterosacral ligaments which can be identi-
fied o n vaginal examination, especiall)• if thickened by
disease such as endomeu·iosis and cance r ce rvix.
Squamocolumnar j unction, also known as u-ansitional
zone, is clinically a ' ery important junction where the squa-
mous epithelium lining tl1e vagina merges witllthe columnar
epithelium of tl1e endocervix and is 1-10 mm (Fig. 2.9) .
Here, tl1e constant cellular activiLy of tl1e cells takes place,
and the cells are highly sensitive to irritants, mutagens and
viral agents such as papilloma virtL5 16, 18. T hese agents cause
nuclear changes tl1at ca n evenLUall y lead tO dysplasia and
carcinoma cervix, which is the most co mmon malignancy of
tl1e female geniLal tra ct in Ind ia. Squamocolumnar junction
is of two types: first one is embryo nic when columnar epithe-
lium spreads over the exte rna l os. Afte r pube rt)\ metaplasia
of colu mnar epitl1e liu m unde r the infl uence of oestroge n
brings sq uamous epitheliu m close to Lhe ex ternal os, thus
creati ng a u·ansitional zone be twee n the two j unc tions. In
women exposed to DES in utero, tl1is zone is well outside the
os, spreading over tl1e \'llgi nal vau lt. In a menopausal woman,
it gets indrawn inside tlle os. During pregnancy and with oral
conu-aceptives, it pouts o uL of os.
The squamoco lumnarjunction is well outside me external
os dLLring tl1 e reprod uctive period, and in Pap smear tl1is area
is scraped and tl1 e C) tolog) of its cells swdied for the nuclear
changes, in me scree ning programme for ca nce r cervix.
Dw·ing pregnane), tl1e ex1.e m al os becomes patulous and
the squamocolumnar junction is well exposed all round.
Pap smear> ields the most accu rate C) tological findings.
ln menopausal women, the cervix sh•·inks and the squa-
mocolumnar junction gets indrawn into the cervical canal.
Columnar
epithelium
Figure 2.9 Squamocolumnar junction. In the 'ideal' cervix, the
original squamous epithelium abuts the columnar epithelium. (Soun::e:
Hacker NF, Ganbone JC, Hobel CJ, Hacker CW'ld Moore's Essentials ot
Obstetres ard Gynecology, 5th ed Pliladelphia: Elsevier, 201 0.)
18 SHAW'S TEXTBOOK OF GYN AECOLOGY
lt is therefore not easily accessib le, and ill exposed to the
vagina, for visua l inspection. This explains high false-nega-
tive findings in Pap smear in older women. Giving oestrogen
locally or orall) or prostaglandin E (misoprosLOI) pessary
allows this junction to pout out and improves t11e efficacy of
t.he Pap smear C) to log).
The squamocolumnarjunction is SLUdied colposcopically
when t.he Pap smear shows abnormal cells, and t11e abnor-
mal areas are biopsied fo•· cancer detection.
THE UTERUS
The uterus is py.-iform in shape and measures approxi-
mate!)' 9 em in length, 6.5 em in width and 3.5 em in
tl1ickness. It is divided anatom icall y and fun ction all y
into body and ce1vix. It weighs I o unce (60 g). T he line
of division correspo nds to the level ofth e intern al os, and
here the muco us membra ne lining the cavity of the
uter us beco mes con tinuo us witl1 that of th e cervical ca nal
(Fig. 2.1 0). At thi s level, the pe ri to ne um of the front of
t11e ute rus is reflected o n to the bladde r, a nd the uterine
artery, after passing a lmost tra nsverse!)' ac ross the pe lvis,
reac hes tl1e uterus, tu rns at r ight angle and passes verti-
cally upwards a long the latera l wa ll of the u terus. T he
ce1vix is divided into vagina l and supravaginal portions.
The fundus of the uterus is that part of the corpus uteri
which lies above the insertion of the fallopian tubes. The
cavity of t11e uterus communicates above wit11 t11e open-
ings of the fallopian tubes, and by way of t11eir abdominal
ostia is in direct con tin uit) with t11e peritOneal cavity. The
uterine caviL) is triangular in shape witll a capacity of
3 mL. The lower angle is formed by the internal os. The
lateral angle connecting to the fallopian tube is called t11e
cornual end. The wall of the uterus consistS of tluee layers,
t.he peritoneal co,·ering called pe•·imetrium, tl1e muscle
layer or myomeu·ium and t.he mucous membrane or
endomeu·ium.
The ute•·us is capable of distension during pregnancy,
haematometra as well as with distended media du.-i ng
hysteroscopic examination. Otherwise tl1e two walls are in
opposition.
Infundibulum Intramural
(Interstitial) par t
Cervical canal
Vaginal cervix or
(portio vaginalis)
Rgure 2.10 A nulliparous uterus showing the anatomical structures.
PERITONEAL COVERING
The peritoneal covering of the utems is incomplete. Anteri-
orly, t11e whole bod) of t11e ULerus is covered witll peritoneum.
1l1e peritoneum is reflected on to t11e bladder at t11e level of
t.he imemal os. ll1e cen1x of t11e uterus has t11erefore no peri-
toneal covering ameliorl). Post.e•iorl), tl1e whole body of t.he
uterus is covered b) pelitoneum, as is the supravaginal portion
oft.he cen·ix. The pel"itoneum is reflected from t.he supravagi-
nal portion of t.he eel"\ ix on to the poste•·iorvaginal wall in tl1e
region of t.he postelior fomix. The peritOneal la)er is incom-
plete laterally because of the insertion of t.he fallopian tubes,
t.he row1d and ovarian ligaments into t.he uterus, and below
t.his level tl1e two sheets of peritoneum, which constitute t.he
broad ligament, leave a tl1in bare area laterall y on each side.
MYOMETRIUM
T he myome u·ium is the thickest of t11e t11ree laye rs ofthe wall
of the ute n.ts. ln the cen>ix, the m>•ometrium consists of plain
muscle tissue together witJ1 a large amo unt of fibrous tissue,
which gives it a hard consistency. T he muscle fibres and
fibro us tissues are mixed togctJlcrwithout an orderl)' arrange-
menL ln tJ1e bod)' of tJ1e utenJS, tJ1e myomeuium measures
aboutl 0-20 mm in tJ1 ickness, and tJ1ree layers can be d istin-
gu ished which are best marked in tJ1e pregnam and puerperal
uterus. The extemal layer lies immediately beneath the peri-
tonewn and is longitudinal, tJ1e fibres passing from t11e cervix
anteriorly over tl1e ft.uldus to reach tJ1e posterior surface of
the cervix. ll1is la)er is Lhin and cannot easily be identified in
ilie nulliparous uterus. The main function of tJ1is layer is a
dem.ISor action during tJ1e expulsion oftJle fetus. The middle
layer is t.he thickest of the tJwee and consists of bLUldles of
muscle sepamted b) a connecti'e tissue, the exact amow1t of
whid1 varies with age; plain muscle tissue is best marked in tl1e
childbearing pe•iod, especially during pregnancy whereas
before pubeny and after menopause it is much less plentiful.
There is a tendency for tJ1e muscle bundles to imerlace, and
as t.he blood vessels supplying blood to the uterus are dist.lib-
uted in the connective tissues, tJ1e calibre of the vessels is in
part controlled by tJ1e of tJ1e muscle cells. The
purpose of tl1is la>•er is therefore in part haemostatic, tl1ough
its exp ulsive role is equally importa nt. T his layer is clesclibed
as living of the uteno, and is responsible for comrol of
bleeding in the thi rd stage of labo ur. Inefficient contrac tion
and re u·act.i on of these muscle fib res ca use prolonged labo ur
and atOni c postpartwn haemo •Thage (PI)I-1).
T he inner muscle la>•er COI1Sists of circula r fib res. T he
layer is never we ll marked and is best rep rese med by tl1 e
circ ular mt.ISc le fibres around the in te rnal os a nd tJ1e ope n-
ings of the fallopian tubes. It can be regarded as sp hin cteric
in action. The myomeui um is th ickest at the fund us
( 1-2 em) and thinnest at tJ1e cornual end (3-4 mm), one
should t11erefore be careful during curettage and endome-
trial ablation not to perforate tJ1e com ual end.
ENDOMETRIUM
The endomeu·ium or mucot.IS membrane lining tJ1e
of the uterus has a different structure from that of tl1e
enclocervix. It is described in Chapter 3, ' onnal histology
ofOvaryand Endometdum'.

The cer vix is spind le shaped and measures 2.5 em or a
little more. It is bounded above by the internal os and
below by the external os (Fig. 2. 10). The mucosal lining
of tJ1e cervix differs from that of the body of tJ1e uterus by
tJ1e absence of a submucosa. The endocervix is lined by a
single la)er of high columnar ciliated epitJ1elium \vith
spindle-shaped nuclei I) ing adjacent to the basement
membrane with abundam C)LOplasm and mucin. The
direction of the cilia is downwards towarcls the external
os. The glan<ls are racemose in t) pe (Fig. 2.llA and B)
and secrete mucus with a high content of fructose glyco-
protein, mucopolysaccharide and sodium chlo•·ide. The
secretion is alkaline and has a p H of 7.8 and itS fructose
contem render·s it atu-active to ascend ing spe•·maLOzoa.
This secretion collectS as a plug in the cervical ca nal an d
possibly h inders ascending infections. In gonococcal an d
chl amydia! infections of th e ce rvix, tJ1 e orga nisms collect
amongst t he cryptS of th e cervical glands. In nulli paro us
. • It allows capaci tati o n of spe rms.
" . . .
- - ·. :c..•·
·· "'..
-.•
' between tl1e endomeuium of the body and the mucous
Rgure 2.11 (A) Normal endocervical cells. (B) Normal cervical
glands. These are of the racemose type and are lined by high co-
lumnar epithelium which secretes mucous (X250). (Source tor
(B): Seama Khuni, CervtxPremalignCW"It/preinvasive lesions. 2003-
2017, PalhologyOutlines.com, Inc.)
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 19
women, the external OS is circ ular b ut vagina l de livery
resul tS in tJ1e transverse slit which characterizes the paro us
cervix. The cervix contains more of fibrous tissue and col-
lagen than the muscle fibres, which are dispersed scarcely
amongst the fibrous tissue. Cervix contains mainly colla-
gen and on I) 10% of muscle fibres. Light microscopic ex-
amination reveals 29% muscle fibres in itS upper one-
third, IS% in tJ1e middle one-third and only 6% in the
lower one-tJ1ird, whereas the body of me utems contains
70% muscle fibres. The change from fibrous tissue of cer·
vix to the muscle tissue of the body is quite abrupL ln late
pregnancy and at tenn, under the influence of prostagla n-
din, collagenase dissolves collagen into fluid form a nd
renders tJ1e cervix soft and stretchable during labour.
Functions of the endoce•·vical cell li n ing are as follows:
• T he cilia are directed downwards and prevent ascending
infection.
• T he cells sieve o ut abnormal sperms a nd allow h ealthy
sperms to en ter the uterus.
• It provides nu ui tio n to the sperms.
Structu rall)' and func ti onally, tl1e bOd)' ofLhe ute rus and
that of tl1e cervix are in marked contrast. T he ce rvical epi-
the liu m shows no periodic alteration d uri ng the mensu·ual
cycle, and the decidual reaction of pregnancy is seen o nly
rarely in the cervix. Similarly, t11e malignant disease of tl1e
uterus is an adenocarcinoma of the endometrium, whereas
carcinoma ofthe ce1vix is usuall) a squamous cell growtl1 of
high malignrulC).
An intennediate Lone, tltl' istlm1us, 6 mm in length, lies
membrane of the ce•' ical canal. ItS epitJ1elial lining resem-
bles and behaves like the endomeu·ium of me body. The
isthmic po•·tion stretches cllll·ing pregnanq• and fonns tJ1e
lower uterine segment in late pregnancy. This isthmic por·
tion is less contractile dlll·ing pregnancy and labour but
funher stretches under uterine conu-actions. It is identified
during caesarean delivery by the loose fold of pe•iwneal
lining cove•·ing itS amel"ior surface.
The relationship between the lengtll of the cenrix and that
of me body of tJ1e uterus '"''ies with age. Before pube11.y, the
cervix to co•pus ratio is 2: 1. At pubeny, tJ1is ratio is reversed LO
1:2, and during the reproductive years, ce•vix to corp us ratio
may be 1:3 or even 1:4. Afte r tl1e whole organ
atrophies and tl1e portio vagina lis may eventuall y d isappear.
Al tl1o ugh the endomeui al sec retio n is sca nty and fl uid in
na ture, the cervical sec reti on is abunda nt and itS q ua li ty and
q uantity change in the d ifferen t phases of tl1e menstrua l cy-
cle, under d ifferent hormonal effectS. T he cenrical mucous
is rich in fntctose, glycoprotein a nd mucopolysacc harides.
Fructose is n utritive tO sperms cl uling tl1eir passage in me
cervical canal. Under oesu·ogenic infl uence in the preovula-
LOry phase, tJ1e glycoprotein network is arranged parallel to
each otJ1er and facilitates sperm peneu-ation, whereas under
the progesterone secretion, t11e network forms interlacing
b1idges and prevents their entr) into the canal. This
prope•1.) of progesterone is ttSed in a contraceptive pill a11d
progesterone-impregnated in u-aute•ine conu-aceptive de-
vice. Sodium chlol'ide coment in the mucous increases at
ovulation and fonns a fem-like pattern when a drop of mu-
cous is dried on a slide and studied under a microscope.
20 SHAW'S TEXTBOOK OF GYN AECOLOGY
POSITION OF THE UTERUS
The uterus nonnally lies in a posilion of anteversion and ante-
flexion. The bod> of the ULenLS is bem forwards on t11e cenix
approximate!> at t11e level of t11e imemal os, and t11is forward
inclination of t11e bod) of t11e uterus on t11e cervix constiLUtes
anteflexion. The direction of t11e axis of me cervix depends
upon t11e position oft11e uterus. In (Fig. 2.128), me
external os is do,,nwards and backwards so t11at on
'aginal examination t11e examining fingers find t11at t11e lowest
pan of me cervix is t11e ame•ior lip. When me uten.tS is reuu-
'ened me cen•ix is directed d0\\11wards and forwards, and t11e
lowest partoft11e ce1vix is eit11er me ex1emal OS or t11e posterior
lip. As a result of its nonnal position of anteflexion, the body of
me uterus lies agai nst t11e bladder. The poud1 of pe•·itOneum
t11at separates t11e bladder from t11e uterus is t11e uterovesical
pouch. The pelitoneum is reflected from t11e from of me
uterus on to t11e bladder at t11e level of t11e ime mal os.
Posteriorly, a large periton eal pouc h lies between the
uterus and the rec tosigmo id colo n. If t11 e ute rus is pulled
forwards, two fo lds of peritone um ca n be see n to pass
Ligament
of ovary
uterus
recess
A
Normal
(anteverted,
8 anteflexed)
Rgure 2.12 (A) The relationship of the female reproductive organs: sagittal section. (B) Anteverted, anteflexed and retroverted uterus.
tor (A): From Fg 7 1. Chris Brooker· AleXCW)de(s Nursing Practice, 4th Ed. Churchill Uvi'lgstone: Else\4er, 2011 .}
backwards from t11 e uterus to reac h the parietal peritone um
lateral to the rectum. These folds, t11e uterosacral folds, lie
at the level of t11e intern al os and pass backwards and up-
wards. The uterosacral ligame nts are condensalion of t11e
pelvic cellular tissues and lie at a lower level and witl1in me
uterosacral folds. The pouch of periLOneum below the level
of me uterosacral folds, which is bounded in from by me
peritoneum covering the upper pan oft11e poste•·ior vaginal
wall and posteriorly by t11e pe•·itoneu m cove•·ing t11e sig-
moid colon and the upper end of t11e recLUm, is the pouch
of Douglas. The posterior fornix of the vagina is in close
relation to me pe•itoneal cavity, as only the posterior vagi-
nal wall and a si ngle la)er ofpe•itoneum separate the vagina
from the pe•·itoneal cavity. Collection of pus in the pouch of
Douglas can t11 erefo•·e be evacuated without difficulty by
incising t11e vagina in t11 e region of the posterior fomix. On
the contrary, t11 e uterovesical pouch is approach ecl wim dif-
ficulty from the vagina; first the vagina must be incised and
the n the bladder sepa rated fro m t11 e ce rvix a nd the vesico-
cervical space u·aversed before t11e ute rovesical fold of the
peritoneum is reac hed (Fig. 2 . 12A).
Ovary
Recto-uterine
fold
Recto-uterine
recess
Posterior part
of fornix
Cervix uteri
Rectal
ampulla
Anal canal
Long axis
of the
vagina
Retroversion

THE UTERINE APPENDAGES
The uterus projects upwards from the pelvic floor into the
peritoneal cavil) and carries on each side of it two folds of
peritoneum. which pass laterall) to the pelvic wall and fonn
the lmxulligammt.s. The fallopian tubes pass outwards from
the uterine cornua and lie in the upper border of the broad
ligamems. The ov;u·ian ligaments poste•·iorly, and the row1d
ligaments anteriorly, also pass into the ute•·ine cornua, but
at a slightly lower level than the fallopian tubes. Both
these ligaments and the fallopian tubes are covered with
peritoneum.
The round lig<1ment passes from the ute•·ine comua be-
neath the anterior peritoneal fold of the broad ligament tO
reach the intemal abdom ina l •·ing. In tl1is pan of its course
it is cu rved and lies immediately ben eath the peritOn eum,
and is easily distinguished. T he roun d ligament passes
down th e inguinal canal and finally e nds by becoming
adherent to tJ1e skin of the lab ia m"!jora . T he ligamen ts
co nsist of p la in muscle a nd co nnec tive tissue and vary co n-
siderably in tJ1ickn ess. T hey hypenro phy during pregna ncy.
T he roun d ligaments are much beu er developed in
multiparae tJ1an in null ipa rae. T hey are most remarkabl)'
h)'peru·ophied in the presence of large fibro ids whe n th ey
may attain a d iameter of I em. T hey correspond deve lop-
mentally to the gubernac ulu m testis and are morp ho logi-
cally continuous with tJ1e ovarian ligaments, as during
inu-auterine life the ovarian and round ligaments are con-
tinuoLLS and connect tJ1e lower pole of t11e primitive ovary
to the inguinal canal. The round ligaments are lax and,
except during labour, are free of tension. There is no evi-
dence that the nonnal position of anteflexion and amever-
sion of the uterus is produced b) conu-action of the round
ligaments. The ligaments, however, may be shonened by
opemtion or they may be attached to the anterior abdomi-
nal wall, both procedures being used to cause ameversion in
a utems which is pathologically retrovened. The round liga-
ments are supplied by a bmnch oftJ1e ov;u·ian anery de.-ived
from its anastomosis with the uterine anery, h ence there
is the necessity for ligation of tJ1e round ligamem du.-i ng
hysterectomy. Along it lymphatic vessels pass from the
fu ndus, which connect with those d raining t11 e labium
maj us into tJ1e inguinal glands. T his explains the possibility
of metastases in these gla nds in late cases of ca nce r of the
endome u·ium of the fun d us.
T he 111mrirm ligaments pass upwa rds and inwards fro m the
inner poles of tJ1e ova ri es to reac h tJ1 e corn ua of the ute n1s
(Fig. 2. 13) below the level of the au.achment ofLhe fallopian
tubes. They lie beneath the posterior pe riw neal fold of the
broad ligament and measure about 2.5 em in length. Uke
tJ1e ro und ligaments, they consist of plain mt.LScle fibres and
connective tissue, but they are not so prominent becat.LSe
tJ1ey contain less plain muscle tissue. They are morphologi-
cally a continuation of the round ligamem (contents of
broad ligaments are listed in Table 2.1 ).
l nfundibulopelvic ligament is t11at portion of the broad
ligament that extends from tJ1e infundibulum of tlle fallo-
pi;m tube to tJ1e late•-al pelvic wall. It encloses the ov;u;;m
vessels, l)lnphalics and nerYeS of tJ1e ov;u-y. The ureter is
also in a close contact and can be damaged dlll·ing clrunping
of this ligamenL
CHAPTER 2- ANATOMY OF FEMALE GENITAL TRACT 21
Gartner's duct Fallopian tube
Ovarian
fimbria
Ovarian ligament White line
R gure 2.13 The right uterine appendages viewed from behind.
Table 2.1 Contents of Broad Li gament
• Fallopian tube - upper portion
• Round ligament - anteriorly
• Ovari an ligament - posterior fold
• Vestigial structures of Wolffian body - epoophoron and
paroophoron
Vestigial structure of Wolffian duct - Gartner's duct
Ureter
uterine vessels
Pelvic nerves
Parametrial lymph node
Pelvic cellular tissue condensed to form Mackenrodt 's ligament
lnfundibutopellllc ligament
Mesovarium attaches tJ1e ovary to tJ1e poste•·ior fold of
peritoneum of tJ1e broad ligament and contains vessels,
lymphatics and ne•,es of the ovary. Mesosalpinx lies be-
tween tJ1e fallopian tube and tJ1e ovary and contains the
anastomotic vessels between the ovary and uterus and
the vestigial structures of tJ1e Wolffian body and t11e duct
(see section on T he Ovaries).
iFALLOPIAN TUBES
Eac h fa ll opian tube (Figs 2. 13 and 2. 1tJ ) is attached to tJ1e
uterine com u and passes outwa rds and bac kwards in th e
upper pan of the broad ligamem. T he fa llopian Lube mea-
sures 4 inch ( 10 em) or more in lengtJ1 and app roxi mate!)'
8 mm in diameter, but t.he d iameter d imin ishes near the
corn u of the uterus to 1 mm. The fallopian tube is divided
anatomically imo fotu· parts:
I. The irttentitiltl portion is tJ1e innermost pan of tl1e rube
which u-averses the m>ometrium LO open into tlle endo-
metdal cavil). It is the shortest part oftlle tube, its lengtll
being the th ick.ness of tJ1e uterine mLLScle, about 18 mm.
It is also the narrowest part, its intemal diameter being
I mm or less so tJ1aL only tJ1e finest cannula can be passed
imo it during falloscopy examination. There ru·e no
22 SHAW'S TEXTBOOK OF GYN AECOLOGY
Rgure 2.14 Laparoscoplc v iew of t he pelvis showing normal uterus
and bilateral adnexa. (Courtesy: Dr Marwah.)
longiwdinal muscle fibres here but the circular fibres are
well deve loped.
2. The comprises the nex t and inner part of the tube
and represents abo ut o ne-third of Lh e LOtal length, i.e.
35 mm. It is narrow but a li Llie wider than the in terstitial
part and its lumen has a diameter of 2 mm. Its muscle
wall contains both longiwdinal and circular fibres, and it
is covered by peritoneum except for a small inferior bare
area related to the broad ligament. It is relatively suaighL
3. TIU! ampul/it is tJ1e lateral, widest and longest part of the
tube and comprises rough I) two-tJ1 irds of the tube, mea-
suring 2.5-3 inch (60-75 mm) in length. Here me mu-
cosa is a•·borescem witJ1 man> complex folds (Fig. 2.15).
Fe•·tiliation occurs in tJ1e ampu llary portion of the
fullopian wbe.
4. The fimbriated e.\1rt'mity or infimdibulwn is where the
abdominal ostium opens into me pe•·iLOneal cavity. The
fimbriae are motile and almost prehensile, and e•"Uoy
a considerable r·a nge of movement and action. One
fimbria- tJ1e ovadan fimb1ia- is larger and longer than
Figure 2.15 Ampullary portion of fallopian tube to show arrange-
ment of plicae (x18) (COO'Iesy Dr Sancleep Mathu-, AIIMS.)
the others and is attached to the region of tJ1e ovary. This
fimbria embraces the ovar>• at ovulatio n, picks up t11e
ovum and carries it to tJ1e ampullary portion.
The fallopian tube represents the crania l e nd of the
Miille 1ian dueL and its lumen is continuous witJ1 t11e
of the uterus. Consequent!), spe•matoLoa and tJ1e fertilized
ovum can pass along the tube. Fl uids such as d)eS a nd gases
such as carbon dioxide may be injected mrough the ULerus
and by me way of tJ1e fallopian tubes imo me pe•·iwneal
cavity, and by mese means tJ1e patency of tJ1e fallopian tubes
can be investigated clinically by a d)e test (Fig. 2. 16). The
fallopian tubes lie in the upper part of me broad ligamen lS
and are covered witJ1 pedtoneum except along a tJ1in area
inferiorly, which is left bare by the reflection of the pe•ito-
neum to fom1 the two layers of tJ1e broad ligamenL The
blood supply of tJ1 e fa llopia n tube is main ly derived from
the tubal branches of the ova lian artery, but tJ1 e anastomos·
ing branch of the uterine artery s uppli es its inner parL Un-
like the vermiform append ix, the fa llopian tube does not
become ga ngrenous when ac utely inflamed, as it has two
so urces of b lood supp ly whi ch reac h it a t opposite ends. The
lymp ha tics of the fa ll opian tube communicate with tJ1e lym·
phatics of tJ1e fundus of the ULerus and witJ1 those of th e
ovary, and me)' drain along tJ1 e in fund ib ulopelvic ligament
to the para-aortic glands near tJ1e origin of the ovarian
artery from t.he aorta. Some drain into the pelvic glands.
The fallopian tubes have three layers: sero us, muscular
and mucous. The serous la)er consists of l11e mesotJ1elium
of tJ1e pedtoneum. Intervening between th e mesotJ1elium
and me muscle Ia) er is a well-<lefi ned subserous layer in
which numerous small blood vessels and lymphatics can be
demonsu"ated. The muscular la)er consists of ouLer lo ngiLu·
dina! and inner circular fibl'eS. The circular fibres are best.
developed in tJ1e istJm1us and are tJ1inned ouL near the fim-
briaLed ext.remity. The mucous membrane is thrown imo
folds or plicae. ear the isLhmus tlll-ee folds can be recog-
niLed, buL when t.raced lateJ'lllly they divide and subdivide so
thaL in t.he ampullary region mey become highly complex.
Each plica consisLS of su-oma which is covered by epitll e-
lium. The st.roma is cellular and its cells are in some ways
Figure 2.16 Fimbria! end of a patent fallopian tube. Dye test shows
spill.

similar to those of the endome u·iu m. T he b lood vessels of
t11e sLroma are plentiful and are parl.icularly well marked in
t11e ampullary region. The epithelium of the mucous mem-
brane consists of three t)'Pes of cells: t11e most common is
ciliated. and is either columnar or cubical in I:)'Pe. Its func-
tion is to propel a fluid currentLOwarcls the uterus and plays
some part in the u-anspon of the inen ovum which, unlike
t11e sperm, has no motile power of its own. ext in order of
frequency is a goblet-shaped cell, not ciliated, which does
not give the histochemical reactions for mucin. Its funclion
is lubricant and possibly nutritive to the ovum. A cell inter·
mediate in type to the two already mentioned can be d isti n-
guished, and small t·O<I-shaped cells are also presen L These
are the so-called peg cells whose purpose is not known. lL
has been possible to demonsLrate differences in the hisLO·
logical appeamnces of the epit11elium oft11e fallopian tubes
during the mensu·ual cycle. T he hyst.erosalpingogram, sOJwsal-
fJiugogrmn and litparo:.tojJic chro11wtubation are t11e clinical
me tl1ods of testing tJ1c patency of tJ1 e fallopia n tubes. Lapa-
roscopy also ide nti Fies ex te rnal tubal adhesions.
THE OVARIES
Eac h ovary we ighs 4-8 g and measures abo ut 35 mm in
lengt11, 25 mm in width and 18 mm in thickness. The ovat)'
(Figs 2 .11 and 2. 17) is almond shaped, pearly grey d ue to
a compact tunica a lbuginea, and tJ1e surface is slightly cor-
rugated. Before pubert), the ovaries are small and located
near t11e pelvic brim. After menopause t11ey aLrophy and
become shrunken and t11e grooves and furrows on ilie
surface become well marked. The menopausal ovary mea-
sures 20 mm X 10 mm X 15 mm witJ1 a volume of8 mL or
less. An ovaq larger than this as measured ullrasonically is
Paroophoron Epoophoron
(distal tubules of (proximal tubules of
the mesonephros)
the mesonephros)
; 1 - - - Gartner's duct
(vestigial remnant)
Fig ure 2.17 Remnants of the mesonephric (Wolffian) ducts that may
persist in the anterolateral vagina or adjacent to the uterus within the
broad ligament or mesosalpinx.
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 23
of great concern in menopausal women. The ovary is at-
tached to t11e back of the broad ligament by a th in mesen-
tery, t11e Latet<lll), t11e ovat)' is related LO t11e
fossa below the bifurcation of the common iliac artery and
t11e LLreter. Medial I), it is close to t11e Fimbria of t11e fallo-
pian tube. which sLretches over it around ovulalion. It is
attached to the com u of the uterus by the ovarian liga-
ment. The inflUlCiibulopelvic ligament is the outer bordet·
of the broad ligament and contains tlle ov:u·ian vessels,
nerves and l)lnphatics. The ov:u·ies are not nonnally palpa-
ble during bimanual examination, but cause pain on LOudl.
The epoophoron, also known as the organ of Rosenmiiller,
represents the CJ-anial end of tlle 'v\'olffian body. It consistS
of a set·ies of vet·tical tubules in t11e mesovarium and meso-
salpinx between t11e fallopian tube above and t11e ovary
below. Each wbule is surrounded by pla in muscle and is
lined by cubical cells.
T he paroop horon represe nts t he caudal end of t11 e
Wolffi an body and similarly co nta ins ve n.i cal tubules. It
so metimes forms pa raovarian C)'SL.
T he Wolffoan duct (Ga rt ne r's duct) is an impe rfec t d uct
which runs parallel to, but below, tJ1e fa llopian wbe in t11 e
mesosalp in x. T he d uct passes downwa rds b)' tJ1e side of t11 e
uterus LO the level of the irHernal os whe re it passes into
the tissues of t11e ce rvix. It tJ1en runs fo rwards to reac h me
amerolateral aspect of the vagi nal wall and may reac h as far
down as t11e hymen. The duct some Limes forms a cyst, called
Gartner cyst, in ll1e broad ligament or in the vagina, and
may need surgical enucleation (Fig. 2. 17). HistOlogy of t11e
ovary is described in Chapter 3.
THE URETHRA
The urethra measures 35 mm in length and 5-6 mm in
diameter. It passes downwards and forwards from the base
of the bladder behind the S)lnph)Sis pubis to end in the
external meatus. lts epithelial lining consists of squamous
epithelium at the extemal meatus, bm becomes tran si-
tional in the canal. Deep to the epit11elium is a larer •·ich
in small vessels and connective tissue. Th e urethral wall
comprises inner longiwdina l and outer circul at· involun-
tary mt.LScle fibres, which arc arra nged as crisscross spirals.
T he lo ngitudinal Fibres co ntract and sh on e n t11 e ure tl1ra
du ring mi cturiti o n. T he o ute r circular Fi bres keep the in-
te rnal sphincter closed.
T he nec k of tJ1e bladde r (inte rnal urethral sph incte r)
lies above ll1e leva to r an i muscles and thus maintains t11e
co ntin ence of urine b)' receiving the sa me abdomina l p res-
sure as the b ladde t: T he b ladder base fo tms an angle of
100• with t11e poste tior ure tJua l wall (poste rior urethrovesi-
cal angle), wh ich is also respo nsib le for ma in taining utin at)'
continence.
RELATIONS
Postedorl). upper portion of the urethra is loosely con-
nected to the vagina b) 'esicovaginal fascia and can be
dissected easil). In its lower one-third, it is finnly auached
LO the vagina by pubou•·etht-al ligament and requires a
sharp dissection. Laterally, it is surrounded by tlle areol:u·
tissue, the compressor uretht-a and the supe t·Ficial perineal
24 SHAW'S TEXTBOOK OF GYN AECOLOGY
muscles. PuboureLhral ligament fixes the mid- urethra to
t11e pubic bone and Lhe lateral pelvic wall and maintains
continence of urine. Anteriorly, t11e uret11ra is separated
from the pubic bone b) Lhe areolar tissue.
The external urinal") meaLus lies in t11e vestibule, 2 em
below the clitoris and is part!> concealed by t11e upper end
of the labia minora. umerous periuretl1ral glands sur-
round tl1e urethra and open b) till)' duelS into iiS lumen.
These are analogues of Lhe prosLaLe in males. The paraure-
mral glands of Skene are imporLanL paired glands which lie
alongside me floor of Lhe urethra and open by tiny duelS
close to me external meatus. The glands when infeCLed
form periuretlual abscess and cysiS.
The proximal tu·etlwa derives blood supply from me
inferior vesical anery and distal uret11ra from in temal puden-
dal ane•l'· The veins drain into t11e vesical plexus and intemal
pudendal vein. T he uretlwa is innervated by the internal
pudendal nerve. T he uretlwa is developed from the cloaca.
T he proximity of tl1e uret11 ra to the vagina makes it
suscep ti ble to infection sp reading from the lower ge niLal tract.
T he commonest infec ti ve orga nisms are N. go norrhoea, Chla-
m>•dia u-ac homatis and trichomonads. T he ure t11ral swab,
cultw·e and uri ne can iden ti fy Lhe o rganisms.
THE BLADDER
The bladder is a smooLh muscle organ witl1 a body and a
trigone. It lies between Lhe spnphysis pubis in from and t11e
uterus behind, being separated from tl1e uterus by t11e
uterovesical peritoneum. It is a pelvic organ with a capacity
to hold 500-600 mL of urine. The bladder distends upwards
with a fixed base at tl1e Lrigone, and t11en becomes palpable
abdominal!).
The bladder has an apex, a base, a supe•·ior and L\1'0
inferolaLeral surfaces. The neck of the bladder (internal
Ulinary sphincter) lies abo1e the ani muscles, so
mal me raised abdominal pressure transmitS me pressure
equall)' Lo Lhe bladder and itS neck, hence mainLaining uri-
nal")' cominence dur-ing coughing and sneezing. Ameriorly,
lies tl1e cave of Reuius (t'Cu·opubic space). Posteriorly, iLis
in proximity to tl1e uterus and supt·avaginal portion of the
cervix, sepamted from them by t11e uterovesical pouch of
peritone um.
T he ureters en ter tl1e bladde r obliquely, and t11e area
be tween tl1e ure te ric openin gs and the inte rnal urinar y
sphincter fo rms a fixed tri angular a rea called u·igo ne. T he
apex is co nti nuo us witl1 tJ1e urac hus.
T he b ladder receives b lood suppl)' from the s uperior and
inferior vesical arteries, and the pub ic branc h of the infe rior
epigastric anery. T he venous plex us drains in to in te m al
iliac vein. T he lymphatics dra in into interna l and extemal
iliac glands.
NERVESUPPLY
The spnpathetic outflow is from first and second ltunbar
segmeniS of tl1e spinal cord which inhibiiS conu-act.ions of
me detrusor (bladder) mtLScle and main Lains internal
sphincteric contraction. The pa•-as)lnpathetic outflow from
52, 53 and 5 I stimulates tl1e detnLSor muscle and relaxes tl1e
internal sphincter, tlnLS initiating micw•·ition. The sensory
nerve fibres reach the cenu·al nervous system via the
splanchnic nerves (p<11<1S)1npathetic S2-S4). The somatic
afferent fibres travel witl1 S)'lnpathetic nerves via hypogasu·ic
plextLS and enter the first and second lumbar segmentS of
tl1e spinal corcl The bladder wall is lined by u-ansit.ional
epimelium. which gets folded when empty but allows blad-
der distension. The lining membrane of 1he trigone is fixed
1.0 the muscle wall. The mtLScular coat of t11e bladder is com-
posed ofsmoom muscle kno11n as deu·tLSor. The neck oftl1e
bladder (internal Ulinarysphincter) is suiTounded by circu-
lar muscle fib•·es.
THE URETERS
£vel")' gynaecologist should be fam iliar witl1 t11e anawmy of
the pelvic portion of tl1e UI'Cter, as iflj u ry ca n occu r el uti ng
pelvic s urge •/'· T he 1u·eter needs to be dissected d l.lling
Wertheim 's hys terec tomy for ca ncer of tl1e ce rvix. T he ure-
ter may run in a close re latio n to tl1 e broad liga ment cyst
a nd myoma.
T he pelvic poni on of tl1e ureter is 13 em lo ng a nd 5 mm
in dia me ter. It passes over th e b ifurcatio n of 1.h e co mmo n
iliac artel")• and ru ns downwards and fo rwards in the ovar-
ian fossa deep to the peritoneum, where it e me rs the true
pelvis at tl1e brim, it is crossed by the ovarian vesse ls, and
on tl1e left side the mesosigmoid is an anterior relation. In
this sitLtation, tl1e obturator vessels and nerve lie laterally,
and tl1e h)pogastric lymph nodes are closely related. The
cottrse of tl1e ureter is then dowmvards and forwards
immediately beneatl1 tl1e peritoneum to which it is always
closely atLached.
O n the pelvic floor, the ureter pierces MackenrodL's
ligament where a canal, the Lu·ete•·ic canal, is developed. IL
is necessary that the ureter mLLSL have room for normal
peristalsis without any pressure from me SUITOundingsu·uc-
Lures, and the ureteric canal protects me ureter from t11e
outside pressure. In its passage through me urete•·ic canal,
the ureter is crossed by 1he uterine aner)' above and t11e
uterine plexus of veins below, thus being forked between
the uterine vessels. After leaving the ureteric canal, t11e
ureter passes fot·wards and mediall y LO reach t11 e bladder,
being separated from tl1e cervix by a disLa nce of 1-2 em
(Fig. 2. 18). T he co urse of the ureter thro ugh the pelvis is
not always consta nt. At ope ratio n, t11 e ureter is recogn ized
by iiS pale gliste ni ng appea rance and by a fine lo ngitud inal
p lexus of vesse ls o n its surface, b ut mo re parti cula rly b)' its
peristalti c move men ts. It can also be recognized by palpa-
tion between the fi nger and th e thu mb as a firm co rd,
which, as it escapes, gives a characteristic snap. T he ureter
is rare ly d up licated. In advanced stage of cancer of th e cer-
vix witl1 extensive involvement of the parame u·iu m, su·ic-
ture of t11e ureter causes hydronephrosis and uraemia.
The ureter derives its blood supply from the common,
external and internal iliac arteries in addition LOa consLam
vessel from the uterine and inferior vesical anery. The ves-
sels fo1m a longitudinal anastomosis up and down me ure-
Ler which protects the ureter from ischaemia if one vessel is
ligaLed or i•'\iured. Howe. er, damage of seveml small vessels
can cause avascular necrosis and urete•·ic fistula. TI1e small
branches of tl1e renal a•·teL}' also suppl)' blood LO me ureLer
above the peh·ic brim.

External iliac
artery & vein
Obliterated ----...1
umbilical and sup.
vesical artery
Obturator nerve
Obturator
Inferior
epigastric
artery
Round
ligament
Figure 2.1 8 Relation of the ureter to the pelvic vessels in the ovarian fossa.
Th e b lood supply to iJ1e pelvic ureter is principally from
ilie lateral side, and iJ1e urete ric d issec tion sho uld be done
along iLS medial side.
The ir"tiury to iJ1e ureter occurs at the infun dib ulopelvic
ligament on the lateral pelvic wall, in iJ1e ureteric canal
when the Ulerine vessels are ligated, near the internal cervi-
cal os and near the uterosacralligamenL It is imponam w
identif) the ureter during WeriJ1eim hysterectomy, broad
ligamem nunour dissection and while ligating the imernal
iliac anef).
The l)lnphatics drain intO intemal and extemal iliac
glands. The S) mpaiJ1etic nerve supply comes from hypogas-
tric and peh·ic plexus; paraS) mpathetic from sao-a I plexus.
THE RECTUM AND ANAL CANAL
The rectwn is the continuation of the pelvic colon and lies
in the pelvis at the level of third sacral vertebrae. It mea-
sures 12-15 em and co ntinues as anal canal. It is covered
anteriorly and latera ll y by pelvic peritOneum which forms
iJ1e posterior s urface of the pouch of Douglas. Lower down,
it is in a close contact wiiJ1 the posterior vaginal wall, sepa-
ra ted by rec tovaginal septu m. The a nal ca nal is separated
from the lower one-third of posteri or vagina l wall by the
perineal bod)'· Poste tiorly, it lies close to the sac rum and
coCC)'X wi iJ1 loose a rt icular tissue, middle sacral anery and
pelvic nerve p lexus. Lmemlly lie the two uterosacral liga-
menLS above and levator ani muscles below and ischiorectal
fossa. The rectum is surrounded by rectal fascia. The ana l
canal measures 2.5 em. Anteriorly, it is related to the peri-
neal body and posteriorly to iJ1e anococcygeal body. It has
two sphinCLers: (i) irwoluntal") intemal sphincter in the up·
per two-thirds and (ii) voluntary external sphincter sur-
rounded b) puborectalis muscle of the levator ani muscle
below.
The rectum and anal canal receive ilie blood supply from
(i) superior rectal br-anch of imerior mesemeric artery
and (ii) midcUe and inferior rectal branches of internal iliac
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 25
Internal
Iliac artery
'--1-__:::,.__ Obturator
lnternus muscle
artery. The rectum and upper one-third of anal canal drain
via superior rectal veins into ponal circ ula tion. Lower one-
third portion of anal canal drains in tO inferior rectal vein
(systemic ci1·culaLion).
THE LYMPHATICS
The rectum and upper one-iJ1 ird of anus drain in tO imen1al
iliac and preaortic I) mphatic nodes. Lower one-third dr-ains
imo superficial inguinal I) mph nodes.
AutOnomic pehic plexus innerYates iJ1e recwm and up-
per portion of iJ1e anal canal. The lower por·tion of the anal
canal is innenmed by the inferior haemont10idal ner\'e.
The rectum and upper two-thirds of ilie ana l canal develop
from ilie dorsal portion of the cloaca. The lower anal canal
is derived fi·om ectodenn.
THE PELVIC MUSCULATURE
T he pelvic muscles of importance in gynaecology are those
of the pelvic floor. T hese muscles are grouped into three
layers: (i) those of the pe lvic d iap hragm, (ii) iJ1ose of th e
urogenital di ap hragm and (iii ) iJ1e superficial muscles of
the pe Ivic floor.
PELVIC DIAPHRAGM
The pelvic diaphragm consists of two levator an i muscles.
Each levator ani muscle co nsists of iJHee main d ivisions: the
pubococcygeus, tl1e iliococcygeus and iJ1e ischiococcygeus.
The pubococcygeus muscle arises from the posterior sur-
face of the bod) of iJ1e pubic bone and passes backwards,
later-al to the vagina and iJ1e rectum, to be inserted into tl1e
anococc)geal raphe and into iJ1e COCC)'X. The inner· fibres
which come together posterior to iJ1e rectum are known as
the puborectalis ponion of the muscle: the)' sling up and
support ilie rectum. Some of the inner fibres of the pu-
borectalis fuse wiili the outer wall of the vagina as they pass
26 SHAW'S TEXTBOOK OF GYN AECOLOGY
lateral to iL Other fibres decussate between the vagina and
t11e rectum in tl1e siwatio n of the perineal body. These de-
cussat.ing fibres divide the space between t11e two levatOr ani
muscles in to a n amerior portion, tJ1e hiatus uroge nitalis,
mro ugh which passes t11e urethra and vagina, and a poste-
•ior portion. the hiaws rectalis, t11rough which passes the
recttLm. The dimensions of the hiaLUs uroge nitalis depend
upon two main factors: the tone of t11e levator muscles and
me existence of tlle decussating fibres of me puborectalis
muscle.
Pe1ineal tears occtu·•·ing during panu•·ition divide tltese
decussating fibres, causing the hiatus urogenitalis to become
patulous and lead to prolapse. In visceroptosis and asmenic
states, tlte levator muscles become lax, tlt e dimensions ofthe
hiatus urogenitalis are increased and there is a tendency for
t11e pelvic viscera to p•·olapse. The iliococcygeus is a fan-
shaped muscle a !ising from a broad o rigin along the white
li ne of tl1 e pelvic fascia and passing backwards and inwards
to be inse•ted into tlte coccyx. T he isc hi ococcyge us or coc-
cyge us muscle has a narrow o rigin from t11e isc hial spine and
spreads o ut posteri ori)' to be inserted into tlte front of the
coccyx (Figs 2. 19 and 2.20).
T he leva tor muscles toge t11 er co nstiune the pelvic dia-
phragm and support the pelvic viscera: co nu·action of the
levatOr muscle p ul ls th e rec LUm and vagina towards me sym-
p hysis p ubis; the recwm is thereby kinked and closed, and
tlte vagina na11·owed ante roposte rio rly. T he origin of the
levatOr muscle is faxed because the muscle arises ante1iorly
eitJ1er from bone or from fascia which is attached LO ll1e
bone; posteriori) the insertion is e itJ1er imo me anococcy-
geal raphe or into the COCC)'X, botl1 of which are moveable.
It follows tl1atthe conuaction of t11e levator muscles leads to
t11e poste•·ior attachments being pulled wwards ll1e S)1nphy-
sis pubis. The movement of the intemal rota tion of the
presenting part during panurition is assisted by ll1is prop-
erty of me levator muscles. Ute•ine contracti ons push the
presenting pan down upon the le,>ator ani (pelvic floor)
and cause the muscles to contract as a result of tlte direct
pressu•·e of tlt e presenting part. The lowest pan of the fetus
is carried forwards during t11e contracti ons of the levator
muscles, and as the anterior fibres of the muscles are
Obturator lnternus
lllococcygeus 4----"7' - - - -
White line
Figure 2.19 The muscular peMc floor seen from above alter the removal of the pelvic viscera and pelvic fascia.
directed inwards as well as fo rwa rds, t11 e presenting part
rotates forwards and inwards.
The superior and inferior surfaces of tJ1e levatOr muscles
are covered by the pelvic fascia, which separates t11e muscles
from t11e cellular tissues of t11e parametrium above and from
the fibrous and fat!) tissues of t11e ischiorectal fossa below.
UROGENITAL DIAPHRAGM
The urogenital diaphragm is also called the u·iangular liga-
ment. It is not so well de,eloped in me female as in tlte
male. It extends from the pubic arch anteriorly to t11e cen-
tral point of the pe.-ineum posteriorly a nd consists of two
layers of fascia tltrough which pass t11e vagina and t11e ure-
thr-a. The central point of the female perineum lies be-
tween the vagina and th e rccwm. Within t11e two fascial
layers of th e urogenita l diaphragm lies the deep transverse
perineal muscle, whi ch ex te nds latera ll y o n each side to
reac h t11 e ramus of the pubic bone. This muscle is so poorly
developed th at it is diffi cult to dissec t in anatom ical speci-
mens a nd needs a specia l histological tec hnique for its
de monstratio n . Its functiona l significa nce is dubious. The
s triped muscle or vo lu ntary sp hincter of the urethra also
lies between tl1 e two la)'ei'S of the u·ia ngular ligame nt.
SUPERFICIAL MUSCLES
FoLu· muscles are ide ntified in tl1is layer. The external
sphincter mLLScle of t11 e anus is aLtac hed anteriorly to Ute
cenual point of the perineum and su•To unds the antLS.
The bulbospongiosus muscle, or as it is sometimes called
the sphincter vaginae, extends from the central point of the
pe1inewn along each side of t11e '>agina to be attached ame-
.-iorly to the S) mph) sis pubis. It lies arou nd and lateral to the
urethml bulb. The ischioca,ernosus exte nds on each
side of me ischial tuberosity in •-elatio n to me cmra of ll1e
clitOris to reach it in the midline. The supe•·ficial u-ansverse
muscle of me perineum passes late•-ally on each side from the
central point of the perineum to the pubic mmus (Fig. 2.21 ).
Deep to mese superficial muscles and between them and the
infelior la yer oftlte ligament lie t11e vestibular bulb
and tlte greater vestibular glands of &1rrlwlin.
 CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 27

Fallopian tube

Obturator internus muscle

.......__ _ _ _ ___ Superficial perineal pouch

Rgure 2.20 Anatomy of the pelvic floor in coronal section.

Subpubic angle

Body of clitoris - - -- - - - -,.---_., , - - - -- - - - Ischiocavernosus muscle

Glans of clitoris -- - - -+--...

Crus of clitoris - - - - -- -,.<.._;

Bulb of vestibule - -- - -.,L---,1£, muscle

Perineal membrane ------,-.4----J Perineal muscle

transverse
muscle

Perineal body

Anus
' -- - - Sphincter ani
" - - - - - Levator ani
Anococcygeal body
' - - - - - - Gluteus maximus
Coccyx
Figure 2.21 The perineum.
28 SHAW'S TEXTBOOK OF GYN AECOLOGY
The perineal body intervenes between the posterior vagi-
nal wall and the anal canal. It is pyramidal in shape with itS
apex on a level with the j unclion of 1J1e middle and lower
thirds of the posterior vaginal wall. The three layers of the
muscles of the pelvic floor are represented in the perineal
body, and the intenening lissue consisli ng offatand fibrous
lissue. Superficial!), passing from the ce ntral point of the
perineum are the external sphincter of the anus, the bulbo-
spongiosus and the superficial transverse muscle of the
pe.-ineum. Deep to this la)er lies the fascialla)er of the uro-
genital diaphragm (triangular ligamem) enclosing the deep
transverse nntSCle of the perineum. Deeper still, the pelvic
diaphragm is represented by the fibres of the levator ani
muscl es which decussate between the vagina and the rec-
tum. The perineal body is exa mined by inspeclion and by
palpation. Two fingers arc placed in the vagina and flexed
laterally; the thumb being applied externally over the
labium majus, the leva tor muscles ca n be palpated with a
remarkable ease and the si:.te of the hi a tus urogenitalis can
be assessed . On asking the palient to co nu·act her pelvic
floor muscles, tl1e LOne of these muscles ca n be estimated.
Pro lapse of tl1e ge nita l tract. stress inco nlinence of
urine and faecal inconlin c nce a re all re lated LO laxity and
aton icity of the muscles of th e pe lvic floor as well as dener-
vation of pelvic ne rves d uring childbirth. Late ly, perineal
ulu·aso und and M Rl have grea tly im proved o ur knowledge
of these supportive su·uctures in maintaining the uterine
position and co nLinence of urine a nd faeces.
THE PELVIC CELLULAR TISSUE
The pelvic cellular lissue consistS of loose areolar lissue
which imenenes between tJ1e peh·ic pe•itoneum above and
the peh·ic fascia below. It is conlinuous with the subperito-
neal connecti,·e tissue and witJ1 the loose lissue of tl1e peri-
nephric •·egion. The areolar tissue is loose, and when
inflamed in the condition of pelvic cellulilis it may lead to
the form ation of a palpable swelling. As tl1ere is a direct
continuation between tJ1e pe•inephric and pelvic cellulru·
tissues, effusions a.-isi ng in eitJ1er of these situalions may
u-ack to point as an abscess in tJ1e other. In tl1e pelvis, the
pelvic cellular tissue is bo unded above by the peritOneum
and below by tl1e fascia which covers the upper surface of the
levator an i muscles. Late rail )' it is bounded by tl1 e pelvic wall,
mainl y by the fascia whi ch cove rs tJ1 e inner surface of the
obturator internus whereas mediall y it comes in tO contact
with tl1e uterus and th e up pe r part of the vagina.
T he paraiiU!trium is tJ1at part of the pelvic cellular tissue
which surro unds tl1 e uterus. It is b)' definition extraperito-
neal and is most plenlifu l on eac h side of tl1 e uterus below
tl1e level of the internal os. The e ndopelvic fascia in this
region thickens to form ligamento us s upportS called Mack-
enrodt Above tll is level, the presence
of the broad ligamentS reduces the amount of pa•-ame-
t.-iLUn to a minimum. It should be remembered that the
level of the levator an i muscle is well below the level of the
ce•·,-ix. being more than halfwa) down the vagina. The pel-
,.jc cellular tissue is usuall) ve•') plen liful o n each side of
the vagina, where it is called pa•-avaginal cellular lissue or
paJ-acolpos.
A distinction is drawn between the pelvic fascia and the
endopelvic fascia. The pelvic fascia co nsistS of tl1e dense
connective tissue which covers tJ1e surfaces above and below
the levator ani and the obturator inte rnus muscles. On the
contrary. the endopelvic fascia forms the connective tissue
cove1ings for tl1e vagina, tJ1e sup•-avagina l ponion of the
cen-ix, 1.he uterus. the bladder, the uretJ1ra and the rectum.
In addjtion, condensed bands of e ndopeh.jc fascia pass
from these mo,·eable organs to tJ1e back of the pubic bones,
to the lateral walls of tl1e pelvis and to the from of the sa-
crum. The function of tl1e endopelvic fascia is pan.ly to
convey blood ' 'essels to the pelvic o•·gans and panly 1.0 sup-
pon tl1em. Be1.ween tl1e different tarers of t11e endopelvic
fascia are bloocUess spaces which are imponam 1.0 identify
in vaginal plastic ope•-ations. The term pelvic cellular tissue
should be restricted to cellular tissue wh icl1 intervenes be-
tween tl1 e differe nt layers of tJ1 e endopelvic fascia and
which lies between the peritone um above and tl1e u·ue pel-
vic fascia below.
Anteriorly, the b ladde r is cove red by an e ndopelvic fas-
cial layer called the vesical fascia, whereas be hind it lie the
vagina a nd the supravagina l portio n of the cervix covered
by 1.heir own enclopelvic fasc ial layers.
lmmediaLel)' behind the ute rus and vagina, tl1e perito-
neum which covers tl1e back of tJ1e ute ms and tl1e posterior
vaginal fornix red uces the pelvic cellular lissue to a mini-
lllLUll in tl1ese situations. Deep to tJ1e uterosacral folds of
peritoneum the endopelvic fascia is plentiful, and here it is
condensed to form tl1 e uterosacral ligamentS which pass
backwards and upwards from the uterus in the from to
reach the sao·um lateral to the rectosigmoid. The uterosac-
ralligrunen tS help to support tJ1e utenLS a nd prevent it from
being forced down b) inu-aabdominal pressure. By their
wne tlle)• also tend to pull back tJ1e cervix and tl1ereby aJ1-
teven the ULerus. Plain muscle fibres can be demonsu-ated
in them. They contain S)lnpatlletic and
nerves. Mackenrodt's ligamentS, similar to uterosacral liga-
ments, help 1.0 suppon the uterus and prevent it from being
forced down when tl1e intraabdominal pressure is raised.
The)' are composed almost entirely of conneclive tissue and
contain very liule plai n muscle (Fig. 2.22).
A third and equally important pan of tl1e supporting
mechanism of tl1e pelvic viscera is tJ1 e p ubovesicocervical
Vesicocervical
space
Paravesical
space
- --+-r+t- Rectovaginal
space
.,/,,t-.::;::::_ Pararectal
space
Retrorectal
space
fascia
Figure 2.22 The pelvic cellular tissue shown in the cross-section of
the pelvis.

fascia or the pubocervical fascia. This is a condensation of
tlte endopelvic fascia which passes from tlte anterolateral
aspect of tlte cervix to be attached to tlte back of tlte pubic
bone lateral to tlte symphysis. Some of its cervical attach-
ment fans out lateral!) and imperceptibly into the lt'ans-
verse cervical or Mackenrodt's ligament. It can, merefore,
be regarded morphological!) and functionally as a pan of
tltis structure.
If Fig. 2.22 is studied, the suppons of me uterus and the
bladder are seen to be triradiate condensation of
fuscia:
I. The anterior spoke is the pubocervical fascia or so-called
pubocervical ligament.
2. The lateral spoke is Mackenrodt's ligament.
3. The poster·ior spoke is the uterosacral ligamenL
All these three embrace and insen imo the cervix and,
when in tact, operate on it suc h as t11e strin gs of a hammock,
preventing desce nt. If one o r two su·ings are torn, t11 e co n-
tentS of t11e ha mm oc k prolapse with resulting descent of the
bladder and t11e ute rus.
The endopelvic fasc ial tissue contains tlt e uterine arter-
ies and veins, toge ther with the venous plex us aro und the
cervix and the la teral fornices of the vagina. The lymphat-
ics from tlt e upper two-thirds of the vagina and from the
uterus, the ovaries and the fa llopian tubes also pass through
tlte pelvic cellular tissue. On each side of the uterus tltere
is sometimes a small inconstant lymphatic gland known as
tlte gland of tlte parametrium, about the size of tlte pin's
head. near the ureteric canal. The tHeter passes mrough
me parametrium' ia the ureteric canal in an ameroposte-
lior direction, about I em lateral to t11e tO reach the
bladder. It passes below the level of me utet;ne \'essels,
which cross it as they nut transversely mrough the tO
reach the uterus. S)mpathetic nen•e ganglia and nen·e fi-
bres are plentiful in the parameu·ium (Frankenhauser's
plexus).
In the condition of parametritis, tlte parametrium is
inflamed and thickened. Rarely a large swelling forms
which extends as far down as the fascia covet·ing the leva-
Lor ani muscles, and mediall y it comes d irectly into contact
witlt t11 e uterus and the upper pan of t11e vagina. Laterally
it extends as far out as the pelvic wa ll. Posteriorly it ex-
tends along th e ute rosac ral ligamentS in a close relation to
t11 e rectosigmoid. Suc h a swelli ng may trac k upwards
out of the pelvis to reac h the subpe ri wneal tissues of t11 e
iliac region whe n the effus ions may point above Poup art's
ligament latera l tO tlt c g reat vesse ls. In o t11 e r cases, the
swelli ng may trac k upwards to the perinephric region. In
advanced cases of carcinoma of the ce rvix, the cancer cells
infilu·ate the parametrium when they spread e ither later-
ally along Mackenrodt's ligamentS or posteriorly along the
uterosacral ligaments. Clinically, infiltration oftlte parame-
trium is detected by determining the mobility of tlte cervix
and the bod) of the uteniS, b) palpating in the situation of
Mackenrodt's ligament through the lateral fornix of the
vagina and b) examining the uterosacral ligamentS by rec-
tal examination. The fibrosis resulting from chronic para-
meu·itis causes chronic peh·ic pain and uretet·ic obstruction
(Table 2.2).
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 29
Ta ble 2.2 Supports of the Genital Organs
Levell uterosacral ligaments and ca-dinalligaments
support the uterus and vaginal vault
Level II Pelvic fascia and pa-acolpos which connect the
vagina to the white line on the lateral pelvic
wall through arcus tendinous
Level Ill Levator ani muscles support the lower one-third
of vagina
THE PELVIC BLOOD VESSELS
The ovarian aneries atise from t11e aona, just below me
level ofthe rena l aneties. They pass downwards tO cross first
the ureter and t11 en t11 e external iliac anet)', and tlt en mey
pass into t11e infundibulopelvic fold. T he ovarian artery
sends branches to the ovaries and tO tlte o ute r pa tt of t11 e
fallopian tubes; it e nds b)' anastomosing witlt tlt e terminal
part of the ute rin e artery after giving off a branch to t11 e
corn u and one to the round liga ment.
Internal iliac artery is one of the b ifurcations of the com-
mon iliac a11.ery. lt is 2 ern in le ngth. T he ureter lies anterior
and the internal iliac vein posterior to it. lt d ivides into an
anterior and a posterior branch. The anterior branch sup-
plies the pelvic organs. In obstetric and gynaecological
surgery. profuse haemorrhage is conu·olled by ligating tlte
internal iliac arte11 on the either side. During tllis proce-
dLLre, the anterior relation of the ureter to the artery should
be remembered and injut') to the ureter avoided.
The uterine artery arises from t11e anterior tnmk of me
internal iliac (or h)pogastric ane•1 ). LLS course is at first
and fon,•;utls until it reaches the parameu·iwn
when it turns medially towards the uterus. It reaches tlte
ULerus at the Je,el of t11e internal os, where ittut't\S upwards,
at right angles, and follows a spiral course along tlte lateral
border of t11e uterus to the region of the uterine cornu;
here it sell(ls a branch to supply t11e fallopian tube and ends
by anastomosing with tlte ovarian artery. The tOrtuosity is
lost when tlte uterus enlarges during pregnancy. During t11e
vertical pan ofiLS course, it sends branches whi ch run u·ans-
versely and pass into the myometrium ( Fig. 2.23). T hese are
called t11 e arcuate a rte ti es and from t11em a tises a series of
radial arteries almost at right angles. T hese rad ial arteries
reach the basal layers of the endometrium where t11ey are
termed as t11 e basal a ttelies. From these the te nnina l spiral
and su·aight arterioles of tJt c e ndom etrium are derived. T he
least vascu lar pa rt of t11e uterus is in the mid line. T he vagi-
nal branch of the uterine anery arises before the utetine
artery passes vertica lly upwards at tJt e level of the internal
os. lt passes downwards tlHough the parameu·ium to reach
tlte vagina in tlte region of tJte lateral fornix. This descend-
ing vaginal artery is of great importance during t11e opera-
tion oftotal h)sterecLOm) because, ifnotseparatelyclamped
and Lied. it ma> lead to dangerOLIS operative haemorrhage.
The arcuate arteries that suppl) the are sometimes
called me circular artet') of tJ1e cervix. From these or me
descending vaginal branches the ante t·ior and posterior
U)gos atteties of me vagina are de•·ived (Fig. 2.21).
30 SHAW'S TEXTBOOK OF GYN AECOLOGY

The relation of tl1e uterine anery to the ureter is of great

Rgure 2.23 The uterine artery and its branches In t he uterus.
T he fo ll owing are the branc hes of the ute rine artery:
o Ure te ri c
o Descending vagina l - these unite to fo rm th e ante rior
and posterior azygos artery of t.he vagina
o Circ ular cervical
o Arcuate-+ rad ial -+ basal -+ spira l and straight arterioles
of tl1 e functional layer of the endo metrium
o Anastomotic with tl1e ovarian anery
importance. The uterine anery crosses above the ureter in
the parameLJ'ium where it gives off an importam ureteric
branch to tl1at su·ucture. The anery runs u-an sversely
whereas tl1e ureter runs approximately ameroposteriorly
tlu-ough tl1e ureteric canal of the parameLrium.
Middle sacral artet') is a single anery wh ich arises from
the terminal aorta. It descends in the middle of ll1e lumbar
vertebra and tlle sact'\tm to the Lip of the coccp:.
There is an extenshe network of collatera l connections
in the pelvic anel'ial vasculature that provides a r·ich anasto-
motic communication between major vessel systems. This
degree of communication is importam to ensure adequate
suppl )• of ox)gen and nutl'ients in the event of major u-auma
or· other vascular compr·omise. Hypogastric (imemal iliac)
anery ligation continues to be used as a su-ategy for the
managemem of massive pelvic haemorrhage when other
measures have fai led. Bilate r-al h ypogasu·ic anery ligatio n
effectively reduces p ulse pressure in tl1e pelvis, co nve rting
flow characteristi cs from that of an an erial LO a venous sys-
tem and a ll owing collatera l chan nels of circul ati o n to pro-
vide with adeq uate b lood suppl y to the pelvic su·uctures.
T his function is best illusu·a tccl by the examp le of preserva-
tion of reprod ucti ve functions, fo llowed b)' successful preg-
nancies occuning afte r unclenaking th e lifesaving opera-
tion of bilateral ligation, of both hypogastric and ovarian
ar'\eries for unconLro lled ato nic PPH after de livery. Details
of collateral circulation are given in Table 2.3.

From posterior trunk of

Internal iliac artery

_,---Anterior trunk of
internal iliac artery

. - - - - Inferior gluteal
ar tery

rectal
Right urete r ---+--.;....- - - - - - - -- ....,.:'11 ar tery
Internal pudendal
ar tery

Uterine artery _ _ _ _ _.....,-

Umbilical artery _ _ _ _..../
Vaginal artery----"'
Obturator artery - - - - '
Superior vesical artery

Ftgure 2.24 Major and Mi'lor pelvis vessels seen in the picture are the branches of anterior and posterior division of internal liac artery. (Srun::e:
Raveartanath Veerarnari, Sunl Jonathan Hola, PM<ash Chand, Suril Olumber: Q-ay's Anatcrny br Students, 11'st South Asia Ed. Else.1er, 2017 J
 CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 31

t11e crw·a of tJ1e clitolis contain a large amount of erectile tis-

Table 2.3 Co llateral Arterial Alrc ulation of the Pelvis sue. Lacerations of the ante •ior pa•"L of tJ1 e vulva duling clliid-
Prima ry Arte ries Collateral Arte ries birtll may be accompanied b) severe bleeding. The tenninal
branches of tJ1e internal pudendal ane•)' anastomose witl1
Aorta superficial and deep pudendal aneries whicl1 are branches of
Ovarian artery Uterine artery t11e femoral ane•)· This anastomosis is important as it pro, ides
an altemaLive blood suppl) to t11 e bladder in extended
Superior rectal artery Middle rectal artery Inferior surge•)' when the vesical b1-anches of tJ1e hypogasuic :u·e Lied
(inferior mesenteric artery) rectal artery (internal
off or eve n the main u·w1k of t11e h) pogasu·ic itself may have
pudeodaO
been ligated at iiS source.
Lumbar arteries Iliolumbar artery

Vertebral arteries Iliolumbar artery THE PElVIC VEINS

Middle sacral artery Lateral sacral artery
External lilac
Deep iliac c ircumflex artery Iliolumbar artery; superior
g luteal artery
In feri or epigastric artery Obturator artery
Fe moral
Medial femoral circum flex Obturator artery; inferior
artery gluteal artery
Lateral femoral circumflex Superior gluteal; iliolumbar
artery artery
THE VAGINAL ARTERIES
Usual I) the blood suppl) of the uppe r pan o f the vagina is
de •·ived from the ,·aginal branch of the uterine anery. This
vessel reaches the lateral fornix of the vagina and then
passes downwards along the lateral vaginal wall. It sends
branches U"ai1S\ersely across the vagina, which anastomoses
\lith b1-anches on the opposite side to fonn the :U)gos :u·ter·
ies of the vagina, which run down longitudinally, one in
front of the vagina and one behind. These small vessels :u·e
encountered in th e operations of anterior and posterior
colporrhaphy. In some cases, the vaginal ane•)' does not
arise direct from the uterine an e•)' but at·ises from the ante·
ti or division of th e hypogastric anet)', when it corresponds
to the inferior vesical arte t) ' in the male.
THE ARTERIES Of THE VULVA AND PERINEUM
The blood vessels of the perineum and ex te mal genitalia are
detived from tl1e interna l pudendal an er)•, a terminal branch
of t11e an terior division of t11e in Lerna! iliac an.et)'· The artery
leaves the pelvis through greater sciaLic foramen, winds round
t11e ischial spine and e nLers t11e ischiorectal fossa. The main
vessel passes forwards in t11e ischiorec tal fossa adjacent to the
obturator ime mus muscle in Alcoc k's canal. it gives off the
infetior haemorrhoidal anery and the u-ansverse perineal ar·
tery which supplies t11e perineum and t11e region of the exter·
nal sphincter. it t11en pierces t11e urogenital diaphragm and
sends anotJ1er u-anS\erse branch to supply tl1e posterior pat"t
of the labia and to suppl) the erecLile tissue which stu"l·ounds
tJ1e ' aginal orifice. The inte mal pudenclal an e •)' ends as t11e
dorsal at"Let) ' of t11e clitot·is, suppl) ing tlle clitotis atld vesLi-
bule. The Lissues around t11 e ' oaginal orifice, the clitOris and
The left ovari:u1 vein ends by passing intO tl1e left renal
vein. The right ovar·ian vein terminates in t11e infeti or vena
cava. The most impor"tant fcawre of the pelvic veit1S is that
they form plexuses. These a rc well marked in tl1e case of
the ovarian veins in t11e infundibulopelvic fold where they
form a pampinifonn plexus a nd ca use chronic pelvic pain .
Occasionall y, this p lexus beco mes varicose and the large
di lated veins form a va ri cocele s imi lar LO the condiLi on seen
in the ma le. The ute rine plexus is fo und aro und the uter-
ine artet)' near the ute rus and Ll1 e vagina l plex us aro und
the latera l fornix of the vagina. These veno us p lex uses are
we ll deve loped in tl1 e presence of large myomas and also
during pregnancy when a venous plexus can be distin-
guished between tl1 e base of t11 e bladder and tl1e uterus.
The uterine plexus of vein drains into tl1e internal iliac
vein. There are two add itional cha nn els of venous drain-
age which are of interest in explaining une xpected sites of
metastases in malignant disease of tl1e ge nital u-act:
• A portal systemic anastomosis e xistS between tl1e hypogas-
uic vein a nd the po•·tal system 'ia the middle and infetior
haemorrh oidal ,.ei11S of t11e systemic a nd tlle superior
haemorrhoidal ' ei11S of the portal system. This accow11S
for some liver metastases of t11e genital u-act malignancies.
• A combinaLion between t11 e middle a nd latet-al sacral atld
lateral lwnbar ven ous S)Stem and t11 e vertebral plexus,
which tn ll)' explain some vertebral and even inu-acranial
metastases, is rarely seen in genital tract cancers. in such
patieniS, the lungs may escape metastases as t11ey are by-
passed by tl1 e malignant emboli.
• Uterine veins communica te witJ1 the vaginal veins. This
explains vagina l metastasis in ute rine ca ncer and endome-
triosis. T he midcUe sacl"ill veins are two in number on the
eitJ1erside of the anet")' and d rain into t11e left common iliac
vein. These veins are encountered duri ng presacral neurec-
I.Otn)', vaginal vat J t sac ropcxy and exemeraLion operaLion.
THE LYMPHATIC SYSTEM
The lymphaLics and lymphatic glands which drain tl1e fe-
male ge nital organs are o f special impo rtance in malignam
disease. The surgical re moval o r radiation should include
all tlle regio nal glands for curative effect.
THE LYMPHATIC GlANDS OR NODES
The I) mphaLic gla nds which ch-ain the fe ma le ge nital orgat1S
are as follows (Fig. 2.25).
32 SHAW'S TEXTBOOK OF GYN AECOLOGY

External

, '
lntemal '
iliac glands ,' ' :
,, '
1 Hypogastric ,'
,,
I 1 I
Superficial I
I
I
1

inguinal glands I
I
1
I
,
,'
11
, (} • • • •

--
I

,-0 --- ----- Parametrial

gland

CeiVix
Rgure 2.25 Pelv ic lymphatic drainage of the ceNix.

THE INGUINAL GLANDS
This group of glands consists of a horizo ntal and a venical
group. The horuontal gnoup lies superficially, parallel to
Poupart's ligament whereas the vertical group, otherwise
known as the deep femoral glands, follows the saphenous
and femoral veins. The uppermost of the deep femoral
glands, called the gland of Cloquet or the gland of Rosen-
muller, lies beneath Poupa•t ·s ligamem in the femoral canal
between Gimbernat's ligamem and the femoral vein. lncon-
stant deep inguinal nodes a re found in the inguinal canal,
along the course of the round ligament, a nd in the tissues
of the mons veneris. In such conditi ons, as p•·imary sore and
Banholin's abscess, the ho•iL.Ontal inguinal group becomes
inflamed. There is some evidence that lymphatics from the
fundus of t11e uterus pass along t11e round ligament and
drain into the hori:wntal inguin al group. It is more likely
t11at these glands will beco me in volved after the appearance
of t11 e la te subure thral metaSL<'l.Sis see n in advanced carci-
no ma corporis ute ri, whe re t11e growth has spread clown the
vagina by a retrograde l)•mphatic spread. The inguinal
gla nds drain the vulva a nd lowe r t11ird of t11e vagina, the
lymp hati cs of t11 e medial portion of the vulva co mmunicate
with l)•mphatics of th e opposite side. It is the refore neces-
sary to perform bilate ral inguinal lymphadenectomy when
cancer occurs in t11e medial portion of the vulva.
THE GLANDS OF THE PARAMETRIUM
The h)pogastric group (internal iliac glands ) contains all
t11e regional glands for t11e cervix, the bladder, t11e upper
third of t11e vagina and also t11e greater pan of the body of
the uterus. This group of glands may be extensively involved
in carcinoma of t11e uterus, cervix and vagina. The glands
are most numerotLS immediate!)' below the bifurcat.ion of
the common iliac group. A further group of t11ese glands
situated in tl1e obturator fossa is ofte n called the obu..rawr
glands and is freq uen U)' the most obvio usly involved in
carcinoma of tl1 e cervix. These drain into external and
common iliac glands.
EXTERNAL IUAC GLANDS
This group of glands, several in number, is situated in rela-
t.ion 1.0 the external iliac anery and ,·ein. A clean clissect.ion
oflhe extemal iliac glands can only be made if both vessels
are completely mobilit.ed as some of the glancls lie lateral to
the vessels between tl1em and the latera l pelvic wall. These
glands receive drainage from the obturator and hypogastric
glands and a•·e involved in late cervical ca ncer.
COMMON ILIAC GLANDS
T his gro up is the upward co ntinuation of the external and
h ypogastric group and, t11erefore, involved next in genital
trac t cance1:
THE SACRAL GROUP
T hese gla nds lie o n eac h side of the rec tum and receive
lympha tics fro m the ce rvix of the uterus and from the up-
per third of the vagina whi ch have pas.sed backwards along
the uterosacral ligaments. Two gno ups of glands can be
recognized, a lateral group lying late ral 1.0 the rectum and
a medial group lyi ng in front of t11e promontory of tl1e sa-
crum. The lymphatics from these glands pass directly either
to tl1e inferior lumbar gro up or to the commo n iliac group.
THE LUMBAR GROUP OF GLANDS
These lymphatic glands are divided into a n inferior gJ"Oup
that lies in from of tl1e aorta below the o rigin of tl1e infe.;or
mesenteric ane•) ' and a superior lumbar group which lies
near the origin of the ovarian ane•·ies. The supe•·ior group

of lumbar glands receives lympha l.ics from the ovaries and
fallopian tubes as we ll as fro m the inferio r lumbar glands.
The lymphatics from th e fundus of th e uterus j oin the ovar-
ian lymph al.ics to pass to the same gro up.
The l)lnphal.ic glands already menl.ioned, namely, t11e
glands of t11 e parametrium, t11 e superficial inguinal, t11e hypo-
gasu·ic, external and co mmon iliac, t11e sao-a! and t11e lumbar
receive l) mphatics 'direct' from the female generative organs
and are known as t11e ' regio nal l)lnphati c glands' o f t11e
female genitalia.
Th ese regional I) mph nodes are n ot palpable clinica Uy,
but can be identi fied on Cr and MRJ scan if t11ey :u·e en-
la rged to I em or more. At su•·ger y, these glands should be
palpated, 1-emoved or biopsied. This helps in staging the
ca ncer and in the postoperative •-adi ot11erapy.
THE NERVE SUPPLY
Both sympatheti c a nd pan\S)•mpathetic systems supply the
fema le gen ital orga ns as we ll as the bladder (Fig. 2.26) .
Rgure 2.26 Lymphatic drainage of the peMc lymph nodes.
Table 2.4 Nerve Supply In the Pelvis
Organ
Perineum, vulva, lower vagina
Upper vag ina, cervix, lower uterine segment, posterior
urethra, bladder trigone, uterosacral and cardinal
li gaments, rectosigmoid , lower ureter
Uterin e fundus, proximal fallopian tubes, broad ligament,
upper bladder, caecum, appendix, terminal large bowel
Outer two-thirds of fallopian tubes, upper ureter
Ovaries
Abdominal wall
CHAPTER 2- ANATOMY OF FEMALE GENITAL TRACT 33
The sympathe tic sys te m co nsists o f the presacral nerve
which lies in fro nt of the sac ral promo ntory. This nerve
plexus divides into two h)'POgastric nerves which pass down-
wards and latera II) a lo ng the pe lvic wa ll to te rmin ate in t11e
inferio r h)pogasuic plex us. This ple xus is diffuse and lies in
the situation of t11 e uterosacral ligamen tS. It also receives
fibres from t11 e paras)ln pathetic S)Stem co nsisting of sacral
fibres 2, 3 and 4. Fro m here, the nerve fibres pass tO all the
pe lvic organs.
The cen·ix is well surrounded by a •·ich plexus of nerves
called Frankenhause•·'s plexus. The lower vagina is inner-
\'<l ted b)• pudendal nen e.
The O\'<lries derh e their n en ·e supply from the coeliac
atld ren al ganglia which follow the course of the ovarian
vessels.
The ilioinguinal ne•·ve, derived from Ll , and t11e genital
branch of the genitofe mo ral n erve (LI and L2) s upply t11e
mons, the uppe r and outer aspec t of the labia majora and
the perineum.
T he pudendal ne rve derived fro m sacral second, third
and fourth segmentS supplies th e lowe r vagina, cliwlis, pos-
terior pa11. of the labia a nd th e pe rineum. Presacral
neurecLOm)' is rarel)' pe 1fonn ed to re lieve chronic pelvic
pain, and pain due to e ndo metliosis. Pudendal b lock is
needed in operative vaginal de liveries (Table 2.<1) .
APPLIED ANATOMY AND ITS CUNICAL
SIGNIFICANCE
I . Vulva. The skin of the extern al genitalia is prone LO local
atld ge neral de nnatitis. The moist ime nrigi nous pan s o f
the vulva are susceptible to d u onic infection. Mucous
glatlcls in the ' estibula•· locatio n ma) become cystic. A
cyst of t11e canal of uck may be mista ken fo r atl indirect
inguinal h ernia. The loose areolar tiss ue o f the ,•uh'<l atld
iLS ri ch vascul arity account for the large haemawmas t11a t
Spinal Segments Nerves
S2-4 Pudendal, Inguinal, genitofemoral, postero-
femoral cutaneous
82-4 Pelvic parasympathetlcs
T11 - 12, L1 Sympathetlcs via hypogastric plexus
T9-10 Sympathetics via aortic and superior
mesenteric plexus
T9-10 Sympathetics via renal and aortic plexus
and celiac and mesenteric ganglia
T12- L1 Iliohypogastric
T12- L1 Ilioinguinal
L1 - 2 Genhofemoral
34 SHAW'S TEXTBOOK OF GYN AECOLOGY
are formed as a co nseq uence of vasc ular ury dttring
childbinh or accide nLal Vulval cancer is rare
and occurs in old age. Lymphatic drainage of vulva is
relevam in radical vulvectOmy for cancer. Pudendal nerve
block is required in episiotOm) and forceps delivery. The
imet·nal pudendal block is perfonned by local
anaeSLheLic drug into the nerve at the level of ischial
spine, as the net'\e winds round this spine.
2. Vagina. The posteriot· '-aginal fomix lies in proximity to
the pet·iwneal pouch of Douglas. It is a conveniem site
for access to the petitoneal caviL)\ colpopunCLure, colpo-
cemesis and diagnostic culdoscopy in the diagnosis of
pelvic abscess, ectopic pregnancy and pelvic endomeu·io-
sis. The ureters have a close relation to the lateral vaginal
fornices, panicularly in patients with uterine prolapse.
Ureteric injw)' sh ould be guarded against during vaginal
surger)' on the uterus, as also when anempting LO suture
vaginal lacerations (colporrhexis) hi gh in th e vaginal
vault. T he a natom ic proximity of the bladde r base, ure-
thra and vagina and th e inte rrelalions hip between their
vascu lar and lymphatic networks result in inflammation
of the vagina (vaginitis) ca using wina t)' u·act symptoms
such as frequenC)' and dys uria. Ga rtne r's duct cysts repre-
sen t a C)'Stic di lata tion of the re mnants of the embryo nic
mesonephros. T hey are presem in the lateral walls of the
vagina. T hese are ge ne ra lly asymp tomatic, but they may
cause dyspareunia o r vagina l discomfort. ln the lower
third of the vagina, Gartner's duct cysts are located ante-
riorly and ma) mimic a large ure thral diverticulum.
Squamous cell carci noma of vagina is very rare and oc-
CLu·s usuall) over the decubitus ulcer in a woman wit11
\<aginal prolapse. Adenocarcinoma of '-agina has been
repo11.ed in )Oung girls who were exposed to DES in
utero and can occu t· in the upper pan of the \<agi na.
L) mphatic drainage of nth-a is rele,<am in radical vulvec-
tOm)' for cancer. Pudendal nerve block is required in
episiotomy and forceps delivet)'. The internal pudendal
block is performed by irtiecting local anaesthetist drug
into the nel'\'e at t11e level of ischial spine as t11e nen•e
winds round this spine.
3. Cervix. The major \<aSCular supply ofthe cen•i.x is located
laterally. Deep lateral sutu res placed latet·all y to include
the vaginal mucosa and the substance of t11 e cervix would
help tO con u·ol bleeding du ring surgical procedures on
t11e cervix such as o r the surgical evac uation
of t11e cen>ical ca na l in cervi cal ec topic pregnancy. The
su·oma of tl1e e ndoce rvix un like the ectOce rvix is rich in
nerve endings; hence, manipu lati o n of tl1e cervical canal
can cause an un ex pected vasovagal attack and severe
brad)•carclia or eve n cardiac arresL T he lymp ha tics of the
cen•ix are ver>' co mp lex invo lving m ultip le chains of
nodes. The principal regio nal nodes are the obturator,
common iliac, intern al iliac and visceral nodes of the
parametria; others ma)' also be occasionally involved,
hence th e need for a wide nocla l disseCLion during the
treaunent of cancer cervi.x employing radical surgery.
Squamocolumnar junction is tJ1e site of cancer of ilie
cervi.x. Precancerous lesio n of the cervix needs ablalion
or excisio n depending upon the age of t11e woman and
its grade (Fig. 2.27).
Superior
mesenteric
rJI....a.-- Renal ganglion
L1
/ Inferior
/ mesenteric artery
Inferior
hypogastric
plexus
52
53
Pelvic p lexus
54
Rgure 2.27 Pelvic innervation.
4. Uterus. Dysmenon-I10ea is not an uncommon spnpwm,
necessitating u·eaunent in cla)-tO-da)' practice. Although
most cases of pl'imat)' drsmenon·hoea are treated suc-
cessfully by prostaglandinS) nthetase inhibitors, there are
occasional cases \\i1ere oral medications may not suffice.
ln these women, the division of the sensory nen•es t11at
accompany t11e S)•mpathetic nerves can lead to relief.
The oper·a tions of pr-esacral neurectOm)' and the endo-
scopic division of the uterosacral ligamentS near the
uterine attachment (laparoscopic uterosacr·al nen•e abla-
tion) have bee n designed to meet t11is end. Th e surgeon
must be careful to avoid irtiury to tl1 e ure te i'S. The uterus
receives itS main blood suppl )' fro m t11e laterall y placed
uterine arteries, so the opera ti o n of myo mec tomy of an-
terior wall uterine Fibroids through a mid li ne incision is
a ue nded witl1 the leas t amo ulll of blood loss. Earlier, it
has been d iscussed tllatthc uterus has a rich b lood sup-
ply from tl1 e branches of the vasc ular anastomotic arcade
between the uterine arte ries and the ovarian arteries.
There is also presence of an ex tensive pelvic collatera l
circ ulation to e nsure e no ugh blood supply in emer-
gency situations wherein bilateral surgical ligation of t11e
hypogasll'ic vessels becomes necessary as a life-saving
procedure. such as postpartum haemorrhage.
5. Fallopian tubes. The right fallopian tube lies in proxim-
ity to the appendix. Therefore, it is ofte n difficult to dif-
ferenliate between acute appe ndicilis and acute salpingi-
Lis. The wide mesosalpinx of the ampu lla t) ' portion of
 CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 35

the tube permiLS Lhis part to undergo torsion. Mesonep h- The genital prolapse is caused by atOn ic ity, relaxation
ric remnanLS in Lhe broad ligament may be the cause of or damage to the ne1ve of the pelvic floor muscles and
formation of paraovarian cysLS. These often mimic ovar- the supporting ligamenLS. The knowledge of these ana-
ian neoplasms. The) have been reponed to Ltndergo tOmical strucwres is necessary in the repair of variOLLS
torsion. Falloscop) visuali.ces the tubal mucosa and pa- types of prolapse and in enhancement and buttressing
tenc> of the medial end and salpingoscopy studies the these structures.
mucosa and patenc> of the ampullary end of the fullo- Stress incontinence of urine can be cured by elevating
pian tube, and enables us to decide between wbal sur- the neck of the bladder and mid-urethral ligamenta!)' sus-
gery and in ,•iu·o fertili.tation in tubal infertility. pension.
6. O varies. There is a wide variation in the siLe of the ova-
•·ies during the childbearing )Cars and after menopause.
Atrophic menopausal ovluies are not palpable on vagi-
nal examination. Therefore, any palpable adnexal mass KEY POINTS
in a posunenopausal woman should be viewed with
• Anatomical knowledge of t11e pelvic o1·gans is essential
suspicion and investigated thoroughly to exclude a neo-
to interpret t11e clinical findings as well as t11ose of
plasm. The location of the ovary in the ovarian fossa
ultrasound, CT and MR I to make an accurate gynae-
lies in proximity to the uretei'S. Hence, during pelvic
cological di agnosis.
s urgical procedures for severe e ndometriosis or pelvic
• Normal vaginal secreti ons are small in amount and
infla mma tOI)' disease that involve the ovaries, great
varies wit.l1 the phase of th e mensm tal cycle. Doder-
caution mus t be exe rcised to avo id ureteric injury. Ultra-
le in's bacill i are C l-a m-positive microorganisms wh ich
sound scanning fo r an>' adnexa l mass, polycys tic ovarian
grow anaerobica lly in an ac id med iu m of 4.5 p H. Low
di sease a nd ovulatio n mo nitorin g is possib le and is easy,
acidity of vagina does not allow other organisms to
cost effec tive, acc urate and no ninvasive. Additional
grow and cause vaginitis.
ho nnonal monitoring is, howeve r, required in in vitro
• Nonnal cervix has several physiological functions. The
fertilization p rogramme.
alkaline secretion attractsspenns at ovulaLion and sieves
7. Surgical precautions during gynaecological operations.
out t11e abnom1al sperms in tl1eir ascent. The plug of
The anatomic proximity of female reproductive organs
ce1vical mucous pt--e,ents enur o f sperms as well as bac-
with the ureters, urinary bladder and recn.un in the pel-
teria. and pre,enLS p1--egnanq and pelvic inflammatOry
vis is a major consideration during gynaecologic surgery.
disease. C'..apacitation of spenns occurs in t11e cenical
Surgical compromise of the ureter may occur during
canal. 111e imemal os remains dosed during pregnancy,
clamping or ligation of the folds, but effuces as itS collagen dissol,es near tenn.
clamping and ligation of the cardinal ligamentS, reperi-
• Fallopian tube. The secretions of e ndosalpinx, perl-
of t11e lateral wall following hysterectomy
staltic mo,emenLS of t11e LUbe and ovaria n fimb.-ia play
or du.-ing wide app•·oximation of endopelvic fuscia dur-
impo•·tant role in fertilit).
ing anterior colpon·haphy repair.
• Knowledge of I) mphatic drainage of t11e peh·ic organs
is impo•·tant in staging of cancel'S, radiation planning
At the base of the broad ligamentS, the ute1·ine anery
and complete surgical removal of tumour. Rem nantS
crosses the ureter. DUJ·ing \\'enheim's operation, when in
of the Wolffian duct can cause paraovarian C)'St and
doubt whetJ1er t11e structure under view is a blood vessel or
Gartner's duct C)SL
the ureter, the feel of t11e structure is helpful; also, mild
• The pelvic po•·tion oftJ1e ureter lies close 1.0 the genital
stroking lengthwise invokes a wave of pe•istalsis in the ure-
organs. It is recogniLCd by its pale glistening appear-
ter. During abdom inal hysterectomy for benign uterine
ance and pe.-istalsis. It needs to be dissected and pro-
disease, the practice of intrafascial clamping of th e parame-
tected against injul)' during gynaecological surgery.
trium also helps to prevent ure te 1ic i1"!ju1)'. SubtOtal h yster-
• Pelvic floor muscles and fasciae hold the pelvic organs
ectomy in younger women in whom the cervix is healthy
in place. Prolapse of uterus, su--ess inco nti nence of UJine
(Pap test no 1mal) has the adva ntage of retain ing the cervix
are related to t.l1e lax it)' and aton icity of these su·uctu res.
for sexua l reasons and for reducing t11e 1isk of future vaul t
Denervation of t.l1e pelvic nerves during childb irt.l1 can
prolapse. The uri na 1)' b ladder if we ll drained d uring pelvic
predisposed to urinal)' and faeca l inco nti nence.
surgery wi ll be less vu lnerable to inadvenem trauma.
• The bladde1; rec tum and anal ca nal share t.l1e same
During colposuspension operatio ns for su·ess urinary incon-
muscular and ligame ntary supports. Laxity of these
tinence, t11ere ma>' be significan t venous bleeding in the
supportive structures causes genital prolapse as well as
cave of Retzius. Lf proper drainage not provided, there is
Ulin;ur. faecal incominence.
a possibility of occun·ence of a large subfascial haematOma
t11at may extend up to t11e umbilicus. Rectal injuries occur
most freq uen t.ly during vaginal hysterecwmy associated witl1
high posterior colporrhaph) and enterocele repair. The
rectum is also vulnerable to injul)' in t11e presence of wide SELF-ASSESSMENT
adhesions. obliterating the pouch of Douglas in cases of
extensive pelvic endomeuiosis, chronic pelvic inAammaLOI)' l. Deso;be the anatom) ofBanholin's gland and itS clinical
disease or advanced peh,ic malignancr significance.
36 SHAW'S TEXTBOOK OF GYN AECOLOGY

2. Describe Lhe anato my of pelvic eli a ph ragm and its impor- SUGGESTED READING
Lance in geni t.'\1 o rga n prolapse. Cunnittgham FG, Lc•cno KL Bloom SL Cl (t'<is) . William 's Obncuks.
3. Describe Lhe pelvic cellula r Liss ue suppo rts of the 23rtl Ed. .Mt-Gr.tw II ill, 2010 ; 14-35.
uLer us. SchorgcJO. SchafferJ l, llal\'orwn L\1 ct al. (cds). William 's
logy. 1st Ed. tl:cw York. II ill, 2008 ; 798.
4. Oesct·ibe th e co urse of t11 e urete r in t11 e pe lvis. What
are the sites where urete r is vulnerable tO i11jury during
pelvic surgery?
 Normal Histology of Ovary
and Endometrium
The Ovary 37 Ovarian Fundions 45
Ovulation 39 Key Points 46
The Endomelrium 41 Self-Assessment 47
Histo logica l study of th e endometrium is n eeded lO detect
the hormonal causes of inferti li ty and abnorma l me n-
stnial panerns. However, lately, smdying ovulation pattern
in infertility by endometrial examination has lost consid-
erab le importance and is superseeded by ultrasonic scan-
ning, which is noninvasive and accurate in deteCLing the
timin g of ovu lation and the resu lt is ava il ab le on the spot.
Endometrial Ludy is needed in suspected gen ita l tract
t11bercu losis and cancer. The morpho logica l swdy of the
ovary and adnexa l mass is also possib le with ultrasound
scann ing.
THE OVARY
At term, the fetal ovary measures 10-16 mm in lel'lg
is situated at th e leve l of the brim of the peh . fa u on
is taken through the OVaJ')' and examined his to o ·caL] , the
fo ll owing can be recognized:
The surface epitheliwn. T his is a single layer f cuboidal
ce lls, which later g ives rise to the u a~ ep1 1 ium of the
adult ovary. l tis morphologically o tinl!O with the meso-
th e liu m of th e peritoneum.
The subepithelial connective t&
rise to the tun ica a lbuginea of the dull ovary and to the
basement membrane beneath the surface epith elium.
The parenchymatous zone. This area is th e cortex and
also the most important area, as it contains the sex cel ls. It
can be divided into the foll owing zones:
• Immediately beneath the surface epith eli um, t.he ex cells
are still grouped together in bunches to form egg nests.
• Below this area, the sex cells take th e form of primordial
fo lli cles and are packed together without orderly arrange-
ment (Fig. 3.1 ).
• Developin g fol li cles are seen in the deeper parts (Fig. 3. 2).
The rete ovary in the medulla represents primary sex
cords. Leydig cells, analogues of testis, are also seen in the
medulla.
Zona vasculosa. This contains the blood vessels. lt consti-
tutes the medulla of the ovary (Fig. 3.3). A few hil ar cells
homologues LO in t.er titi are present in
the medu lla and rarely ar cell tumour of the ovaq1•
As early i1 lli 3r week of gestation, primordia l ge rm
cells ap ear in th ndoderm of t11 e )'Olk sac, an d t11ese mi-
grate aL n th e orsal me emery lO the u rogen ital ridge by
the L' \,\ ek T he fir t evidence of primordial fo lli cle ap-
pea11s at a:fio1 t 20 weeks of fetal life. The fetal ovary con tains
7 rllion primordial foll icles but most degenerate , and th e
n wo rn contains on ly 2 mi ll ion follicles. The primordial
fo lli cle consists of a large cell, the primordia l ovum (oogo-
1 ) , which is surro und ed by flattened cells, best termed as
th e fulli,cle epitheli.al cells. The fo11icle epith elial cells give ri e
to the granulosa ce lls of t11e Graafian fo llicle.
The primitive OV\ltn (primary oocyte) is rot1ghly spheri-
cal in shape and measures 18-24 microns in diameter, the
nucleus 12 m icrons and nu cleolus 6 microns. lt has a well-
defined n 1,clear membrane and its chromatin sta ins clearly.
T h e primary oocyte remain in the prophase of the first
meiotic division 1111 ti! puberty.
The ovary of the newbom is packed with primordial fol-
li cles, approx.imately 2 m illion, dropping to a few hundreds
at puberty. One ofihe most curious features of the ova t')' is
the tendency of the sex cells lO und ergo degeneration. An
enom10us number disappears during intrauterin e life
(I L) , and u1is proce of d egeneration cominues through-
out chil dhood and the childbearing period , with th e resul t
Lhat no ovum can be detected in the ovaries of a woman
wh o has passed the menopause. At birth, about 2 mi llion
fo lli cles seen are red11ced lO 400,000 at puberty; only
400 fo lli cle are available d u ring th e ch ildbearing period for
fertili zation. The oogonia enter the prophase of the first
meiotic division and remain so until pubeny.
THE GRAAFIAN FOLLICLE (Fig. 3.2)
Th e Graafian fo llicle, described by Regn ier de Graaf in
1672, i a vesicle whose ize measures on an average between
12 and 16 mm in diameter afte r puberty. B.efore puberty, it
se ldom reach es more thai1 5 mm in diameter.
37
38 SHAW'S TEXTBOOK OF GYNAECOLOGY

The malUre Graafian follicle is spheroidal or ovoid in

Rgure 3.1 Ovary of a newborn child showing germinal epithelium
and the stroma packed with primordial follicles. (Source : Anctei Gunn,
MD, PhD, Dr Sci, Professor, Department of Obstetrics and Gynecology,
Medical School Chuvash State
Rgure 3.2 Graafian follicle. Discus proligerus showing granulosa
cell s, the ovum and the membrana llmltans externa Theca interna
cell s are few. (Source: David B Fankhauser, PhD.)
shape and comains pem-up secretion, the liquor folliculi.
The lining consists of two layers: (i) theca imema and
(ii) granulosa layer. The outer or tlll!c<t intenw layer consists
of cells that are derived from the stroma cells of tl1e cortex.
The theca cell is responsible for Lhe production of ovarian
horm ones, oes u·ogen and progeste ro ne, some times ex-
tended to tl1e production of and rogens. Within tl1e tl1 eca
imerna layer lies the {,JTaJntlosa cell lttyer, which consists of
cells that have a characte1istic appearance. The cells are
8-10 microns in diameter. The nuclei always stain deeply
and the cells contain relatively little cytoplasm. In one area,
the granulosa cells are collected together to fonn a projec-
tion into tl1e cavity of the Graafian follicle. This p1·ojection
is referred to as the discus proligerus or cum11111.s ooplwntS. The
ovum itself lies witl1in t11e discus proligerus. \\'itl1 tl1e excep-
tion of the area arottnd t11e discus proligerus, the peripheral
granulos.1 cells form a layer only a few cells in thickness,
whereas at tl1e disc us, the cells are between 12 and 20 la)•ers
thick. The gran ulosa layer itse lf is nonvascul ar and capillar-
ies ca nnot be iden tified in it Scattered amongst tl1e gran u-
losa cells, particularly in the vicinity of the discus proligerus,
are small spherical globules around which the gran ulosa
cells are an-anged radially. These structures fonn Call-E:v:ner
bodies. The formation of Call-Exnf'r lxxlie.s is a distinct fea-
wre of granulosa cells and can be readily in
cenain t) pes of granulosa cellwmours. Between the granu-
losa la)er and the t11eca imema is a basement membrane
called the membrana limiums e:xtema, upon which lies the
basal Ia) er of granulosa cells (Fig. 3. I).
The mature ovum measures 120-140 microns in diameter
and its n ucle us measures 20-25 microns. At tl1e periphery
of t11 e cleutoplas m is a vitelline membrane o utside wh ich a
clea r u·ansluce nt capsular ace llular la)•e r of glycopro tein,
kn own as the zona pellucida, envelops tl1e ovum. The
granulosa cells surro und the entire periphery of t11 e ovum
(Fig. 3.5). The ovum remains in the meiotic arrest until
about 36 hours before ovulation when first meiotic division
is completed and first polar body is exu·uded. Second mei-
otic di,,ision occurs only if t11e spenn peneu-ates the wna.
Those gmnulosa cells, which are immediate !) acljacemw
tl1e ovum, have a radial arrangement and form the corona
radiata. The corona mdiata remains attached to tl1e ovum
after its discharge into t11e peritoneal cavity at ovulation.
The tl1eca interna cells enlarge d uring the ma turation of
the fo llicle, and shortly before ov ulation, the)' are larger

Mesovarium Primordial folli cle Primary follicle

Blood

Graafian follicle

Germinal epithelium

Early oorpus luteum Rgure 3.3 Structure of the adult ovary.

 CHAPTER 3 - NORMAL HISTOLOGY OF OVARY AND ENDOMETRIUM
Primordial
follicle
--
Antral
follicle
Rgure 3.4 Folli cular development: Graafian follicle show-
ing granulosa cells, the ovum and t heca lnterna cells.
Graafian folli cle measures 20 mm at ovulation.
Granulosa layer
Figure 3.5 Oocyte.
than the granulosa cells. The third Jarer, the theca extema,
is ill-defined in the ovary.
The liquor follicu li is a clear fluid-containing protein
which coagulates after fom1a li n fixati on. It is secreted by
tl1 e gr·anulosa cells a nd co ntains the ovarian h ormon e
oestrogen.
THE FATE OF THE GRAAFIAN FOlUClE
T he process whe reb)' a primo rdi al follicle is co nve n:ed into a
Graafian fo llicle, foll iculari zation, ca n be recognized as earl)'
as the 32ncl week of JUL. Unti l pubert)', most primordia l fo l-
licles in tl1e ovary undergo retrogression by a process which
is termed as fo llicle atresia. Ovulation, whereby the follicle
discharges its ovu m in to t.he peritoneal cavity, is first seen at
puberty and is resu·icted to the childbearing period of life.
The development of a primordial follicle into a Graafian fol-
licle is under t.he control of t.he follicle-stimulating hormone
(FSH) secreted b) t.he anterior pituitary gland. Several folli-
cles commence to develop in each menstrual cycle. In re-
sponse to FSH, small gap junctions develop between the
granulosa cells and the OOC)te, and these gap junctions pro-
,·ide a path\\'3)' for nuu·ition and metabolic imerchange be-
tween them. Of the several follicles developing in botl1 ova-
ties, one follicle grows faster than the rest and produces
39
Graafian
Preantra• . preovulatory follicle
follicle
Theca externa
•....,..._:.___ Theca Interna
----·
more FSH receptors and oestrogen. The a·ising oesu·ogen
level stimulates luteiniL.ing hormon e (LH ) receptOrs in the
theca cells but causes a negative feedback to t11e amel'ior
pituita•')' gland, leadin g to a progressive fa ll in t11e level of
FSH and gonadou·opic suppon to the ot11er lesser developed
follicles whi ch atrop hy. T he number offollicles that develop
in any one cycle depends upo n t.he levels of FSH and LH as
well as tl1e sensiti vity of the fo llicles. Induction of multiple
ovu la ti ons in in vitro fe rti li zation is based o n tl1is observa-
tio n. ln a spon taneous nO tlnal menstrua l cycle, o nly one
dominant follicle develops into a Graafian follicle resulti ng
in a single ovtJation. Follicular a u·esia begins first in th e
ovum and later in tl1e granu los.'l cells. Hyali ne degeneration
occurs and h)'aline tissue is deposited as a glass membrane.
Gradual absorption of liquor folliculi causes collapse of the
follicle. The tl1eca interna cells persist lo nger as dark-stained
interstitial cells att.he periphery of the follicle.
OVULAnON
Ovulation occw'S when t11e onun surrounded by t11e corona
radiata escapes out oft11e Graafian follicle. It is quickly picked
up by the tubal fimbria, "hich hugs the ovary at ovwation
40 SHAW'S TEXTBOOK OF GYN AECOLOGY

Zona pellucida

Ooplasm

L---+-- Second meiotic

metaphase
chromosomes

r - - - - - 1 L - First polar body

Egg membrane

' - - - - , L - - Perivitelline space

A B
Rgure 3.6 (A) Ovulation. (B) Freshly ovulated ovum.

(Fig. 3.6). T he pea k level of 75 ng/mL of LH is required for Anovulati on occ urs in abo ut I0% cases of infertili ty, and
ovu lation. Ll-1 pea k lasts for 24 ho urs. sporadi call y during th e chi ldbearing yea rs, but its occ ur-
T he ntptw·e of the Graafian foll icle occ urs because of the rence is not uncomm on for a few cycles after th e mena rch e
contrac tion of mi crom uscle present over the theca extema. and jttsL ptior to tl1e onset of menopause.
The conu<1c tions are bro uglll about b)' prostaglandin secreted Un less ferti lized, the ovum does not survive for more
tmder the influence of LH. T he process of matt.ll<ltion and than 24 hours. Thereafte r; it degenerates in th e fallopian
ovulation can be minutely studied by serial ulu·asonogmphy. tube witJ1o ut leaving beh ind any trace.
The Graafian follicle grows at the rate of 1-2 mm daily and
attains tl1e size of 20 m m or more at ovulation. The sudden
shrinkage in the size of a follicle, appearance of fi-ee fluid in
CORPUS LUTEUM (Fig. 3.7 A and B)
tJ1e pouch of Douglas and regrowth of tJ1e collapsed cyst tllere- Soon after ovulaLion. tJ1e Graafian follicle cyst collapses
after suggest tl1at ovulation has occurrecl Knowledge of tl1e andluteiniL.ation of the theca cells and tJ1e gra nulosa cells
timing of ovulation is needed in in vitrO fertiliL.ation, in artifi- takes place. The cells bloat up and increase in size, with
cial insemination and in tJ1e control of fertility. Ovulation is
estimated to occw· II clays before tJ1e lstda)' oftJ1e succeeding
C)cle, and rnis intel'\al is more or less fixed. in ca-;e of irregular
C) cles, it is me follicular phase which ,oa,ies, but tl1e luteal
phase 1-emains more or less constant at 14 clays. Howe,er, we
do encounter cases ofinfertility with a short luteal phase, \\ilen invasion
menstruation begins in less than 14 days after ovulation.
Normally, one lingle wr11n is discha•·ged from the Gmafian
follicle. Howevet; multiple ovulations can occur and result
in a multiple di:c.ygotic pregnancy. Multiple ovulations can
also be thempeuticall y induced with hormones during in
vitro fertilization.
T he aperture through whi ch an egg escapes from the
ovary is called the sti gma, appearing o n lapa roscopy as a red
spot th at heals in 3-'1 clays' tim e. T he ind irec t methods of Luteinized - -liC&SJ
theca cells
detecting ovulati on a re based o n selial vaginal C)• to logy, se-
ria l cervical mucus swcly, premenstrual endometria l biopsy, A
observing dail)' basal body temperature (BBT) and estima-
tion of blood progesterone levels (or urinary pregnanedio l
levels) in the posLOvulatory or immediate premenstrual
phase. Rarely, rupLUre of the Graafian follicle fails, but the
follicle grows into a corpus luteum. This is termed as lutein-
i.t.ed unruptlii'Cd follicle, which causes infertility.
The most important ph)Siological marker of imminemovu-
lation is LH stll'ge and not E.1 peak, as 1J1e latter may not always
ctLimi nate into ovulation. u-1surge catt$es tJ1e following:

l. Completion of meiosis of ovum Figure 3.7 (A) Formation of corpus luteum. (B) Laparoscopic
2. Ovulation appearance of Graafian folllde at the time of ovulation. (Coutesy tor
3. Development of corptts luteum (B): Dr Shyam Desai, Mumbai.)
 CHAPTER 3 - NORMAL HISTOLOGY OF OVARY AND ENDOMETRIUM
pale stammg cytoplasm. The nuclei th erefore appear
small. The cells proliferate and become 8- to 10-fold in
size clue to which tJ1e cyst wall becomes crenated. At the
same time, the corpus lllleum becomes vascularized from
tJ1e vessels in the theca interna layer. Some bleeding may
occur in the ca,it) of the C)St. The corpus luteum reaches
maximum maLUI'it) b) tJ1e 22ncl clay of the nonnal cycle,
when it attains tJ1e si£C of2 em or more. lf pregnancy fails
to occur, by tJ1e 8tJ1 postovulatOry day, the corpus luteum
starts degenerating and hyaliniation sets in. The corpus
luteal fluid contains phospholipid, cholesterol and caro-
tene. Although it appears initially grey, later tJ1e corpus
luteum acquires a yellow colour clue to carotene, also
known as lutein. During tJ1e last premenstrual week, vascu-
larity of the cor·pus IULeum diminishes when atrophy and
degenet<Jtion of g1<Jnulosa cells can be demonsu·ated in
the form of vacuolated cells. Later h ya li ne tissue is depos-
ited, and this hyaline body is known as the corp us albicans.
Re u·ogression of the corp us lu te um is a slow process and it
is calcu lated UHit 9 months may e lapse before it is com-
p lete ly rep laced by h)'a line tissue (Fig . 3.8). T he regression
is attributed to fa ll in the LH level and rise in the level of
oestrogen and PGF 2a.
MENSTRUATION
Mensu·uation is brought about by fall in the levels of oestro-
gen and progesterone fo llowing tJ1e degeneration of the
corpus luteurn. In anovulatory cycles, fall in the level of
oestrogen alone can bring about witJ1clrawal bleeding in tl1e
fonn of menstruation. I lowever, the oestrogen withdrawal
bleeding is far heavier tJ1an tJ1e progesterone witJH:IJ<Jwal
bleeding.
CORPUS LUTEUM OF PREGNANCY
Following fet·tiliation, t11e corpus lllleum continues to grow
and fonns the cot·pus luteum of pregnancy. This corpus lu-
teum is larger and more C)Stic than t11e corpus luteum of
mensu·uation and may attain the si£C of2.5 em. The convolu-
tions are larger and mot-e in u·icate. The individual granulosa
Figure 3.8 Corpus atreticum. The end result of atresia of a Graafan
follicle. The granulosa cells have disappeared and a hyaline lamina
has been deposited. The follicle Is In the process of collapse.
41
cell is also large and measures as much as 40-50 microns.
The secretion also increases. The tJ1eca cells are seen up to
the 20tll week, but tJ1ereafter tJ1ey cannot be identified.
The corpus lute tun of pregnancy is functionall)' active up
to the IOtl1 to 12t11 week in human beings. Thereafter, t11e
placenta takes over tl1e secretOI) function and carries preg-
nancy to tenn. Extirpation of the corptLS luteum after the
l4tl1 week in humans will not tJ1erefore induce abo1·tion.
THE ENDOMETRIUM
The endomeu·ium is tl1e special epithelial lining of that pan
of tl1e cavity of the uterus which lies above tl1e level of the
imernal os. It consists of a stu-face epitl1elium, glands and
stroma. It was not until 1907 that the variations in tl1e histO-
logical strucwre of the endometrium during tl1 e mensrrual
cycle were established by llitschma nn and Adler. This
formed the basis upon wh ich much of the modern work on
the sex hormones rests.
T he endomeui um of tJ1e body of the ute rus can be di-
vided in to two zones: a supe rfi cia l te rm ed tJ1e functional
layer, and a deeper one termed t11e basal la)'e 1; wh ich lies
adjacent to tl1e m)'Ometriwn. The stroma cells of the basal
la)'er stain deep l)' and a re packed closely together. Is lands of
lymphoid tissue are found in the basal layer. This layer is not
shed during mensuration, and 1-egeneration starts before
tl1e end of mensuration.
The vascular S)Stem of tJ1e endometrium is of great im-
portance. Two t) pes of arteries supply tJ1e endometrium.
One of these is restricted to the basal tl1 ircl and consists of
small, su-aight and short arteries. The superficial two-thirds
of the endometrium is supplied b) coiled ane1·ies.
THE PROLIFERATIVE PHASE
The phase of the mensu·ual C)Cie which StaJ'ts when regen-
eration of menstruating endometrium is complete and lasts
until the 14th day of a 28-day cycle is refen-ed to as tl1e pro-
lifet<Jtive or oestrogenic phase. At the end of mensu·uation,
which may occupy from 3 to 5 days, the necrotic superficial
layers have been exfoliated and the endometrium is repre-
sented by only the deep or basal layer. The coiled arteries
have been lost and tJ1e terminal ends of the straight arteries
are sealed off by fibrin. The su·o ma is heavily infiltrated with
le ucocytes and reel cells. Rege nera tion is 1-e markabl)' rapid
and all e le ments of the endometrium, including glands and
new spro uting vessels, arc present at the e nd of 48 ho urs.
The proliferative phase therefore starts and proceeds rap-
idl)' for abo ut 3-5 days, and not late r tJ1an 7 days after the
stan of the mensu·ual cycle. During proliferation the func-
tional and the basal layers are we ll cleft ned. The basal layer
measures I trun in thickness, whereas the functional layer,
conm1encing with an average of 2.5 mm, reaches about
3.5 mm by the 14th clay, and during tl1e secretory phase it
hypertrophies still further so tJ1at immediately before men-
su·uation its avet<Jge tl1ickness is aboutS-10 mm. Dul'ing tl1e
prolifemtive phase, the glands of the functional layer are
simple tubules witl1 regular epithelium (Fig. 3.9). About the
l0tl1 day of the C)cle, the glands become slightly sinuous
and their columnar epitl1elium becomes taller than before.
The glands sometimes show a chai<JCtel·istic appearance in
42 SHAW'S TEXTBOOK OF GYN AECOLOGY

Rgure 3.9 (A) Normal endometrium in t he proliferative phase. (B) The g lands a-e simple tubul es and are shown in longitudinal and transverse
sections (x66). (Source: The Image belongs to Rex Bentley, MD, Department of Pathology, Duke Universlty Medical Center, taken from Ink: http://
www.pathologyplcs.oorn/PictVIew.aspx?ID 11 49. <C> University of Kansas Medical Center, Department of Anatomy and Cell Biology.)

the later proliferative phase as if the gla nd ular epithelium

has been telescoped into tJ1e lumen, rathe r like a n in tus-
suscep tion. T his appearance is fa lse and this te lescoping is
in realit)' d ue to the w ftof epithe liu m which has b udded off
from the gland wall. It is, the refore, mere ly an evidence of
oestrogenic activity in the gland ular epi the liu m. The stroma
becomes extremely oedema to us with wide separation of in-
dividLtal cells. During the lst posunensu1.tal week, the coiled
arteries extend only half way through the endomeuium.
Aftenvards the) grow more rapicUy than the endomeuium
so that the) become more coiled and spiralled. In some
cases, the vascularit) is so intense that blood oozes into the
cavil) of the uterus at the time of ovulation to be discharged
from the vagina. Regular intennenstmal bleeding of this
kind is a well-known clinical S)lnptom and is clue LO t11e in-
tense h) pe.-aemia at the end of t11e proliferative phase. It
almost certainly indicates that ovulation has occurred.
Figure 3.10 Endometrium- secretory hypertrophy (early stage).The
g land is aenated, the lumen oontalns mucous secretion and the inner
THE SECRETORY PHASE border of the cell s is irregular. Subnuclear vacuolation is well seen.
The surrounding stroma is oedematous and the hypertrophied stroma
Progesterone induces secretory changes only if t11e enclome- cells are w idely separated from each other (X200). (Source: The mage
u-ium is ptimed by oesu·ogen, which produces progesterone belongs to Rex Bentley, MD, Department of Pathology, DU<e University
receptors in the endomcu·ial cells. T he secretOry phase of Medical Center, taken from ink: http://www pathologypics.com/Pict-
t11e endomeu·ium begins on t11e l 5t11 day a nd persists un til View.aspx?ID = 11 49.)
t11e onse t of mensu·uation . The most charac te risti c signs of
t11is p hase are found in t11e glands. T heir epitl1elial cells
develop sp herical u·anslucent areas be twee n t11 e nuclei and before me nstruati o n a re full of coagulated sec reLi on th at
t11e basemen t memb rane whi ch co main t11 e p rec urso rs of stains deepl)' witl1 eosin. T he glands beco me cre nated and
t11e gland ul ar secretion and which pe rs is t umil abo ut the assume a charac teristic corkscrew-shaped fo rm (Fig. 3. !1A
2 lstda)' of the crcle. T his characteristic appearance is called and B). The sLroma of the functio nalla)•er remains oedema-
subn uclear vacuo lation and is a presump tive evidence of tot.ts, b ut further interstitial haemorrhage rare except
progesterone activit)' and, therefore, of ovulation. The fl uid immediate!)' prior to t11e onset of mensu·uation. The coiled
in t11ese subn uclear vacuoles consists of mucin and glycogen a11.eries become more spiral and form closely wound per-
(Fig. :3.10), t11e function of wh id1 is presumabl)' to provide pendicular columns through the mucosa. The stroma cells
nutrition to t11e fertili:t.ed ovum. The phase of subnuclear become swollen, and after the 21st day of the cycle t11e)'
vacuolation is rapicU) followed by an increase in intracellu- tend to be collected immediate!) beneatJ1 t11e surface epi-
lar secretion which pttshes the nuclei to the basement mem- tlleliwn where UlC) surround t11e ductS of the glands in such
brane and fills the cell. The subnuclear vacuole later mi- a \vay that tl1e functional la)er can be subdivided into two
past t11e nucleus to t11e surface of the cell. l.n the :tones: tJ1e superficial or compact LOne and a deeper spongy
latter pan. of the secretory phase, the inner border of t11e layer. The swollen su·oma cells of t11e compact pan of the
epithelial cells become in·egular through the clisd1arge of functional la)er represent )Olmg decidual cells, and in every
the secretion into t11e lumina of the glands, which shortly respect the reaction of the compact LOne con·esponds to
 CHAPTER 3 - NORMAL HISTOLOGY OF OVARY AND ENDOMETRIUM
Figure 3.11 (A) Endometrium -secretory hypertrophy- at a slightly
later stage than Fig. 3 10. The secretory vacuoles are now near the
apex of the cell (X124). (B) Endometrium showing compacta, spon-
giosa and basalis layers. (Source: The image belongs to Rex Bentley,
MD, Department of Pathology, Duke LrllverSity Medea! Center, taken
from link: http://www. pathologypics.oom/PictVtew.aspx?ID = 1149.)
,,11at is found in this pan of th e e ndomeu·ium during preg-
nancy. The islands of lymp hoid tissue in th e basal layer of
t11e endome u·ium scatte r l)•mphocytes imo the functional
layer so that at tJ1is stage, the re is a well-marked lymph ocytic
infilu·ati on of t11e whole of the endometrium. T he endome-
trium measures 8-10 mm in t11ickn ess in t11 e secretory
phase. T he endometria l tl1i ckness can be studied ultrasoni-
call)'· This study is useful in ind icating the op tima l time for
embq•o transfer in in vitro ferti lization (Fig. 3. 12). ln spite
of the intense secretory activity of t11 e fw1ctional the
basal layer glands are not similarly affected and retain non-
secretory pattern and miLOsis is rare in this phase.
The secretory phase reaches iLS peak by me 22nd day of
t11e cycle, after which no furtJ1er growt11 e nsues. About the
24th da) of tl1e C)cle some shrinkage of t11e glands is appar-
ent, partl) due to t11e deh)dration of me stroma. The cork-
screw pattern now becomes saw-LOOtl1ed. o supe1ficial ne-
a ·osis has )et occulTed but t11e supe1ficial layers are
noticeably less vascular. just before mensu·uation, t11ere is a
well-marked local leucOC)tic infiltration.
43
Dating of tl1 e endometriu m and the diagnosis of lu teal
phase defect (LPO ) are recognized by corre lating the post-
ovulatory endometrial picture with the menstrual date. A
lag of 2 or more days is conllrmative of corpus LPO. The
estimation of progesterone level in t11e mid-secretOry phase
also indicates progesterone dellcienC).
THE MENSTRUATING ENDOMETRIUM
The mensu·ual changes in the endomeuium are essentially
degenerative. The spiral<oiled a rte1i es undergo vasocon-
striCLion a few h ours before the onset of menstrual bleeding
under the influence of prostaglandin F2a. It is believed t11at
the ischaemia thereby procluced leads to the necrosis of
zones in tl1e walls of t11e small arteries in the superficial pan
of the endomeu·ium. In addition, t11e b uckling oftl1e coiled
arteries produces blood stasis, wh ich may also cause necro-
sis. T his buckling resul ts from the decrease in the depth of
the endome u·ium as a whole and ca uses furtJ1 er tightening
of the arterial coils. Several aclcl itional coils may be detected
in a single vesse l. Bleeding from t11e endometrium is re-
stricted only to the tim es when the coiled a n e ries relax and
whe n the b lood is disc harged from t11 e artery tJu·ough the
damaged necrotic a reas in its wall. T he su·aight arteries im-
mediate!)' beneath the coiled arteries undergo vasospasm at
the time of tl1e me nstrua l bleeding a nd thereby provide a
simple safety mechanism for T his vasospasm
limits t11e menstrual loss. Oellciency of t11e mechanism ma)'
accoLmt for some forms of menorrhagia. The vasospasm is
selective as it on I) affects the superficial layers and does not
extend to the basal la)er, which is t11ereby assured of an
adequate blood suppl) necessa1) for regeneration. The
compact .tone of the functional la)er becomes infilu-ated
a large number of cells, and the surface epitl1elium
ma)' be pushed away from the sub-acljacem stroma. A little
later me glancls of the spongy .1:0ne of me functional layer
disintegrate so mat the epithelial cells sepa1-ate from each
otller and become scattered amongst me red blood cells,
leucocytes and tl1e cells of me stroma (Fig. 3.11 B). The de-
generative process is 1-apicl so that by the 2nd da)' of me
period of bleeding, t11e compact zone and the superficial
part of the spongy zone have degenerated and a la1·ge part
of it has been disch ar'ge<l into the cavity of t11e uterus. It is
certain that the whole of t11 e compact zone ofLhe functional
layer is shed, and probabl)' most of the spo ngy zone of the
e ndo metrium is also s hecl. The basa l laye r is no t shed dur-
ing me nstma ti on. On t11 e 3rd clay of t11e period of b leeding,
the surface of the e nclomeuium is raw and the patulo us
glands of the functiona l la)•er open direct!)' imo t11 e cavity of
the uterus. Active degene ration seems to be resu·icted to th e
first 2 days of mensu·uation. The subseq uen t bleeding is th e
result of oozing from the capilla 1ies of t11e den uded stroma.
It is common to llnd re lics of the glands and stroma of the
endometrium in the shreds and clotS passed on the 5tl1 day
of t11e periocl of bleeding, which affords conclusive proof
t11at a large part of t11e endometrium is shed in nonnal
mensu·uation. There is reason to believe, however, t11at in
some cases of abnormal uterine haemorrhage, t11e disinte-
gJ-ation process is not spread uniform!) over t11e entire en-
domeuium but ma> be locali£ed to limited areas.
The mensu·ual blood loss is conu·olled b)' imeraction be-
tween PGE2, and PGI2 (prostaC)clin) secreted by t11e
 SHAW'S TEXTBOOK OF GYN AECOLOGY

Rgure 3.12 Pelvic sonography showing normal anteverted position of the uterus in sagittal views (A and C) of two separate patients. Note the
polycystic (right) ovary adjaoent to the uterus in the sagittal view (B) and the thickened endometrial linings in the views (C and D). (Courtesy:
Dr Ketar1 Gundavda, Mumbal.)

endomeu·ium. Whe reas PC E...!, PGF20' and th romboxane cause

vasoconsu·iction of tJ1e vessels, prostacyclin ca uses vasodilation
and menon·hagia. The comb ined o ral con u·aceptive p ills
(OCPs) cause au"Ophi c endometrium. predominates in
the pt"O liferative p hase and PGFp in 1J1 e luteal phase.

ENDOMETRIAL REGENERATION
Regeneration of the denuded epithe lium is already in prog·
ress before tJ1e menstrual bleeding has stopped and is com-
pleted 48 hours after the e nd of mensu·uation. Repair is
brought about by tJ1e gland ular epithe lium growing over
tJ1e bare stroma (Fig. :t l :l). This is brought about by vascu-
lar endotJ1elial growth factor (VEGF) produced by oestriol
stimulation. It is not uncommon for relics of crenated
glands to be found in the endometrium during me first
2 da)S following mensu·uation, and one of me great chamc- Figure 3.13 Endometrium on the last day of the period of bleeding,
teristics of me endometrium at this time is me presence of illustrating the compact str001a and the method by which the denuded
a large number of I) mphOC) tes in the su·oma. The relation area is covered by the epithelium which grows over It lr001 the glands.
 CHAPTER 3 - NORMAL HISTOLOGY OF OVARY AND ENDOMETRIUM
of the cyclical changes betwee n th e ovaries a nd the endome-
trium is disc ussed in Chap te r 4.
FUNCTIONAL LAYERS OF ENDOMETRIUM
Using magnetic resonance imaging (MRl) technique, Haicak
desa·ibed Lh ree la)ers of e ndometrium: ( I ) high-imensity
endometrial strip; (2) med ium signal ime nsity over Lhe myo-
meui um; and (3) in between these two la)e rs, a j w1cLio nal
.wne' or 'subendomeuial halo'. UltraSOund shows peristalti c
movements in this subendomeuial halo Lone. These move-
men ts are under honn on al infl uence. T his Lone is thin be-
fore puberty a nd after the menopause, and also in those on
oral combined pills. It increases in size du•·ing pregnan cy and
becomes vascular un der oestrogen influence. This zone is
maximum at the tim e of ovulation . At this time, the increased
peristalti c move ment helps in the u·anspon of sperms imo
the fallopian tubes. The peristaltic movementS diminish dur-
ing th e luteal phase unde r the effec t of progesterone and
help in th e implantation offe n ili zed egg.
The contracti ons or these moveme ntS in the subendome-
u·ial zone have importa nt bearing on reprod uctive process.
The)' he lp in the ra pid u·ansport of spe •m s to th e fallopian
tubes within a few minutes d uring ovu lation, and also help
in implantatio n during th e lu teal phase.
Abno rmal functio n o f this zo ne o ne of the factors re-
sponsible for failure o f concep tio n in IVF programme, o r
occ urrence of a tubal pregna ncy.
THE DECIDUA OF PREGNANCY
ln Lhe earl) weeksofpregnanC), the strucLUre of the endome-
trittm is vel") similar to that found in the late sea ·etory phase.
The di,•ision in to compact and spongy LOnes o f the fwlc-
tio nal la)er is more clearly defined. The basal layer can still
be identified, but its glancls, although staining more d eeply
Lhan Lhe h)peruophied of the spongy la)er, show
some degree of cre nation an d con tain secretion. The 1)111-
phoid islan cls of the basal la)erare not easily identified, for in
the early weeks of pregnan cy lymphocytes are disseminated
extensively into the suu ma of the spongy layer. The glands of
tl1e spongy la)'e •· retain th e gene•-al form fow1d in the late
secretory phase, but they are much more cre nated, so much
tltat tlte impression is give n that they have increased in num-
ber. T he cells li ning the gla ncl5 are irregular in shape and
tend to be e lo nga ted with irregu lar processes projectin g into
the lu mina of the glands and d ischarging secretion. lt is not
uncommon for small papillae to be formed wh ich p •uject
imo tl1e glands, but in spite of the activity of tl1e epithe liu m,
Lhe basement membrane remains well defined. Activity is not
resu·iCLed to the immediate vicinity of the implanted ovum
but is disu·ibuted uniform ly throughout the e ndome1:1·ium of
tlte body of the uterus. The co mpac t laye r shows tlte typical
decidual reactio n of pregnancy. The decidual ce lls are de-
rived fro m suu ma cells: they are stella te in shape, contain
glycogen and are surro unded by an imercellular fibril lary
grottnd substance and I) mphocytes (Fig. 3. 11) .
ECTOPIC DECIDUAL CELLS
Decidual cells are not •·esui ctecl to the endometrium o f tl1e
bocly of Lhe ULea·us. Decidual reacti on has been demonstrated
45
Figure 3.14 Decidua of early pregnancy. The large decidual cells
have a faintly staini ng cytoplasm which Is eosinophilic. They are always
surrounded by lymphocytes and the cells fuse wit h an Intercellular
matrix . (SotN"ce: Taha M. M. Hassan, Ahmad M. S. Hegazy, Mohammed
M. M osaed, Anatomical and Histopathologic Analysis o f Placenta in
Dilation ard Evacuation Specimens, 2(2):2014.)
in vatious ec topic siLUations in the pelvis. The best example
of ectopic decidual reac tio n is found on tlte surface of tlle
ovaties during pregna ncy, wh en small irregular reddish areas
are easily recognited with th e na ked eye and show typical
decidual reac tion on h istological examinaajo n. ln tlte ovaries,
tl1 e decidual reac tion is limi ted to the surface wiLh very little
invasion of the cortex. Ectopic decid ual reaction is a lways
ve ry we ll marked be neatJ) the periLOne um of the back ofLhe
ute n.tS in Lh e po uch of Douglas. It has been demonsu-ated in
ad enom)omas, in the walls of chocolaae cysts, o n tl1e ute•·o-
vesical fo ld of pel'itoneum and in t11e omenuun. Decidual
reacti on can imoariably be demonsu-ated in the isthmical re-
gion of Lhe endo meu·iwn d uring pregnan cy, but only rarely
is Lhe typical reaction found in the glan ds of tl1e ce1v ical ca-
nal. Decidual reaction occurs in the fallopian tube in an ec-
topic pregnanC)', but it is incomplete and deficienL A thick
decidua develops in hydatidifonn mole under the influence
of hormones. The significance of ectopic decidual cells is
unknown. T he deciclual reactio n is controlled by Lhe corpus
luteum, but it is tmknown why only cells witlt tltis curious
di stribution respond to tlte stimuh.L5.
VAGINAL EPITHELIUM
The uppe r portion of the late ral vaginal epi theliu m disp lays
C) clic changes in respo nse to the ovarian hormones. These
1
changes ca n be swdied C)'tologically by sc raping th is por-
tio n of tlte vaginal epitlteliu m and staining it with Shon·
stain. De tails of vaginal cytology a re disc ussed in Chapter 9.
OVARIAN FUNCTIONS
Apat't fro m produci ng a n ovum mo ntl1 ly, O\>a1ies produce
ho rmo nes respo nsible for matumtio n of the Graafian fo lli-
cle, ovulati on, mensu·uatio n and ma in tenance o f pregnat1cy
in the ea rly weeks of gestation. The ste roidal honno nes at·e
oestrogen and progestemne. Oesuugen is mainly secreted
46 SHAW'S TEXTBOOK OF GYNAECOLOGY

by the Graafian follicle in the follicular phase (preovulatory

phase). A small arnoun tis also secreted by the corpus luteum
in the premensu·ual phase. Progesterone is secreted b)' the
corpus Imeum, and the absence o f progesterone in the pre-
menstmal phase denotes anovulation. The comrol of these
hormones is described in Chapter 4. Inhibin is a nonsteroi-
dal hormon e presenL in the Graafian follicle. It is a protein
that inhibits FSH and stimulates Ll-1 secretion by the atue-
•ior pituitary. Excess of inhibin see n in poi)C)'Stic ovarian
disease ( PCOD) is responsible fo r the high level of LH.
The other hormones whi ch the ovary produces in small
amounts are testosterone and androstenedione, mainly se-
creted by th e stromal cells and stimulated b)' LH. Andro-
stenedione gets converted pe•ipherally into oestrone through
aromati£ation in the f<1t tissue. After menopause, oval"ian
oestrogen level falls as Graafian follicles disappear, and pro-
gesterone fui ls to be produced. The increased su·omal cells of Rgure 3.15 Microscopic appearance of dried cervical mucus showing
the 'fern appearance'. htlp://g}'flOOCI'lline.ccm/cefVical_cy::le.htm.)
the menopausal ovary continue to produce some androstene-
dione which gets conve rted into oestrone. Although a weak
oesu·ogen, oestrone is capable of exe rting oesu·ogenic effect and tenacious and impeneu·able to sperms and bacte•ia. T he
on the target tissues. Obese women have, th erefore, more detai ls of cervical mucus are clesclibed in Chapter 16.
oesu·one tl1an a lean woman , and hence a greater tendency Endocervical li ning does not ex hibit cyclical changes li ke
to endomeu·ia l hyperp lasia and ma lignanC}'· the endomeu·ium. In pregnancy, however, adenomawus
h)•perplasia may occw·, and decidua l changes are seen in
10% of tlle patients.
PREGNANCY Oral combined hormonal pills over tl1e years also ca use
ln some cases of uterine and ec topic pregnancies, the endo- hyperplasia of endocervical e pitl1e lium and an abnorma l
metrium shows intense adenomaLOus and hypersecretive ' Pap smear'. Lately, an increased incidence of endocervical
activity within the glandular epithelium. The cells are en- carcinoma has been observed in young women who have
larged; epithelial nucle i show mitosis, hyperchromasia, been on honnonal contraception use. Contrary to tl1is, the
pol)'Pioid) and at} pica I cell t} pes. The cells are hypersecre- pills cause au·ophic e ndometrium in the body uterus.
tive witl1out gl)cogen con ten L This condition is called the
Arias-Stelltt 'tfaction. These changes are focal and often as-
sociated with d ecidua l•·eaction in the stroma. Besides preg-
PROCESS OF FERTIUZATION
natlC)', this endometrial reactio n is see n in endometriosis, Cenain changes are necessa•1' before the p•·ima•)' OOC)'I.e
reaction to oesu·ogen and to gonadou·opins as well as in catl mature for Oogonia that enter the pro-
gestational u·ophoblastic disease (GTD) . phase of tlle first meiotic division are known as primat-y
oocytes, whereas tl1ose oogonia whi ch do not begin the first
meiotic division and not surrounded by granulosa layer
MENOPAUSAL ENDOMETRIUM
undergo atrophy. At puberty, under the LH SUI·ge, p•·imary
ln tl1e majolity of women, oestrogen witl1drawal at meno- oocyte completes the first meiotic division and gives rise LO
pause causes enclomeu·ial atrophy, and the endomeu·ium is secondal)' oocyte, containing most of the cytOplasm, 23X
only 1-3 mm in tl1i ckness. The atrophi c endometl"ium is chromosomes and a small polar body. This secondary oo-
susceptible to infection, resulting in seni le endome u·itis and cyte completes its second meiotic divisio n only after fertil-
postmenopausa l bleed ing. In rare cases, tl1 e endometrium ization, and gives o ut second polar body.
becomes hyperp lastic under the influence of ex u·agen ital T hus, the first stage of mawratio n of the oocyte occurs
oestrogen (oesu·one) prod uced in the peripheral fat from within tl1e Graafian foll icle, b ut t11e second d ivis ion occurs
epianclrostenedione. The posunenopausal endometri um only after tl1e ferti li zation in the fa llopian wbe.
measuring more than 4 mm is co nsidered abnormal. Endo-
metrial h)'perplasia and polyp also occ ur when tamox ifen is
administered to a woman witl1 breast cance.:
KEY POINTS
CERVICAL MUCUS • The ova.-y of tl1e newbom has about 2 million p•imor-
dial foUicles. These are reduced to abo ut 400,000 at
ln 1918, Papanicolaou desclibed the fern test and tl1e cyclical
pubert). atul of these around 400 are available during
cl1at1ges in tl1e cel'\1cal mucus unde r tl1e influence of various
the reproducti' e lifespan.
honnones. A drop of cervical muCtL$ spread and dlied on a
• C)clic cl1anges in the Graafian follicle- leading to ovu-
glass slide in tlle preo' ulatO•) phase (oestrOge nic phase) pres- lation. corpus lute um formation and mensu·uation -
ents a palm leaf or fe m t) pe of reaction, due to tl1e presence a.·e under tl1e conu·ol of the h) pot11alamus, which
of sodium chlol"ide in it (Fig. 3.1.'>). This reaction disappears conu·ols tl1e release of gonadotropins from the atHe-
after O\Uiation under p•·ogesterone influence. Under tl1e in-
rior pituita•)'·
fluence of p•·ogesterone, the cel'\·ical mucus becomes thick
 CHAPTER 3 - NORMAL HISTOLOGY Of OVARY AND ENDOMETRIUM
• Oesu·ogen causes regeneralion of the endomeuium
and leads to proliferalive phase. Progesterone is re-
sponsible for secretory transfonnation of the endome-
u·ium, rendering it favourable for implamalion of
fcrti li Led ovum.
• Peak level of 40-75 ng/ m L of Lll is noted j ust before
ovul ati on.
• In the presem-day practice, se ti alultrasound monitor-
ing of th e Graafian fo llicle is the most preferred
method LO detect ovulation in patienlS undergo ing
u·eatmem for infertility.
• l::ndomeu·ial histology is useful to diagnose endome-
u·ial tuberculosis, endomeu·ial cancer and honnonal
d)Sfunclion.
• l::ndomeuial thicknessofS-12 mm is considered normal
in the premensu·ual phase. In posunenopausal women,
enclomeuialthickness should not exceed 4 mm.
• L H surge is an im portant indicator of imminent ovu·
lation.
47
SELf-ASSESSMENT
I. Deso·ibe the microscopic appearance of the endome-
uium during the proliferative phase.
2. Describe the histological appearance of th e endome-
uium in the sec retOt) ' phase.
3. Describe the e ndometrial changes during pregnancy.
4. What is the significance of cervical mucus changes in
feni lity practice?
SUGGESTED READING
Berek and Textbook of Ada, hi EY, I Iiiiard PA
(ed>) . :--'o,-ak's G)llCCOiogy. 151h ed. Phihtdelphia, PA, Williams &
\\"lll:.in>. 2014.
Mishdl DR J r, Oavajan V (eds) . Infertility. Contmception and Repro-
ducti\ C Endocrinology. 2nd Ed. Or.tdcll, NJ, Economics
Book> Or.-tdell, 1986.
' ov-.tk E, Nov-.1k ER (eds). Textbook of Gynecology. 4th Ed. Baltimore,
Philadelphia, PA, Williams & Wilkins, 1952.
 Physiology of Ovulation
and Menstruation
Hypothalcmic-Pituitary-Ovorian Axis 48 Menstruation 58
Ovarian Steroidogenesis 51 Menstrual Fluid in 'Stem Cell' Therapy 60
Physiology of Menstruation 54 Key Points 60
Feed bock Mechanism in the H- P-o Axis 56 Self-Assessment 60
Leptin 58
C)•clical mensu·uaLion and reprod ucLive func Lions in a
woman occur as a resu lL of fine in Leraction between
hypoLhalamus and anLerior piLUiLary. Hormone prod uction
(follicle-stimulaLing hormone [FSH] and lu te inizing hor-
mone (LH]) from anterior pituiLary in turn is responsible
for follicular maturaLion, ovulaLion, corpus luteum forma-
Lion and producLion of oesLrogen and progesterone
honnones from oval'). Therefore, an understanding of
hypothalamic-pilllital')-<>'-arian (H-P-0) axis is imponam
for knowing ph)siolog> of reproduction and managemem
of \<a1ious diseases associated "ith their malfuncLion.
euroendocrinology with \'<1St honnonal imeracLions is
responsible for mensu·ual C)cle and reprocluCLive functions
in a woman.
HYPOTHALAMIC-PITUITARY-oVARIAN
AXIS
It is now well established that a normal menstrual cycle de-
pends on cyclical ovarian steroid secre Lio ns, whi ch in tum
are con trolled by tJ1e piuti la l) ' and tJ1e hypo tJ1 alamus and,
to some ex tent, are infl uenced by the Lhyro id and adrenal
gla nds. It is tJ1erefo re essen Li al to undersLa nd the H- P- 0
ax is in nonnal women and app ly tJ1is knowledge in thera-
peutic management in inferLi li ty, fam il)' p lann ing a nd vari-
ous g>•naeco logical d isorders.
HYPOTHALAMUS
Hypotl1alamus with its several nuclei and extrinsic connec-
tions is now considered Lhe main nemoendocrine gland and
tl1e regtdaLOI) factor in the d1ain of hypotllalamic-piruitary-
ovarian-meline axis. H) regtdaLes tJ1e functions
of ilie amerior pilllita•) gland ilirough po•·tal vessels by
releasing botJ1 sLimLdaLOI) and inhibiLory honnones iliaL
in Lurn influence tJ1e funcLions of tJ1e targeL Lissues Lhrougll
ilie S)'SLemic circulaLion (Fig. I. IA and B). These hormones
in Lw·n are conLrolled by posiLive and negaLive feedback
48
loops from ovarian hormones. l!:xLernal and ime rnal sLi muli
fur ilier modi f)' or influence h)•poLhalam ic func Lions.
HypotJ1alamus is located aL the base of tJ1e brain be hi nd
opLic chiasma and below the above tl1e p ituitary
and forms tl1e base of the third venLricle. The base of the
hypothalamus forms tuber cinereum, which merges LO form
Lhe piLuital') sLalk. The oligin of tJ1is stalk is known as
median eminence. which is lich in capillary loops as well as
ne•·ve endings. Median eminence is an imponam siLe of
sLomge of chemical signals, which geL transfen·ed imo
porlal circulation LO reach t11e ame•·ior piLUiLary gland.
Schally and Guillemin were t11e first LO discover a decapep-
tide called gonadotropin-releasing honnone (GnRH) in
1971. GnRH is secreted by Lhe median eminence and the
arcuale nucleus, which modulates ilie neural conu·ol of
FSH and LH b)' tJ1e anterior pilllilary gland. IL (arcuaLe
nucleus) also secretes prolactin-inhibiLing facLOr ( PlF),
wh ich is dopamine that inhibits the release of prolactin.
During laLe pregnancy and lactation, a low or absent inhi bi-
LOry factor leads to a high secreLion of prolactin tl1at ini ti-
ates and maintains lactation.
Hypo tJ1alamus is also responsible fo r secreti on of
thyro u·opin-releasing factor, conico u·opin-releasing
ins ulin-like growtJ1 factor and me lanocyte-releasing
Hypo tJ1alamus is connected to tJ1e a me rior p iwitaf)•
gland tJuo ugh special h)•pop hysis piu.tiLa•) ' po rLa l S)'SLem of
vesse ls but connected d irec Lly LO tJ1e poSLe•io r p itui tary
gland (ne uroh)•poph)•sis) b)' Lhe supraoptic and paraven-
tricular nuclei (Fig. 1.2).
Gn RH (decapeptide) is synthesiLecl in arc uate nucleus
and is released at tl1e nerve endings near wber cineret.Un.
GnRH has a half-life of2-'l minutes and is tJ1erefore difficult
LO assay. Its level is assessed through tl1e LH level. It is re-
leased in a pldsalile manner in to t11e portal vessels and
readles tJ1e ame1ior piLUital) gland. 7711! pulsatilit)' a1lll ampli-
liule of its rdK1S1! vary tUith /Ju variou.s phasi!S oftllJ! 1mmstnwl eye/£.
In the preovulaLOI) phase (the follicular phase), it pulses
once in eve•)' 60 minutes, but it slows do"n LO once in 3 hours
in ilie luteal phase, with increased amplitude of each pulse.
 CHAPTER 4 - PHYSIOLOGY OF OVULATION AND M ENSTRUATION 49

External environment

- -- - - Supraoptic
nucleus
. - - - - - Arcuate
Median eminence _ nucleus
Optlc chiasm - --+
Superior
hypophyseal artery
- -.1 1 • ,
GnRH and
prolactin Anterior lobe
+- inhibiting
factors
'--_ Anterior
Figu re 4.2 Hypothalam ic nuclei.
pituitar y gland

- {FSH
LH
e mp loyed in therapy using S)•nthetic analogues of GnRH in
regulati ng ovulatio n in in viu·o fe rti lizatio n and s uppressing
menstruati on in precocious pubeny, in red ucing the size of
Ovary the uterine fibroids and in causing shri nkage of endome-
triosis. Its suppressive effec t o n ov ula tion is also being tried
as a conu·aceptive, but Lhe drug has proved expensive as of
Oestrogens today. The pulsatile adm inisu·ation, o n the other hand,
Progestogens
Androgens causes cyclical re leaseof go nado tropins- FSH firstand later
LH whid1 induces ovulaLion and the possibility of a preg-
nancy. This th erap) is applied in women with anovulatory
A Reproductive tract infertility.
HypothalamtLS ca n be influenced by the higher cortical
cenu·es, especiall) the temporal lobe. Emolional upsets ru·e
Ova rlan ho rmo ne productio n known to stimulate or d ep•·ess the H-P-0 axis a nd disturb
the menstrual C) des. eu roen docri ne sys tem works through
several loops, both positi' e a nd negative.

• Long loops through oestrogen and progesterone

• Short loop through anterior pituitary gland
• Ulu-ashon loop within the hypoth alamus

Epinepl11ine and oestrogen stimulate whereas dopamine,

serotonin and opioicls inhibit the release of GnRH by the
hypo thalamus. Gonadotropins also inhi bit GnRH secreti on.
Un ti l pube•t y, the hypothalam us is in a clo•ma nt state un-
der the inhib itory infl ue nce of adrena l con ex, and the higher
Testosterone and Aromatlzatlon corti cal cen u·es, or it ma)' be insensitive and nonresponsive to
androstenedione E2 , inhibin th ese stimt.J i. It becomes gmd uallysensiLi ve around8-12 years
aromatlzatlon aromatase
and starts its hormona l functions, full)' establishing the
H- P-0 axis b)' tJ1e age of 13- 14 years. What u·iggers Gn RH to
stan function ing is not dear, bm perhaps lep tin produced b)'
( O estrogen )+----' tl1e adipose tissue that initiates tJ1e response. Initially, Gn RH
is released in a ptJsatile manner el uting sleep, b ut later
B throughout 24 hours. In tJ1e follicular phase, witJ1 low oestro-
Rgure 4.1 (A) Hypothalamic-pituitary-ovarian axis. (B) Ovarian
gen (£ 2) level, pulsatility is every 90 minutes, and with rise in
hormone production.
E2 level. tJ1e frequenq lises to every 60 minutes. In the luteal
phase, tJ1e frequenC) slows down to l pulse in 3 hours. Hypo-
GnRH exhibi t.s different actio ns depending on the man- Ulalrumts is sexuall) differentiated at birth. GnRH secretion is
ner in which it is released. It.s con 1jnuous release catLSes sup· continuoLLS in males but pulsatile in females. Administration
pression of gonadou·opins and thereby the ov:uian fw1clions of testosterone tO a female rat at bi•·tJ1 is shom1 to cause a
through the process of 'downregulati on' or desensilization continuous secretion of Gn RH in laler life and alter lhe
of pituitary hormones. This mode of adminisu-alion is now honnonal function to a male l)pe.
50 SHAW'S TEXTBOOK OF GYNAECOLOGY
Synthetic analogues of CnRH are nonapeptides and are
now available and used in Lhe following:
• Preoperative shrinkage of uterine flbroids
• Shrinkage of e ndometriosis
• Sh•·inkage of the e ndometrium prior to endometrial
ablation
• Hirsutism
• Precocious pubeny
• ln ' 'iU'O fe•·tiliation
• Prostatic cancer
Prolonged adminisu-ation over 6 momhs can cause oes-
trogen deficiency and osteoporosis, and therefore the ther-
ap)' should be used on a shon-tenn basis. Th is peptide is
degraded in th e gasu·ointestinal u·act and is t11erefore given
intravenously, subcutaneously or inu·a nasally. Its short life
mandates repeated adm inistration at sho rt intervals. How-
ever, depo t mo nth ly injections are ava ilable.
Side effects ofCnRII a re as follows:
• Inso mnia
• Nausea
• Osteoporosis ca used by oestrogen deflc ienq•, b ut reverts
to no1mal after stoppage of the d rug
• Decrease in breast size- reversib le
• M)ralgia, oedema
• Diz.lin ess
• Decreased libido
• Decrease in high-de nsit} lipoprotein (H DL) and increase
in cholesterol b) 10% each
The drugs and their administration are as follows:
• afarelin 200 meg inu-anasa ll} dail)' for 6 months.
• Buse•·elin 300 meg Li.cl. subcutaneously daily x 5 clays.
• Depoti•'\iectio n ofgoserelin i.m.orimplam3.6 mg momhly.
• Leup•·olicle 3. 75 mg i.m. monthly X 5 months.
• Triptorelin 3. 7 mg i.m. 4 weekly.
• Antagon is CnRH antagonist used in downregulation in
in vitro fertili£ation.
• Hypothalamus also secretes insuli n-li ke growth factor,
tl1yroxin and corticou·oph in releasing fucwrs.
PITUITARY GLAND
Pitui tary gland lies in the sella turcica. It measures 1.2 X
X 0.6 em a nd we ighs 500-900 mg. It comprises the ante rio r
p itui tary glan d (adeno hypop hysis) and t11e pos te lior pitu-
itary gland (ne urohypop hysis). T he ame •io r p illlitary gla nd
originates at t11e I'OOf of the emb•)•onic p ha •)•nx called
Rath ke's po uch and con ta ins chromop hil and chromo-
p hobe cells. T he posterior lobe deve lops from the floor
of tl1e brain. The two lobes of the pituitary gland develop
independently of eac h other. The anterior lobe is ectoder-
mal in origin.
ANTERIOR PITUITARY GLAND (ADENOHYPOPHYSIS)
The amerior pituita•) gland, measuling 30 x 6 x 9 mm in
sue, is located at tl1 e base of t11 e brain in a bony called
sella turcica below tl1e h) pothalamus. It consists of tlHee his-
tologically distinguishable cells: (i) t11e chromophobe or par-
ent cell, (ii ) the chromophil cells desuibed as eosinophil or
alpha (ex) cells and (iii) basophil or cells. The !3-cells
sea·ete tl1e gonadou·opins that control tl1e ovarian fu nction
and menstrual cycles. These gonadou·opins are FSH, LH,
U1)'l'Oid-stimulaLing hormone (TSH) and corticosteroid
honnone. Each of these honnones has ex- and
Although ex-fraction is ide ntical in all (co ntains 92 amino
acids). !3-6-action is speciflc in its action.
Follicle-Stimulating Hormone
FSH is a water-soluble glycoprotein of high molecular
weight and is secreted by the it contains 115 amino
acids in !3-fraction. The carbOh)drate fraction is mannose.
FSH conu·ols tl1e .-ipening of the primordial follicles, and in
co•'\iunction witl1 t11 e LH, it activates the secretion of oestro-
gen. Its activity builds up as the bleeding stan.s to cease,
reaches a peak around the 7th day of the cycle ( 40 ng/ m L)
and then decl ines to disappea r around the 18tl1 day.
Anotl1er small peak occu1'S after ovulation, perh aps as a
result of a fall in t11e level of oestroge n in t11e p remensu·ual
phase. T he half..life of FSH is 4 hours. Low FSH causes de-
fec tive fo ll iculogenesis and short or defec ti ve co rp us lu teal
phase. Oesu'Ogen supp resses FSII sec reti on tl1ro ugh nega-
tive feedbac k mec hanism. It deve lops LH receptOrs in th e
granu losa cells.
Cemzell initia ll)' isolated FSH from the piLUitary of human
cadavers at a utopsy, but it req uired 10 pitui taries to produce
enough FSL-1 for one ovulation. FSH is now commercially
obtained from tl1e Uline of me nopausal women. The prepa-
ration contains botl1 FSl-1 and Ll l. Pure FSH is now available
on tl1e market but is vel') expensive. FSH is stimulated b)'
CnRH, but suppressed b) oestrogen and inhibin B.
Luteinizing Hormone
LH is a water-soluble gl)cop•·otein of high molecular weight
secreted by it also contains 115 amino acids. The
carboh)drate f1-acti on is mannose. Initially, LH pulse occurs
only during sleep, but later extencls throughout the clay. LH
surge initiated by oestrogen lasts for 48 hours and is pre-
ceded by a small amount of progesterone 2 hours earlier.
LH level doubles in 2 how'S and the peak plateaus for
14 hour·s before declining. Progesterone secretion begins
34 how'S after Ll-1 peak. In COI')junction witl1 FSH, it
activates the secretion of oestroge n, b rin gs abo ut the
matu rati on of tl1e ov um and causes ovulatio n. LH stimulates
the co mpletion of the red uctio n d ivisio n of the oocyte.
Following ovulatio n, it prod uces lute ini za ti on of tl1e granu-
losa and the theca cells and initi ates progestei'O ne sec re tio n.
T he LH surge p recedes ovulation by 24-36 ho urs (mean
30 hours) and a mi nimu m of75 ng/ mL is req uired for ovu-
lation. This ti me re lationshi p of LH peak to ov ula tion is
helpful in predicti ng the exact time of ovulation in inferti le
women on gonadotropin the rapy, making it possib le to re-
trieve ova in in vitro ferti lizmion and to arrange for timely
artificial insemination to e nhance chances of conception.
LH stimtdates tl1e secretion of testosterone and androstene-
dione in t11e ova .-ian stroma (th eca cells), which diffuse into
t11e follicular fluid and are aromatit:ed into oestradiol. Low
level causes unrupturecl follicle, non-ovulation and corpus
luteal phase defecL
1 owadays, for diagnostic and therapeutic purposes, a
rapid, visual, semf.quantitati,-e en£)1ne immunoassay dip-
stick test, called OntSTICK, is a\>a ilable for testing urine to
 CHAPTER 4 - PHYSIOLOGY OF OVULATION AND MENSTRUATION
Converted to
androstenedione
1-----+1 and testosterone
converted to
oestrogen by
Granulosa cells by
aromatisation
Rgure 4.3 Two-<:ell two-gonadotropin t heory of ovarian steroido·
genesis.
de tec t Ll-1 surge by underta king dai l)' LH esLimatio ns
around the period of ovulation. T hese ki LS are expensive.
The half-life of LH is 30 minutes (Fig. <1.3 ). Inadeq uate Ll-1
peak causes unrupwred co rpus luteum, anovulation and
corpus lu teal phase defect.
Human Chorionic Gonadotropin
Secreted b) the trophoblasLic Lissue in pregnancy, human
d1orionic gonadotropin (hCC) has a lute inizing action and
is avai lable in form for 1LSe in cases of anovulatory
infertilit). in viu·o fertiliLat.ion, corptLS luteal insufficiency
and habitual abonions. hCC contains cr- and !3-fract.ions.
The cr-fraction resembles LH and TSH, but the !3-fract.ion is
exclusively specific to cho•·ionic Lissue. It is commercially
obtained fi·om the llline of pregnant women. The level is
increased in trophoblastic tumours and some ov.u·ian lll·
mours. Recombinant h CC is now available, which has fewer
side elfeeLS at the site of inject.ion. 250 pg recomb in am hCC
is equivalent to 5000Cu of hCC.
Prolodin
Prolac t.in is an alcohol·soluble protein (polypep tide) ( 198
amin o acids) wi tJ1 out a ca rbohydrate fractio n and with a
half.life of 30 minutes. IL is secre ted by a-cells. Its main
ac Lio n is on lactatio n. IL has a suppressive effect on the
pituitary-ovari an axis, and t11 erefo re the patiem who suffers
from h)•perprolactinaem ia may develop ameno rrh oea or
oligomenorrhoea d ue to anovulatOr)' C)•cles, with or without
galac torrhoea. Normal prolactin level is 25 ng/ mL. Up to
100 ng/ mL occurs in hype rpro lac Linaem ia but over 100 ng/
mL is seen in pituitary tumours. The prepube rtal level of
7 ng/ mL rises to 13 ng!mL at pubercy and 25 ng! mL in an
adult woman. Active prolaCLin is presem in tl1e form of
monomer or 'little prolactin' (50%), whereas dime ric and
mttlt.imetric (big prolactin) forms have negligible biological
act.ivit). ormall), t11e prolactin release is under inhibitor
control b) h)pothalamic release ofprolact.i n inhibiting fac-
tor probably dopamine and is released in to the portal sys·
tem (1-l)pophysio pituitary pon.al system). The level of pro-
lactin is raised during sleep, nipple stimulat.ion and the
51
secretion of tl1 yroid-releasing hormo ne, 13-endorphin, sero-
tonin and oestrogen.
Prolact.in level does not Ouctuate mud1 during the men-
strual cycle. It suppresses LII but not FSH, so hyperprolaill
naemia decreases the UI / FSII raLio.
Growth lwnno111; iluulil1-likt gruwth Jactur, epid.emwl growth
factor, tulnmal cortex and "ISH also participate in the endocri-
nological fw1ct.ions in a woman, through t11eir act.ion on the
h) pothalamus and ante•io•· pituitary gland. A high level of
TSH st.imulates prolactin secretion a nd causes ovulatory
and mensu·ual dysfunction. Interleukin-1 is a cytokine with
anLigonadou·opic act.ivity and it preventS IuteiniLation of
granulose cells.
POSTERIOR PITUITARY GLAND (NEUROHYPOPHYSIS)
Oxytocin and vasopressin arc nonapeptides formed in th e
hypothalamus and released directl)' into the poste•ior pitu·
itary gland. Oxytocin is produced by the paraventricular
nucle us and vasopressin b)' the supraop Li c nucl eus of the
hypothalamus.
Oxytocin
Oxytocin actS rn ainl)' on t11c smoo th muscle of the uterus,
causing con u·action of t11 e muscles and conu·olling the
bleeding in tl1e third stage of labo uc By intermittent uter-
ine comracLions and re laxat.io n, it induces and en hances
the labour pains in the first and seco nd stage of !abo ut: It
caLLSes contraction of the myoepithelial cells lining tl1e
mammary ducts and ejects milk during suckling.
Vasopressin
Vasopressin maintains the blood volume and blood pres-
sure. Both have antidiuret.ic act.io n when given in large
quantiLies (o,•er 20 unitS of OX)tOcin in 24 hours). The
therapeutic applicat.ions of these honnones are described
in chapter on Hormone The rap)'·
OVARIAN STEROIDOGENESIS
The acLive honnones of tl1e ovary are the steroids derived from
cholesterol. These include oestrogens, progesterone, testoster-
one and androsteneclione ( Fig. I. IA). Relaxin and in hi bin are
other nonsteriod secretions. OestrOgen is produced dUJ·ing
follicular phase and progestero ne is luteal
OESTROGEN
Natural oes u·ogens are C 18 stero ids, the main so urce of
which are the tJ1eca and granulosa cells of tJ1e Graafian
follicles and corp1LS lute um , while the adrena l cortex is
the secondary source of supply. Oestrogen is secreted as
oesu·adiol. lt is bound to albumin (30%) and sex
hormone-bindin g glob ulin (SH BC, 69%), and only I % is
biologically active. lt acts b) binding to cytoplasmic recep-
tOrs in the cells. It is inactivated b) the liver and excreted as
of oesu·one, oestradio l and oestriol in urine and
bile {85% in ul'ine, 10% in faeces). The plasma oesu-adiol
level rises approximate!) &-7 days before ovulation from
50 meg daily to the peak level of 300-600 meg about2 clays
before ovulation and app•·oximately 24 hours before tl1e
LH peak (le\elup to 350 pg/ rnL). the oestradiol
52 SHAW'S TEXTBOOK OF GYNAECOLOGY
concenu·ation falls to 150-200 meg daily, but a small rise is
seen again in the mid-luteal phase. The urinary excretOry
level follows the pattern seen in the plasma. The oestradiol
peak seen before ovulation is not a good marker for indicat-
ing ovulation as Ll-1, because follicular maturation does not
always end in 0\ ula lion. A serum Ieve I of oestrogen with
ulu-asonic monitol'ing is ttSed to monitor the optimal time
to administer hCC for the therapeutic induction of ovula-
tion. Although oesu-adiol, which is 10 times as potem as
oesu·one, is present cllll·ing reproductive pe•·iod, it is oes-
trone deri,·ed from periphe•-al aromatiL.ation of andro-
stenedione that is predominant in menopausal women.
The placenta is the main source of oesu·iol. Each cycle
produces 10 mg of oesu-adiol.
Synt11etic oesu·ogens are readil y avai lable in the market
and are used in valious gynaecological disorder·s. Th ey are
absorbed omlly and tlHough vagina and ski n.
AGION S OF OESTROGEN$ (Fig. 4.4)
1. Feminization and secondary sex characteristics. T he tex-
tu re of fe ma le skin a nd hair and t11 e shape of female
form are conside rab ly in fl ue nced by oes u·ogen.
2. Specific action on the genital tract
Vulva and vagina
Development of vu lva
Vascu lar stim ulation of vulva and vagina
Epithelial stim ulation of vu lva and vagina
Central nervous
system
Anterior
pituitary
Systemic effects:
protein metaboli sm,
carbohydrate metabolism,
lipid metabolism,
water & electrolyte balance,
blood clottl ng
Fallopian lube
Figure 4.4 Physiological effects of oestrogen.
Cornification of the superficial layers of vagina wh ich
appear as acidophi lic polyhedral cells witl1 a small
pyknotic nucleus. Oesu·ogen raises t11e karyopyknotic
index in vaginal C)tOIOg) (Chapter 1)
Deposition and metabolism of inu-acellular glycogen
in vaginal epit11elium
Utents
Causes m)Oh)perplasia of m>ometrium and cervix
Increases utel'ine vascula•·ity
Regene•-ates the endomeu·ium after mensu·uation
and is responsible for the prolifemtive (preovula-
tory) g•·owth of endometrium. Oestrogen causes
prolife•-ation of epithelial lining, glandular cells and
stroma and mitosis. Spiral vessels elongate and
stretch t11e entire length of endometrium, and dilate
Stimulant effect on the glands of endocervix and
their mucous secretion
Fallopian
Oestrogen stimul ates th e w bal musc ula ture, wh ich is,
in fact, morp ho logicall)' speciali zed myo metrium
Ovary
No ac ti o n
3. Breast. 1-i)•pe•trop h)' of tJ1c d uctal and pa renchymal tissue
of breast, increased vasc ularity, areolar pigmentation, but
no galactogen ic effecL Large doses supp ress lactatio n.
4. Action on other endocrine glands. Oestrogen suppresses
FSH and thyrotropic ho11nones. It can be used to inh ibit
----1,...
Mammary gland
Bone maturation
and turnover
 CHAPTER 4 - PHYSIOLOGY OF OVULATION AND MENSTRUATION
ovulation as also produClion of mi lk in puerperal pa-
tienL It is a sLimul<mL for LH and thereby corpus luteum
formation, and, to a lesser extent, for ACfH.
5. Skeletal system. It increases calciflcation of bone and the
closure of epiph)Ses in adolescem and is antagonistic tO
somatotropin. In postmenopausal women, decalciflca-
Lion of bone (osteoporosis leading LO k)'Phosis) is, in fuct,
due to oestrogen deflcienC).
6. Water and sodium metabolism. Oestrogen tends tO cause
water and sodium retention. An example is premenstrual
tension, which is caused by congestion and water reten-
tion. It also causes calcium and niu·ogen retemion.
7. Blood cholesterol. Blood cholesterol levels are to a small
extent controlled by oestrogen, hence the impo•·tance of
ovarian consetvation when perfonning hysterectomy in a
young woman. HOL increases under oesu-ogen influ-
ence and is cardioprotective.
• Oestrogen improves skin h)' producing collagen
• By raising fibrinogen level, it ca n cause thromboem-
bolism, and is a side effect of oesu·ogen
• It increases SH BG b)' th e liver
PROGESTERONE
The cot'Pus lu teum is the main source of progesterone, and
a small amount is derived from adrena l gland (2-3 mg)
seen in the proliferative phase. Although progesterone is an
imponant intermediary product in the synthesis of adrenal
corticosteroids, it has litLie, if any, biological action from this
extraovarian source. The plasma level of progesterone rises
after ovulation and reaches a peak level ofl5 ng/ mlat mid-
luteal phase. With the degeneration of the corpus lllleum,
its level falls and this btings about menstruation. In an an-
ovulator> C)cle, progesterone is absem or is in negligible
amount (from exuaovarian sources). Menstruation is then
brought about by a fall in the level of oestrogen. If preg-
nancy occurs, the corpus lllleum persists, even enlarges and
continues to senete progesterone. This high level of hor-
mone prevents mensu·uation and leads LO amenoniloea of
pregnancy. It is excreted in urine as sodium pregnanediol
3-glucuronide and r·ecovered as such for assay in the secre-
tory phase of mensu·ual cycle. Progesterone is bound tO
albumin (80%) and corticosteroid-binding globulin (20%).
Dail y production in the luteal phase is 20-40 mg and daily
urine excreti on is 3-6 mg. Mid-luteal phase level of less than
15 ng/ ml suggests co rpus lu teal phase defect (LPD) and
ovul atory dysfun cti on.
Radioimmun oassay is curren tly used LO estimate the
plasma progesterone levels in mid-lu teal phase in cases
of infenili t)'· However, witl1 developmem of enzyme immu-
noassa>'• a home 'dipstick' test can estimate urinary preg-
nanediol to determine occurrence of ovulation. Salivary
progesterone level is estimated by direct use of solid-phase
enzyme immunoassay (Dooley). Several symheric progester-
ones (progestogens) are now available for commercial use
(Fig. I.! A and B).
AOIONS OF PROGESTERONE$
Endometrium. Progesterones cause secreLOry h)'Pert.r ophy
and decidual formation if the endomeu·iLUn has been previ-
ously ptimed with oestrogen. Glycogen and mucus collect
in tortuous glands.
53
Pregnancy. Progesterone initially from the corpus
lutewn and later from the placenta is essential for the con-
tin ttation of pregnancy.
Uterus. Progestogens cause myohyperplasia of tl1e
uterus. The) increase t11e strengt11 but diminish tl1e
frequenq of uterine contractions.
Fallopian tube. Progestogens cause hyperplasia of tile
muscular lining of t11e fallopian tube and make pe•·istaltic
contractions more powerful as well as increase the secretion
by tubal mucous membrane.
Cervix. Progestogen causes hypertrophy of the cervix
and makes cervical mucus more tenacious. It renders inter·
nal os competent and holds the pregnancy to term.
Vagina. During early pregnancy, t11e vagina becomes
violet in colour due to venous congestion. The epithelial
cells fuil to matw·e and cornify. They are classicall y baso-
philic with fairly lat·ge nuclei and folded edges. Karyopyk-
notic index falls to below I0%.
Breasts. ProgesLOgens, with oestroge n, cause breast
hypertrophy. They increase ac inar epit11elial growtl1.
Pituitary. The exact ac tion of proges togens on t11e pitu-
itary is not known. Progestogens may inhibit t11 e p rod uction
of FSH and suppress ov ul ation. A cenain percentage of pro-
geswgens is metabo lized to oestrogen, and it ma>' we ll be
that the oestrogen so produced is responsible for inhibiting
pituitary activit)'·
fluid retention . Progestogens cause water and sodiu m
retention and are a conu·ibULory factor in premenstrual
tension and weight gain.
Smooth muscles. Progestogens relax smoot11 muscles.
The ute•·ine muscles therefore rela.x in pregnancy. Ureter
dilates tmder its effecL
Thermogenic. Progestogens raise the body temperamre
by 0.5°C. Basal bod) temperawre (BBT) chan is based on
its tllermogenic effect during t11e mensu·ual qcle.
Anabolic effecL Progestogens exert anabolic effect and
this partly accountS for some of the weight gain which may
follow their administration.
Libido. Diminution of libido infrequently occurs.
Vuilization. Altl10ugh pan of t11e administered progesto-
gen is metabolit.ed to oesu-ogcn, it is also partly metabolized
to testostet-one. Lfadministercd to a patiem eluting pregnancy,
some progestogens have virili:t.ing effect on female fetus.
• Li pid metabolism decreases HDL b ut increases low-
density li poprotein. Thus, it is harmful for hearL
• IL improves immune respo nse.
SIDE EFFECTS
If given in large closes, progestogen ca n ca use gastrointes-
tinal S)•mptoms, nausea and vomiting. Headache and
mild e levation of temperature are a lso seen. In fact, all
symptoms of pseudopregnancy state may be observed -
water retention, breast enlargement and tenderness, and
moderate uterine enlargement. Virilism has been re-
ported wi tl1 some S) n Uletic progesLOgens, especially
19-nonestosterones. Some exhibit adverse effects on lipid
metabolism and increase the risk of breast cancer. Throm-
bosis of deep veins, pulmonar> embolism and anedal
thrombosis are rare but a•·e reponed with tllird genera-
Lion of S) nthelic progestogens (gesLOdene and desoges-
trel) (Ta ble 1.1 ).
54 SHAW'S TEXTBOOK OF GYNAECOLOGY

Table 4.1 Effects of Oestrogen and Progesterone ANTI-MULLERIAN HORMONE

on the Female Genital Tract
Anti-Mi:IIIerian hormone (AMH ) is a peptide secreted by
Organ Oest rogen Progesterone Sertoli cells in the testis and gran ulosa cells in the ovary. In
males. AMH starts to be secreted by iJ1e ?iJ1 week of intra-
Breasts DuctaVstromal growth Alveola- growth uteiine life and it cominues unLit pubert)'· lt in hi bits the
Vagina Superficial cells lntennediate cells development of Miilleritm system. Absence of AMH results
with glyoogen in hennaphrodite.
Abundant mucus thin,
In females, AMI-I is seo·eted by granulosa cells after puberty.
Cervix Thick tenacious
viscous. penetrable mucus, impenetra- It helps in follicular de,elopmentand OOC) te matw-ation.
to spenns ble to sperms onnal value is ng/ ml.; level < I ng/ mL shows
poor O\'<II'ian rese1'\e, level > 10 ng/ mL is seen in PCOD
uterus Myohyperplasla Myohyperplasia and hyperstimulation syndrome. Its level is related LO pre-
Endometrium Proliferative Secretory cocious and dela)ed puberty, infertility and premature
endometrium endometrium menopause. Its level is related and the number of
growing follicles.
Fallopian Secretion Increased peristalt ic
movements
Estimation of serum AM H is used in the study of ovarian
t ube
reserve in an infertil e woman and a woman with seconda•1'
Ovary No action No action amenorrhoea. ln in vitro fe rLi li:£iltio n progr·a mme, it carries
a prognosLic value and he lps to decide on donor egg.

RELAXIN SEX HORMONE-BINDING PROTEINS

This hormone rela.xes iJ1e conn ec tive tissue and is probably
secreted b)' tl1e ova ry. Re lax in is a wateNo luble protein and
nonsteroid. It may have a role in pregnancy and may be
responsible for rela.xaLion of pelvic join LS and pelvic floor
muscles.
INHIBIN
lnhibin is a nonsteroidal water-soluble protein (peptide)
secreted b) the Graafian follicle. McCullagh ide ntified tllis
protein and named it inhibin because it is known to sup-
press pituita•)' FSI-I. lnhibin consislS oflwo pepLides, namely
in hi bin A (a-fraction) and inhibin B (J>fracLion). In normal
ov:u·ian folliculogenesis, FSH and LH initiate secreLion of
oestrogen by the Graafian follicle. Oesu·ogen is responsible
for secreLion of inhibin in the Graafian follicle, which in
tum suppresses FSH but sLimulates LH secreLion. Adminis-
tration of inhibin in iJ1e earl y follicular phase can delay
folliculogenesis and in hi bit ovulation and luteinization.
Inhi bin may have a n importa nt role in the conu·ol of ferti l-
ity in both males and fema les. It ca uses aggluLi nation of
sperms, preve nts ce rvical mucus penetraLion and interferes
with egg interaction. In poi)'C)•Stic ova ria n d isea.se (PCOD),
iJ1ere is an increased secretion of inhibin. T his ca uses a low
FSH but a high Ll l secretion by the anterio r p itui ta I) ' gland
and is responsible for a novu laLion. Altho ugh the ex traction
of pwified inhibin is not yet successful, there is a possible
hope of its avai lability in iJ1e nea r fu wre. Norma l level of
50 pg/ mL (> 45 pg) drops to than 15 pg/mL after
menopause due to oesu·ogen deficiency. It is studied by
ELISA test.
ACTIVIN
Activin is secreted b) iJ1e anterior pmmary gla nd and
granulosa cells, stimulates FSH release and enhances
action in tlle 0\'<11).
Follistatin suppresses F H activity by acting against
Most of oestrogens and androge ns are bound to sex
hormone-binding proteins (SHBP) secreted by the
and remain inacuve. On ly free hormones are b iologically
active and influence t11e ir target organs ( I %-2%). Oesu·o-
gen and t11 yroid hormones incnease the secreLion of these
proteins. but androgens lower iJ1eir levels.
TESTOSTERONE
Fifty per cent testosterone comes from O\'<lries and iJ1e rest
from adrenal gland. The O\'<lrian su·omal tissue secretes
androgenic produclS, namely testosterone, deh)droepi-
androsterone (DH EA) and androstenedione. Androstene-
dione gets convened in the periphe•-al fat to oesu·one. The
normal increase in stromal tissue at ovulation causes a
slight increase in the secretion of these ho•·mones. After
menopause, iJ1e increased O\'<lrian stroma is responsible for
the rise in these hoa·mones and development of hirsutism
in some postmenopausal women. Total dai ly production of
testosterone is mg and plasma level is 0.2-0.8 ng/
mL. T he daily production of androstenedione is 3 mg and
plasma level is 1.3-1.5 ng/ mL. Normal 17-keLOs teroid level
is 5-I5 mg in 21 hours. More than 25 mg ind icates adre nal
hyperp lasia. Plasma leve l of OI II!:A s ulphate ove r 5 meg/
mL is seen in adrenal h)•pe rp las ia.
Eighty to e ight)•-five pe r ce nt androgens are bound to
SHBP and 10%-15% to a lbumin. One to two per cent free
testosterone remains biologically acLive and actS at periph-
eral targets, i.e. hair growth and acne by conversion to
dihydrotestosterone by hydroxylase enzyme. Clinically,
administration of androge n causes follicular atresia and
anovulation.
PHYSIOLOGY OF MENSTRUAnON
The prolifemLive phase of t11e endomeu·ium represents tl1e
oesarogenic p;u·t of menstrual cycle. It is initiated :mel con-
trolled by oestrogen. The secretory phase of t11e endometrium
 CHAPTER 4 - PHYSIOLOGY OF OVULATION AND MENSTRUATION 55

is conu"' iled by progestel"'ne, altho ugh the effeet of pl"'ges-

terone is obtained on I)' after the endomeu·ium has been sen-
sitized with oestrogen. This is because oeStrOge n produces
progesterone receptors on which progestel"'ne actS.
All.hough the activit) of endometrium is directly con-
u·olled b) the ovarian function and by the two honnones
secreted b) the ova11, t11e oval') itSe lf is activated by the
pituita11 gland, the secretion of which is under the nerve
control of the h) pothalamus.
At bi1·th, the ovaries are populated with lifetime comple-
ment of eggs located in the primordial follicles, but most of
these follicl es unde1·go au·esia throughout childhood and
only about400 of these primordial follicles are present dur-
ing reproductive age. At puberty, the hypot11alamus startS a
pulsatile secretion of Gn RH , resulting in tl1e activation of
H-P-0 uterine axis and in t11e establishment of menstrual
cycles.

•
Pulsatile Gn RII initiates secretio n of FSH and LH. FSH Oestrogen Suprarenal Progesterone
released by tl1e ante rior p itui ta ry gla nd stimul ates the t
growtl1 of a few ptimordial follicles into t11 e Graafian folli-
cles. Mu ltip le fo llicles s tan growing in bo tl1 t11e ovaries, but A Endometrium
o nly o ne dominant Graafia n fo lli cle is selected which ripens
to fu ll maturiq• and ovulates wh ereas othe r follicles become and progesterone
atre tic. T he Graafian fo ll icles under the infl uence of FSH
together with on ly a minimal amo um of the LH secrete
17-J3-oestradiol (Fig. 1.5A and B). 17-J3-0estradiol has sev-
eral functions: in the first place, it prod uces proliferative
cl1anges in th e endometrium, sec retes inhibin and inhibitS
ntrtl1er secretio n of FSII b) t11e anterior piwitary and stimu-
lates Ll-1 receptors in the t11eca cells a nd stimulates the an-
telior piwitaq to secrete LH. lnhi bin produced by the
Graafian follicle under oesu·ogenic effect is also responsible
for a fall in tl1e FSH level and stim ulation of LH secre tion.
The maximum peak of oesu·ogen secretion is seen about
48 holll'S before ovulation, whereas the LH peak occu1'S
about 24-36 hours before O\'Uiation. LH has tl1e following
functions: In tl1e first place, it sti mulates a Graafian follicle Development of
to secrete 17-13-oestradiol, and secondly, it causes the follicle granulosa cells,
secretion of Positive leedback to LH
to rupture at ovulation and to form a corpus lllleum E2 , inhibin
(Fig. 1.6). It also stimulates t11e secretion of testosterone
and androstenedione by t11eca cells.
The corpus lute um secretes pt"'gesteron e, t11e level of
,,11ich startS rising. The hormo ne progesterone has two
funCLions. In the first place, it s timulates the endometrium
to undergo secre tOl)' h)•pertrophy, and secondl)', it inhibitS
furtl1er production of Ll l b)' t11e am e rio r p iwi ta l) '· Tlte gu-
JUidotropins snnn t.o luwe 110 diretl ejfett upon the endomet·rium of Pregnancy
lite utert.ts (Fig. 1.6). persistent corpus
ln th e absence of pregna ncy, both oes u·ogen and proges- luteum continuation
terone levels decline graduallr and fa ll in tl1e level of these of pregnancy
hormones brings abo uL mensu·uaLion. A fall in th e level of
tl1ese hormones also sta rts off a fresh pos itive feedback
mechanism and triggers th e hypothalamus to release
gonadou"'pin. This is how a menstrual cycle is regulated.
The luteal phase, i.e. time between ovulaLion and menstrua-
tion. is fairl) constant at 14 dars in a menstrual cycle. The B
growth of ovarian follicles a nd endometrial tl1ickness can be
Figure 4.5 (A) A scheme illustrating interrelation of pituit..y
studied b) serial ulu-asound. Oestrogen, LH and mid-luteal
gonadotropic hormones. Indicates stimulat ion and '-' indicates
progesterone te,els can be conveniently and speedily mea- inhibition. (B) Flowchart of menstruation.
sured by mdio-immunoassays (Fig. I. 7; rable 1.2) .
As mentioned earlier, Lh)rOid hormones and adrenal
hormones react with sex honnones and alter the H-P-0
56 SHAW'S TEXTBOOK OF GYNAECOLOGY

miU/mL pg/ml

Initiation of
LH surge
+
100

1()()()

30

10

100

-48 - 24 0 24 48 -48 - 24 0 24 48
Hours Hours

I '

0@ (@ '

........
- - - Oestrogen 100 100 500 20
•••• • Progesterone 18
- - - LH 80 80 400 16
········ FSH 14
::J" 60 12:::?
.¤
::;)
10
E
g.
I 40 8
I
en
u.
20
6
4
I
2
0 0 0

2 14 28
Days of cycle

Menstrual Proliferative Secretory phase

phase phase

E
Q)·E
c- Fu nctlonalis
·- Q)
Gie
5.g
cQ)

} Basalis

0 4 8 12 16 20 24 28
Days of menstrual cycle
Rgure 4.6 Plasma hormone levels in normal menstrual cycles.

paLhwa) b) inhibiting Gn RH secretion. O ral combined
pills, by vinue of inhibiting GnRH and prevenling
ovulation, cause au·opic endometrium. Continuous
oestrogen stimulation leads to endomeu·ia l hyperp lasia
(Fig. 1.8).
FEEDBACK MECHANISM IN THE H-P-o AXIS
As mentioned in the beginning, the ,-a.·ious honnones lib-
erated by the h) pothalamus, the ante•·ior pituitary gland
and the O\<aries are dependent upon each other, each
 CHAPTER 4 - PHYSIOLOGY OF OVULATION AND MENSTRUATION 57

•0 ooco
..
0 0

A 1 2 34 56 789101112131415161718192021222324 252627 2829303132 34 353637 383940414243444546

Ovarian
cycle
• [ <MIIabon

Approximate
Endomelrial
changes
during
menstrual
cycle

Day
I
8 Menstruation
Rgure 4.7 (A) Schroder's Illustration of the relation between ovarian function and the changes in the endometrium during early pregnancy.
(B) Ovarian cycle with corresponding endometrial thickness.

Table 4.2 Normal Hormonal Levels In Different Phases of Menstrual Cycle

Hormone Follic ular Phase Ovulation Luteal Phase Menstrual Phase

FSH 4- 14 miU/mL 12-30 2- 9 3- 15 miU/mL

LH 6-14 miU/mL 14-40 2- 13 3- 12 miU/mL

E2 5D-250 pg/m l 3oo-500 pg/m L 10D-200

p 1 ng/ml 3· 15 ng/ml

17 OH steroids Normal 5-1 0 mg!daily > 25 mg In adrenal hyperplasia

Testosterone Normal 0.2-o.8 ng/mL > 2 ng/ml in androgen-producing ovarian

tumours
Androstenedione Normal 1.3-1.5 ng/ml
DHEA Normal < 5mcg/ml > 5 meg in adrenal hyperplasia

Cortisol < 5 mcg/dl

DHEA.S 800 ng/ml > 800ng/ml (Adrenal hyperplasia, adrenal
tumours)
58 SHAW'S TEXTBOOK OF GYNAECOLOGY
Peripheral
organs and
tissues
B
Rgure 4.8 Neuroendoaine control of menstruation.
reac hing posiLive as well as nega ti ve feedback a t different
levels.
T he fo ll owing are the feedbac k:
1. Long feedback mec han ism from the ovaries to the pitu-
itary and tl1 e h)•pothalamus.
2. Shon feedback mec hanism between tl1 e ame tior pitu-
itary gland and tJ1 e hypothalam us.
3. Ulu·ashort feedback mechanism.
AutoregulaLion of release ofGnRH by the hypothalamus.
Increased secreLion of Gn Rll suppresses itS own synthesis
and vice versa.
LEPTIN
Since its disco,·ery in 199 1, leptin (adipOC) te protein hor-
mone) is linked to null'ition and may bear an important
role in the conti"'I of H-P-0 axis. A diet restriCLion has a
External
control
negati ve impact on the h)•po tJ1alam us and decreases LH
secreti on ca using amenorrh oea as seen in anorexia nervosa.
Leptin is found in fo llicul ar Ouid in the ova ri es a nd presum-
ably s timula tes pulsaLile sec re tion of Gn RH aro und puberLy.
Hence, an obese ado lesce nt reac hes menarche earlier than
a lean girl. Lean girls have a de layed pubert)'· More research
is requi red in this fie ld.
MENSTRUATION
Menstruation is the end point in tJ1e cascade of even LS
starting at tl1e h) pothalamus and ending in tJ1e ut.erus. Men-
su·ual cycle is usuall) of 28 days, measured by the Lime be-
tween the fi I'St da) of one period and the fi I'St day of the
next. The duraLion of bleeding is about days and tl1e
estimated blood loss is between 50 and 200 mL The regular
C) cle of 28 da)'S is seen only in a small proportion of women.
A of 2 or 3 days from the 28-<lay rhythm is quite
 CHAPTER 4 - PHYSIOLOGY OF OVULATION AND MENSTRUATION 59

25 70
60
20
50
...J
...J
.E
:>
15 40 §
e 30 I
e
I
u.. 10
Cl) ...J
20
5
10
0 0
6 8 2 4

500 16

...J 12
E e ...J

8 *E
a> 'a>
cnc
w"' e
100 4 D..
0 0
0 2 4 6 8 10 12 14 : 16 18 20 22 24 26 28 2 4
...
Ovulation
Rgure4.9 Hormonal level during menstrual cycle.

common. The me nstrua l rhythm depends on the H-P-0 interaction of diffe rent prostaglandins secreted b)' tlte
funcl.ion whereas the amo unt of blood loss depends upon endometrium.
ute line condition. Prostaglandin £2 (PCE.2) causes myometrial conuractior\S
A stud) of the coiled arte ries of the endomeu·ium shows but l'<lSOdilatation of 1essels. Prostaglan<tin F!)(l (PCF!)(l)
that there is a slight regressio n of endometrium shonJy causes l'<lsocor\Striction as well as m)OContraction. Prostacy-
after ovulation and that a rapid decrease in thickness can clin (PC1 2) is respo nsibl e for· mLLScl e re laxation and l'<lsodi-
be demonstrated e1en before menst.-uation starts. In the latation. According to tltis, PCE.2 and are resporlSible
regression that starts a few da)S pr·ior to the onset of men- for d ysmenon·hoea, and PCI 2 can cause menon-hagia.
struation, there is a decreased blood flow which may cause Improved ultrasonic imaging and colour Doppler study
shrinkage of the endo m etrium from deh)dration. Dm·ing of the endometrium ha1 e improved our knowledge related
menstruation itself, r eduction in the thickness of the to menstrual disorder-s.
endometrium is determined by both desquamation and
resorption. The coiled arteries become buckled with sub-
sequent stasis of blood flow. Necrosis of tl1e superficial
layers of the endometrium is produ ced either by local sta-
sis or by th e clea rly demonsu·a ted vasoconstriction of Negative Development of granulosa cells and
coiled arteries. Me nstrua l bleedin g occurs when the open effect on FSH secretion of oestrogen inhibin
arteries da maged by necrosis re lax and d isc harge blood in
the uterine caviL)'· So me degree of venous haemorrhage +effectof LH
also occurs. Fragments become de tac hed from the superfi-
cial la)'er of tl1 e endometrium by tlt e end of the first day Ovulation, meiosis of ovum and corpus luteum
(Figs '1 .7- 1.10 ).
An imporun t feautre of mensut.tal changes is the con traction
and consuiction of coiled arteries. causes nea-osis and
disintegration of tlte superficial zone. The regeneration of vascu-
lar system is probabl)' brought about by tl1e development of
anastomosing aateties. ·rhe re-epitllelialiation is brought about Pregnancy and persistence
of corpus luteum
by cells growing from tlle moutJ1 of tl1e base of tl1e glands
that remain in tlte LU\Shed basal layer of the endometriLUn.
In anovulaLOI') menstruation, there is tl1e same shedding
of a tl1in necrotic super·ficialla) er of tJ1e endometriLUn, and
it is to be presumed tJ1at exactly the same factor is at work
to cause l'<lSCular changes with resultant ischaemia.
Vascular changes in the endomeu·ium and the amount
and duration of menstrual bleeding are controlled by the Rgure 4.10 Mensuration and pregnancy.
60 SHAW'S TEXTBOOK OF GYNAECOLOGY
MENSTRUAL FWID IN 'STEM CELL' THERAPY
The stem cells are the basic building blocks of every ot11er cell
in the bod). Whereas organ cells have specific functions, t11e
stem cells are 'blank' but have the potential to take up any
function. Under suitable enviro nment and sun·ounded by
specific organ cells, the stem cells divide into either stem cells
or another t} pe of cells with their attached functions. Thus,
me stem cells ha,·e a vital •"Ole in ' regenerative medicine' in
degenemth·e and life-threatening diseases such as Alzheimer
disease, atlle•"Osclerosis, diabetes, heart disease, bowel dis-
ease, Parkinson disease and rheumatoid artlllitis.
The sources of stem cells were until recently seen in bone
man"Ow, embryo, amni otic fluid and umbilical cord blood
but now in menstrual fluid as well. The mensu·ual fluid con-
tains mesench ymal cells s uch as mononuclear cells and fi-
broblasts. T hese cells, h owever, dete ri orate with advancing
age. T herefore, cells from yo ung women are s uitable for
donati o n, and for self-usc at a later age if needed. The kit
contains an tibi o ti cs tO preve nt infec tion, and the menstrual
fluid is cryop rese rved a nd harvested. The proced ure is
simple, noninvasive and painless as we ll as possible.
KEY POINTS
• Neuroendocrinolog) with its \'3SL hormonal network is
ke) to nom1almenstrual C)Cies a nd reproductive func-
tion in a woman.
• H)pothalamus, with its pulsatile secretion of GnRH
(decapeptide), is the main neuroendoc•·ine gland a nd
regulator> factor in the chain of H- P- 0 axis. The
higher conical ce nu-es can modif) or influence h) po-
thalamic secretion.
• Pulsatile secretion of Gn RH resultS in secretion of
FSH and LH from anterior piwitary gland.
• FSH and LH secreted from ante•·ior pituitary in turn
results in follicular matumtion and ovulation, which
in turn a•·e •·esponsible for secretion of oestrogen and
progesterone from ova•)'·
• Proliferative phase of endometrium represents oestro-
ge ni c acti o n of ovary.
• Progestero ne ca uses secretory endom e trium only if
the Iauer is plimed with oestroge n.
• Therapeutic management in infertility, family plan-
ning and ID naecological disorders is based on a sound
knowledge o f neuroendocrinolog> and the intemc-
tion of various honnones.
• S)ntlletic analogues ofGnRH , FSH and LH are used
in infertilit) and amenorrhoea.
• Oesu·ogen and progeste•"One ha' e specific I"Oies in men-
su·ual C)cle and in the de,elopment of genital organs.
• Oilier honnones pa•·ticipate in the maintenance of
normal mensuuation.
• LH surge is the key marker of imminent o' ulation.
• LH causes maturation of Grnafian follicle, meiosis of
ovum before ovulation, ovulation and development of
corpus luteum.
• Leptin appeal'S to have a rol e in the development and
onset of puberty.
• Menstrual fluid is rece ntly discovered LO co ntain stem
cells and may prove useful in s te m cell the rapy. Only
yo ung women are s uitab le for donation.
SELF-ASSESSMENT
l. Desclibe tl1e neuroe ndocrine co ntm l of mensm.ta l cycle .
2. Desc•ibe tl1e fom1ation and pt"Ocesses that lead to the
formation of Graafian follicles.
3. Desclibe the mechanism of ovulatio n.
4. Desclibe tl1 e microscopic appearnnce of endometrium
dLLring tl1 e valious phases of menstrual cycle.
SUGGESTED READING
Bloom FE. :\euroendocrinc mechanism.: cells and systems. In Yen
SCC.Jaffe RB (eds) . Rcproduc li\e Endocrinology. Philadelphia, WB
Saunders Co. 1991: 2-24.
Plant Thl. Krey LC, Moo>.>yj et al. 1l>e arcuate nude us and the control
of the gonadotropin and prolactin ..ecretion in the female rhesus
monkey. Endocrinology 1978; 102: 52-62.
Rabin D, McNeil LW. Pituitary and gonadal desensitization after con·
tinuous h.ue::inizing honnonc releasing hormone infusion in nonnal
females.] Clin Endocrinol Mc1ab 1980; 51: 873-6.
M. PfalfDW. Origin of Luteinizing hormone rele-;c;ing
hormone neurons. Nau orc 1989; 338: 161-4.
Soules MR, Steiner RA, Cohen M cl al. Noctumal slowing of pulsatile
luteinizing hormone M:Crccion in wo•ncn dllring 1hc follicular phase
of the mcns1rual Clin Endocrinol Me1ab 1985; 61:43-9.
 Development of Female
Reproductive Organs and
Related Disorders
Developmen t of the Female Genital Wollfion Duct Anomalies 73
Organs 6 1 Renal Tract Abnormalities 73
Development of the Ovaries 64 Key Points 7 4
Malformati ons of the Rectum and Sell-Assessment 7 4
Anal Conal 73
Anoma lies o f Mi:dle rian duc ts are seen in 1%-2% of
females. Most a no malies do not have any effect on
menstrual o r rep rod uctive function and remain undiag-
nosed. However, some of th e a no malies can cause recur-
rent abortions, preterm delivery, malpresemations or
other obstetric complications. Mens trual irregulatities are
Lmcommon with these anomalies but at times can caLLSe
haematocolpos, C)clical pain in abdome n, etc. Knowledge
of a natomical development of ge nital o rgan s is helpful in
unde rstanding these condi tions.
DEVELOPMENT OF THE FEMALE GENITAL
ORGANS
Urogenital diiTer·enti ation is a complex process involving
genetic, honnonal and environmenta l influences. T he
genital and urin ary systems develop in close relationship, so
developmental e n·o t-s in bo th these systems often coexist. lf
a u·ansver-se secti on is cut th ro ugh th e upper part of
t11e coelom ic caviL)' of an emb ryo of 8 wee ks, the primitive
mesen tery is seen to prqject in to t11e coelo mic cavity poste-
riorly near the mid li ne. O n each side of the p rimitive mes-
enter)', ano tJ1er projec tion, the intermed iate cell mass, can
be distinguished. On t11e inne r side of the intennediate ceU
b)' the end of the 8th week, a ridge has appeared- the
genital ridge. The Wolffian body witJ1 primitive tubules and
primitive glomeruli occ upies th e rest of the intermediate
mass (Figs 5. 1 and 5.2).
DEVELOPMENT OF URINARY SYSTEM
l11e primitroe uritWT)' sy.stem consists of the pronephros, the
meso nephros o r Wo lfllan bOd) and t11 e metanephros, which
gives rise to tl1e pet·manent kidney. Each of t11ese systems is
derived from the urogenital plates of the pt·imitive somites.
ln the human fe male, the pro nep hros disappears, and the
Wolffian body is rep rese nted by the su·aight tub ules of tl1e
epoophoron, or o rgan of Rose nmit lle r, found in the meso-
salpinx of an adult whereas the tubules o f t11e paroophoron
represe nt tJ1e relics of the re na lwbules o f L11e Wolffian sys-
tem. and the Gartner's duct represents L11e Wo lffian duct
(Fig. 5.3). The metanephros gives rise to t11 e tubules of the
permanent lddne) whereas the ureter and re nal are
fonned from a di, et·ticulum from the lowe r e nd of t11e
Wolffian dueL In an em bt)O, two tidges appea r between
fifth and eighth week, mesonephric (Wolffian) and parame-
sonephric ducts. The form er disappears in females, and tJ1e
latter, paramesonephri c duct (Mullet·ian), develops into
female genital organs. The Mi:tllerian duct is fonned as a
•·esult of invagination of th e mesothelium of tJ1e coelomic
cavity on tl1 e venu·al pan of the interm ediate cell mass. The
invagination extends from the proneph ros region above to
the sacral region below, and bo th ducts tenn inate in tJ1e
primi tive cloaca. T he position of the Mulleria n d uct is of
im portance, for it lies ventral to the Wolffia n d uct o n th e
o uter s urface of t11e intermed iate cell ma\is. In hum an
e mbr)•O, tl1e cauda l pa rts of the two MCtll eri an ductS fuse
to form tl1e uterus, whe reas the uppe r pa ns re ma in as t11 e
fallopian tubes (Fig. 5.:3).
DEVELOPMENT OF THE UTERUS, CERVIX
AND VAGINA
The uterus can be ide ntified as ea rly as by t11e end of Ll1e
3rd month. Uterus, fallopian tubes and most of Ll1e vagina
are derived from the M i:tllerian duct in t11e absence of
Y chromosome. The upper e nd of the ML:tlle rian duct be-
comes t11e alxlominal ostium of the fallopian tube, and it
is not uncommo n for small accesso•1 ostia to be foLUld
(Fig. 5. 1). In tl1 e 7th week of inu-a ute t·ine life (IUL) of t11e
e mbi)O, a n invagination of coelomi c mesothe lium occurs
61
 ___ ___
62 SHAW'S TEXTBOOK OF GYNAECOLOGY

,..,.._
X.... X
...
lndiflerenl gonad ----+
( ""'
Mesonephros - - - - _ . . . ,-t---11
WoiHian duct - - - -----1
Mullerian duct ---:-:-;-:--H

Bladder
·:'.. .
........ .::c. Genital Rectum
.... tubercle

.:. •·... Figure 5.3 Development of genital tract -und ifferentiated stage.

·.·
Ovary ------{}j Tube

_ _ _ _.::)
Remnants of ________:-:
mesonephros
Uterus
UGS
Kidney - --1
Rgure 5.1 Diagram of urogenital system: X - intermediate cel l
mass, shaded area is the genital ridge. (1) lnfundibulopelvic ligament,
(2) ovary, (3) ovarian ligament and (4) round ligament. Dotted outline Gartner's - - ---tH
is Wolflian duct (Gartner's (a) Pronephros , (b) epoophoron duel
and (c) mesonephros. Solid block is MOIIerlan ducts. Q) Fimbria, Bladder
QQ fallopian tube, QiQ uterus, (iv) upper three-fourths of the vagina.
UGS - urogenital sinus.

R gure 5.4 Female genital tract development.

Paroophoron Epoophoron close to the primitive gonad in the upper lateral portion
(distal tubules of (proximal tubules of
the mesonephros) the mesonephros) of the intennedi ate cell mass; this is called the Mullerian
duct (paramesonephric duct). As the two Mullerian
ductS, one o n either side, develop and grow caudally. they
approach each other in the midline after crossing the
Wolffian duct (meso nephric duct} a nd fuse (Figs 5. 1
and 5.2 ). The cranial-free pan of the MCalleria.n ductS
deve lops into fa llopian tubes. The midd le fused portion
forms the ute rus and cervix, and the cauda l fused ponion
forms the upper one-thi rd of vagina. ln itia ll)', the in ter-
ve ni ng sep ta are prese n t b u t la te r d isappea r as a s ing le
continuous passage. Tlms, the 1Wmwl development of the
Miilii'Tian comprises rmd later
sf'jJifd
The muscle wall of the uterus is differentiated from
mesoblastic tissues, and during the 5th month, a circular
la)er of muscle can be distinguished. The longitudinal
1:1- - - - Gartnefs duct muscles of uterus can be recogniLed during the 7th month,
(vestigial remnant) and this muscle layer is continuous morphologically with
the plain muscle tissue of the ovarian ligament, tl1e roLmd
ligament and tl1e muscle fibres fo und in the uterosacra l
ligaments (Fig. 5.5).
In the ea rly stage of the developmen t, the cervix of the
Rgure 5.2 Remnants of t he mesonephric (Wolflian) ducts that m ay uterus is longer and thi cker tha n the bOd)', and tJ1is propor-
persist In the anterolateral vag ina or adjacent to the uterus w it hin t he tion persistS until p uberty. T he proportion may persist in
broad ligament or mesosal pinx. adult life, when the uterus is described as infantile in type.
 CHAPTER 5 - DEVELOPMENT OF FEMALE REPRODUCTIVE ORGANS AND RELATED DISORDERS 63

Wolffian duct DEVELOPMENT Of VAGINA

(mesonephric duct)
Mullerian duct
Mullerian
vaginal cords
Figure 5.5 MUllerian and Wolffian systems.
The cervical glands can be recognized in the 6th month,
whereas the glands of the body of th e uterus develop only
during the last mon th of IUL, although primiti ve glands are
prese nt a t tl1e 4th month.
T he primit.ive clolU'll is d ivided by the fo 1mation of the
w·orectal sep tum into a ventra l pan, the urogen ital sinus
(UGS) and a dorsal pan, the rectum. T he urorectal septum
ulti ma tel)' deve lops into the pe rineal body.
The lower ends of the MCIIIeiian duelS tem1inate in t11e
ttrogenital sinus, into the posterior part of which t11ey
project as a solid Ml'IIIerian tubercle. A solid vaginal cord
resulls from proliferation of cells at t11e caudal tip of fused
Miilleiian ducts. the cord elongates to meet the bilateral
endodennal evaginalions (sinovaginal bulbs) from t11e pos-
terior aspect of urogenital sin us below, and botl1 fuse tO
form vaginal plate. Vagina is formed by rne subsequent
canali.t.ation of rne vaginal cord followed by epirnelialization
wirn cells de1·ived from urogenital sinus. Recent proposals
hold that only t11e upper one-third of vagina is fonned from
MiiJlel'ian ducts and the lower vagina develops from rne
vaginal plate of lll'ogenital sinus. The hymen is the embryo-
logic septum between the sinovaginal bulbs above and t11e
urogenital sinus below.
DEVELOPMENT Of THE EXTERNAL GENITAL ORGANS
(Figs 5.6 and 5.7)
T he cloaca becomes d ivided in to two pa ns by tl1e deve lop-
ment of the m orectal septum , wh ich originalt)' consists of
two fo lds which project on eac h side and then fuse caudally
to divide the cloaca into a dorsal pan, tl1 e recwm, and a

Fused
paramesonephric
ducts

Bladder

Genital
tubercle
Sinovaginal Vagina
bulb plate

5.6 Development of the lower genital organs.

 SHAW'S TEXTBOOK OF GYN AECOLOGY
Urogenital
groove
Glans cli tori dis
Genl tal - - - - 1 - --\+
fold
B c
Figure 5.7 Development of the external genitalia.
venu-al ponion, the urogenital sinus. The p•imitive cloaca is
closed b)' the cloacal membrane, which can be recognized
very early in the de,elopmem of the embryo and from
which the vessels of the allantois are developed. The primi-
tive intestines enter th e dorsal pan of the cloaca. Both
Wolffian ducts, both Mi:.Uerian dueLS and the allamois, from
which the bladder and the urethra are differemiated, enter
the urogenital sinus. Originall y, the u reter arises from the
lower end of the Wolffian duct nea r th e openi ng of the duct
in to th e urogeni tal sin us. Subseq uentl y, as a resul t of the
growth of tl1e surround ing mesoblasti c ti ssues, the ure te r is
d isplaced cra ni al! )' so that it e nters tl1 e uroge ni tal sinus
indepenclen tl )' of the Wolffia n d ueL. T his d isplace me nt of
tl1e ure ter expla ins the aberrant L)•pe of ure te r which is
some ti mes encountered in gynaecological s w·gery. T he part
of the urogenita l sinus wh ich lies ven u·al to the mo uths of
tl1e Wo lffian ducts becomes clifferemiated into the bladder,
whereas tl1e al lantois is rep resented by the urach us passing
upwards from the apex of the bladder to the umbilicus.
Before tl1e 9tll week, it is not possible to recognize the fetal
sex by exLemal genitalia.
ll1e clitolis deve lops from the genital tubercle, whid1 ap-
pears about the 5th week and is o liginally a bilateral sLruc-
ture de lived from mesoderm. From the region of tl1e genital
tubercle, a genital fold passes backwards lateral tO the
urogenital sinus to fonn the labium majus (scrotum in
the male). Between the ge nital folds lies the urogenital or
Genital
swelling
Vestibule
4'---1-- - - - Labium
minora
'+.. ! - - - - - - Labium
majora
anterior pan of the cloacal membrane, which breaks
down to form the labia minora (6th week). The vestibule
and urethra are tl1us derived from the ame•·ior pan of tl1e
urogenital sinus, and Bartholin's glands and Skene's para-
uretlu-al glands a•·e developed ft-om downgrowths of the
urogenital sinus. T he female uret11ra represents tl1e uppe•·
part of tl1e ma le uretlu-a, and the pa ra- and periuretl1ral
glands are homologous to t11 e male prostate. The external
genitalia are recogni:t.able by the 12tll week of IUL In fe-
males, ure tl1ral groove rema ins ope n LO fo rm the ves tibul e.
DEVELOPMENT OF THE OVARIES
Ovaries begin to develop by the 5th wee k. T he ovarian d if-
feremia tion is determ ined b)' the presence of a dete nn inant
located on tl1e gene of tl1e short ann of X-c hromosome,
a lthough tl1e alllosomes are a lso involved in tl1e ovarian
clevelopmenL Two intact sex chromosomes (XX) are neces-
sary for tl1e development of t11 e ovaries.
The genital l'idge extends from tl1e pronephric region
above to the sacml region below, and, in itS earliest fonn, is
represented b) an e longated vertical prominence. Very
soon it develops a mesente11 of its own, the mesov:uium,
by which it is attached to imermediate cell mass. The
infundibulopeh·ic fold passes upwarcls from the upper pole
of the ovary and contains the O\>arian vessels. The ovari:m
 CHAPTER 5 - DEVELOPMEN T OF FEMALE REPRODUCTIVE ORGANS AND RELATED DISORDERS
vessels of an adu l4 a tising from the abdom inal aorta, ill us-
trate tl1e original lumbar position of tl1e upper part of the
genital ridge. The genital fold of peritOneum passes down-
wards from the lower pole of the ovary tO the region of the
internal abdominal ring. The MCtllerian duct originally lies
on the outer aspect of tlle genital ridge but crosses tlle
genital fold below. As tJ1e Ml:tllerian duct o ·osses tl1e genital
fold, the two su·uctures fuse, and after muscle tissue has
fonned around the Ml:tllet·ian duct, it passes into the tissues
of tlle genital fold. The part of tlle genital fold lying
proximal to its point of intersection with the Mullerian duct
becomes tlle ovarian ligament, whereas the distal portion
becomes tl1e round ligament (Fig. 5.1 ). This corresponds to
tl1e gubernaculum of the ma le. The ovaries are developed
by the 12th week.
Undescended ovaries. At birth , t11e ovaries are located at
tl1e pelvic brim. T hey g•·ad uall y descend tO the pelvis by
puben.y. Undescended ovaries ( rare) are associated witl1
absent Mt"tllerian system in as much as 40% cases and
t.mi co rnuate uterus in 20% cases, and ca n co nfuse the
sca nning. The undescended ova ries are at risk
of ma lignanC)' as witJ1 un desce nded testes. It is a rare
condition.
Th e ovaries can be located b)' ultraso und sca nning,
comp med tomograp h)' (CT) and magne tic resonance
imaging (MRl ).
The significance of undesce nded ovaries is as fo llows:
• They are associated witJ1 tJ1e Mitllerian d uct anomalies
and ma) ad\ersel) influence the menstrual and reproduc-
tive fu nCLio ns.
• Ovulation monitoring ma) be difficuiL
• Ov;u·ian pain ma) be misimerpreted as appendicitis or
intestinal pain.
• 0\<arian wmour may be misime•·preted as other abdomi-
nal LUmour.
• Risk of malignancy.
These abnormally located ovaries may develop malig-
nanC)', so it may be advisable to remove tl1em and put the
woman on hot·monal replacement tJ1empy. In viu·o fertili za-
tion witl1 donor egg may be possible iftJ1e uterus is presenL
Th e ovary descends from itS o ri ginal lum bar position so
tl1at at term it lies at tJ1e level ofthe pelvic brim ''1th irs lon g
axis di rec ted venicall )'·
T he sex ge rm cells first appea r in the gen ital ridge.
Prese ntly, it is accep ted tJ1aL the ge tm o ti ginate in the
endodermal cells of tJ1e )'Oik sac by the 4th wee k fro m the
hind gm of the embryo and migrate alo ng tl1e dorsal mes-
em ry to tl1 e gen ital ridge. At fi rs4 the sex cells are
arranged in colu mns perpendicular to the s utface by the
6th week. T hese columns are called primat)' sex cords and
tl1ey lie deep ly in the substance of the genital ridge. At a
later elate, secondat)' cords develop nearer to the surface
epitl1elium. Both primary and secondary cords consist of
cells derived from tJ1e local stroma of the genital ridge. The
egg cells or primordial ova are distinguished by tlleir large
sue ;md peculiar mitochondria. It is believed tl1at tlle sex
cells act as organi£ers to tJ1e adjacent su·oma cells, which
tJ1en are comened into granulosa cells. ln tl1e male, the
cells of the ptimary co•·cls predominate whereas in tl1e ovary
tlle secondary corcls are marked most.
65
Urogenital differentiation in tJ1e embryo is a ramer
complex process involving genetic, honnonal and environ-
mental influences. The genital and urinary systems develop
in close relationship, so developmental errors in botl1 of
these systems often coexisL Some anomalies are obviot.t.S at
birth, but most come LO light on I) at puberty, when tl1e giti
fails to menstruate.
GONADS
The chromosomal sex of tJ1e fertili.t:ed ovum detenn ines tl1e
development of the embi")Onic gonad into tJ1e ovaries or
the testes, and this in tum directS tlle further differen tiation
;mel development of t11e internal and external geni tal
organs. The gonads r·emain undifferentiated unti l 6tl1 week.
About the 6tl1 week of IUL, a geni ta l ridge appears
(crown-rump lengtl1 of 5 mm) ( Figs 5. 1-5.5) on tl1 e dorsal
aspec t of tl1e emb t)'O o n eithe r side of the midli ne. It con-
sistS of p rolifera ti on and thi ckenin g of tJ1 e coelomic epithe-
li um overl ying so me mesenc h)'mal ti ssue nea r t11e develop-
ing kidney. In tl1e female embl')'OS, ge nn originate in
the e ndoderm of tl1e )'Oik sac nea r the deve loping hindgut;
they migrate a long the root of the dorsal mesen te t)' tO e nter
the developing gonad. Columns of coelom ic epithe lia l cells
designated as sex co rds invade tJ1e cortex of the deve loping
gonad and surrO tUld tJ1e germ cells, tJll.ls forming me
primitive ptimordial fo ll icles. T he primordial follicles are
recognizable by 20th week of IUL These prolifemte tO
reach about 7 million in tJ1e ?tJ1 mon tJ1 of fetal life.
However. as the gonadal stroma prolifemtes, many of tl1ese
follicles degenerate so tllatthe ovaries at bird1 contain about
2 million follicles. Of these, on I) 300-400 will ever ovulate.
The first meiotic division begins in the OOC)'le by tlle
20tll week in tlle embt)O, but remains donnant in the pro-
phase until O\'lllation occurs at puberty. The second meiotic
division occurs only at fe•·tilitation when tlle spenn pene-
tmtes the tona pellucida. The ovary plays no role in tl1e
development of internal genital o•·gans.
By tl1e lOth week of IUL, tJ1e female gonad assumes
histological chat-actel'istics of tJ1e ovary. T he basic sexual
pauem is female in all embryos. It is the andt·ogen of tes-
ticul ar origin in tl1e male embi")'O whi ch causes the male
elements tO gr·ow. ItS absence in embryo develops along tl1 e
female line. ln the ma le emb ryo, tJ1 e fetal testis elabo rates
two substances: (i) a Mitll eria n supp ression substance which
inhibi ts tl1e develop me nt of tJ1e M \tll e ti a n dueLS, Mulle rian-
inh ib iting fac to r (MIF) gi)'COprotein sec reted by t11e Sertoli
cells of tl1e tes tes, and (ii ) testoste rone de rived fro m Leydig
cells which is respo nsib le for co mple ting the deve lopmen t
of the Wolffian s u·uctu res, and fusio n of tl1 e lab iosc rotal
folds and deve lop ment of tJ1e phallus so tJ1 at me exte rnal
gen italia develop along the male line. In th e abse nce of
androgen, the gen ita I organs develop along the female li ne.
The male external genitalia develop in response tO dihy-
drotestosterone derived b) conversion of testosterone by
enz)'lne 5 a-reductase.
However. if tl1e eati) embi")Onic state of bisexuality
persists into adult life, iL resultS in a state of true hennaph-
rodism wherein masculine and feminine elementS ru·e
observed in the gonad as well as in the external and intemal
genitalia. The O\'lll)' plays no role in the development of
internal genital organs.
66 SHAW'S TEXTBOOK OF GYNAECOLOGY

Ln a female pseudo he m1aphrodite, the go nad and the Mi:u-
lerian system are no rmal, tho ugh perhaps t.mderdeveloped as
far as the level of tJ1e urogenita l si niL5. The Wolffian vestigial
pe rsist as usual, bu t tJ1e phallus (clitOris) is h)p ertrophic,
the labia appear fused in the mid line and tJ1e urogenital sinus
opens at tJ1 e base of tJ1 e phal lt.LS. Sud 1 females may be re-
garded as males ,,; th a h) pospad ias. The source of the
androge n responsible for tJ1 e altered develo pmem o f the
extem al genitalia is commonl)' of adrenal o rigin sud1 as in
congeni tal adrenal h) perp lasia. Kt10\\l edge o f the nuclear sex
at birth is essenti al to decide the proper sex of rea1ing.
Lf the female embJ)O in utero is exposed to androgen se-
creted by matem al or adrenal neoplasms (anilenoblas-
toma or hilar cell ttmlour), or to progestogens, which are mildly
androgeni c, then such altered hormonal enviro nment can lead
to va•ying degrees of masculini zatio n oftJ1e female fetus.
Co mplete aplasia of ova ry is rare, agen esis may appears
as streak o vary as in Turne r syndrom e. The streak ovary
contains uncUffe renti ated strom a devoid of genn cells. T his
happens if the chromosome pattern is 45/XO, when the
germ ce lls fa il to mi gmte along the do rsal mesen tery in to
tJ1e gonad.
MULLERIAN DUCTS
Lt is desirable to reca pitulate tJ1 e deve lo pment of the
MCdle rian dueLS desc ribed in tJ1e beginning of the chapteJ:
AITestin tJ1e no nnal development of the MCdlerian ductS can
cause several anomalies as listed below (Jo nes'
I. in which tJ1e o rgans fa il 10 develo p.
2. in which tJ1 e o rgans are rudime ntary.
3. Atresia, in which there is partial o r co mp lete failure of ca-
nalizatio n of these dueLS, leading to varying degrees of
gynatresia.
4. Miillerilm duct anomalies, such as asymme uic develop-
me nt. ma> lead to a unico rnuate uten LS, with o r witJ1o ut
a rudime m a•1 ho rn. Fa ilure of in pan o r itS
e ntirety ma> lead to du plicatio n of the ge nital tract, and
fai lure of disappearance of the in te rve ning sepLUm may
lead to a septate or subseptate ute n LS, whi ch may coexist
with a septate vagina.
5. Hermaphroditism and jJM'udolu-mwjJimxlitism may be the
resul t of a bnonnalities of d evelopm ent of th e gonads,
sex dueLS and extem al geni ta li a.
6. Deudoj>mental tlefecll of the urogenital sinus m ay manifest
in the form of defective development of the u•·in ary
bladder, hymen and the perine um.
Structura l homologues in males and females are
discussed in Table 5. 1.
Mullerian duct anomalies: Some anoma li es are detected
at b irth, i.e. ex terna l ge nita l orga ns. Some may be detected
a t puberty wh ile investi ga ting fo r primary amenorrhoea.
Some are revealed durin g invcsLiga tio ns of infertili ty and
repeated pregnane>' losses. AILho ugh a greaL n umber of
anomalies of the ute rus have been desc ribed, tJ1ese can be
broadly gro uped as fo llo ws:
I. Agenesis
2. A110malies arising out of defects in vertical fusion (Fig. 5.8;
see also Fig. 5.16) between lhe downgrowing fused
Miille 1i an dueLS and the upgrowing de rivative fro m the

Table 5 .1 Structural Homologues in Males and Females

Male Female Detennlnl ng Factors
Gonadal

Germ cells Spermatozoa Oogonia Sex chromosomes

Coelomic epithelium Sertoll cells Granulosa cel ls
Mesenchyme Leydig cells Theca cells rete ovarii

Ductal

Paramesonephric duct Hydatid testis Fallopian tubes, uterus and upper Absence of Y-chromosome
(M ullerian) three ·fourths of vagina

Mesonephric duct Vas deterens sem inal vesicles Epoophoron Paroophoron Gartner's Testosterone MIF
(WoiHian) epididymis duct
External genitalia

Urogenital sinus Prostrate Cowper's glands Lower vagina Skene's tubercles Presence or absence of testoster-
Bartholin 's gland one and dlhydrotestosterone
Genital tubercle Penis Clitoris

Urogenital folds Corpora spongiosa Labia minora

Genital folds Scrotum Labia majora

Urogenital s inus Bladder. urethra prostrate, bulbo- Lower portion of vagina, Bartholin's
urethral glands gland, paraurethral gland, url nlrf
bladder, urethra
 CHAPTER 5 - DEVELOPMENT OF FEMALE REPRODUCTIVE ORGANS AND RELATED DISORDERS 67

Rgure 5.8 (A) Hysteroscopy showing septum In t he uterus d ividing

the uterine cavity. (B) Hysterosalpingography film of the same patient.
(Courtesy (A): Dr Shyam Desai, Mumbal.)

urogen ital s in us. These may manifest as (a) obstructive Figure 5.9 Haematocolpos. The Illustration shows the distended
lesions or (b) nonobSLructive lesions. vagina filled with blood.
3. Anomalies out of defects of lateml fiuion or resorption
resu lti ng in dup lication defects. These ma)' manifest as
(a) obstmcLive lesions or (b) nonobstmctive lesions.

Congrmital am OCf ur bec(I'IISP of till' follmuing:

(a) Failure of initial descent- agenesis.

(b) Failure of vertical fusion - u-ansverse vaginal septum,
imperforate h)lnen.
(c) Failure of late•-al fusion -this ma)' result in complete or
partial duplication, which may be either S)1nmeu'ical or
as)lnmetrical. )lnmetrical fusion defects would lead
to bicomuate uterus or uterus didelphys whereas the
as)lnmetrical fusion defects would result in one
well-de, eloped ute•·ine hom with the other being .-udi-
mentary. Noncommunicating hom of the ute•·us is an
example of obstructive defect.
(d) Defects in the resorption of the septum - example, Rgure 5.10 Suprapubic bulge caused by haematocolpos.
septate UleiUS.

urine) and ofte n the palpation of a midline h y-

DETAILED CONSIDERATION OF MULLERIAN DEFECTS
(a) Vertical defects
1. Vagi1wl atmia: Sim pson ( 1976) stated that vaginal
atresia is a cond ition in whi ch the lower portion of
the vagina is rep resented me re ly by fibrous tissue,
whereas the contiguo us superior s u·uctures (uterus)
are well differentiated.
2. vagiual It occ urs in the upper
portion of vagina in 50%, midd le portion in 30%-
40% and lower portion in 10% cases.
(a) Imperforate hymen - this is entirely of urogenital
origin. Failure of canalization may lead to for-
mation of a mucocolpos; this ma)• be recognized
in earl) infanC) and get treated. However, the
anomal) often continues unrecognized Lllltil pu-
bert), when amenorrhoea in the presence of
seconda11' sexual cha•-acters, C)clic abdominal
discomfon, lll·inary S)lnptoms (retention of
pogastric lump leads LO th e examination of the
externa l genitalis, parting of th e labia reveals
the presence of a te ll ta le b luish b ul ging mem-
brane in th e region ofthe hymen that points to
the di agnosis of hae matocolpos. A sim p le cruci-
ate incision fo llowed by excision of th e tags of
h)•men allows drainage of the retained men-
strual b lood. The ope ration should be per-
formed under aseptic conditions and under an
adequate antibiotic cover to avoid any ascend-
ing infection. The vagina regains its wne very
quickly (Figs 5.9-5. 11).
(b) Congtmital abJetlce of vagina- M agenesis
(absent vagina)
INTRODUGION
The commonS) non) ms in clinical usage include Mullerian
agenesis (MA), Ma)er-Rokitanskr-KusLer-Hauser (MRKH )
68 SHAW' S TEXTBOOK OF GYNAECOLOGY
Rgure 5.11 Vaginal introitus showing the bulging membrane caused
by haematocolpos.
Rgure 5.12 Imperforate hymen causing haematocolpos, haemato-
rnetra and haematosalpinx.
Rgure 5.13 Imperforate hymen - ultrasonography showing haema-
tocolpos (distended vagin a) and haematometra (distended uterus).
(Courtesy: Dr Rajeev H Kothari, Mumbal.)
Figure 5.14 CT showing haem atometra and haematocolpos.
(Courtesy: Dr Parveen Gulati, New Delhi.)
S) ndrome and vagina l age nesis. This condition , though
commo n I) re fe n·ed to as congtmillll absnw• of tiU! vagina -a
misno mer, is u·taly a deve lopme ma l defect o f the MCallerian
dueLS resulting in t11 e co nditio n desc ribed as the 1\tlRKH
The MRKH syndrome occurs in 1:5000-1:20,000
wom en a t b irth, and is d iagnosed in approximate!)' 1:1500
gynaecologic ad missions.
DEFINING FEATURES
Clinicall y identifi ed by th e absence of structures derived
from Muller-i an dueLS, namely th e uterus, cerv ix and up-
p er vagina, 25% patienLS may have a sh ort vaginal pouch.
Rudim en tary wbes are often prese nt. The gonads a re
ovat·ies. The kal") Ot) pe is XX; the disorde r see ms to be an
accide n t of developme nt. 1n clinical practice, t11 e wo rking
diagnosis fo r an y individual prese nting with primary
a me no rrhoea, fe minine seco ndary se xual charac te ristics
and a n abse m vag ina is MRKH sy ndro me (Griffin e t al.,
1976), with a fam ilia lte nde nq • in ute rus is prese n t in o nly
7 %- 8% cases.
CHARAOERISTIC FEATURES
• Congeni tal absence of uterus and vagina (smal l rudimen-
tary ULedne bulbs are usually present).
• Norm al ova tia n function, including ovul ati on.
• Sex of real"ing- fema le.
• PhenOt) pic sex - fe male (nonna l development o f
breasts, bod) propo rtio ns, ha ir distri bution and externa l
ge ni ta lia).
• Ge ne tic sex- fe ma le (46, XX- ka ryo type) .
• Freq uent associatio n with other co nge ni ta l a noma lies,
ske letal a nd spine abnormalities (20%-30%) urologic
abnorm alities s uch as ma lrota ti o n of ki d ney, ec topic
ki d ne)' (horseshoe kidn ey, pelvi c ki d ne>•) and ano malies
of tuinaty-collecti ng system needLO be invesLiga ted for-
by intrave nous pyelogram or ulu·aso und (40%).
 CHAPTER 5 - DEVELOPMENT OF FEMALE REPRODUCTIVE ORGANS AND RELATED DISORDERS
DIFFERENTIAL DIAGNOSIS
• Imperforate hymen
• Transverse vaginal septum
• Complete androgen insensitivity syndrome {testicular
feminization S) ndrome)
Imperforate h)lnen can be detected by observing the
vaginal outlet. On performing t11e Valsalva manoeuvre, the
membrane bulges. Peh·ic sonograph)' reveals presence of
haematocolpos and intemal genitalia. Transverse septum
reveals presence of a short 'oagina, absence of bulging on
Valsalva manoeuvre. Testicular feminit.ation or androgen
insensitivity S)•ndrome closely mimics one another, and
efforts to dilfer·entiate between these two have therapeutic
bearings.
INVESTIGATIONS
• Pelvis and abdomen ultrasound - pelvic organs and
kidneys.
• 3-D ulu·asoun d is very precise in detecting these malfor-
mations (100% sensitive and specific) , less costly than
MRI. One sho uld move on to MRl only if any do ubt
prevails.
• MRI gives more precise defin ition of pelvic viscera.
• Karyot)•pe.
• Laparoscopy (invasive proced ure) may be avo ided,
exti1·pation of t11e M("allerian remnants is not necessary
unless it is causing problems such as fibroids, haemaw-
metra. endometriosis or symptOmatic hemiation into the
inguinal canal.
• Radioloro -descending P> elography to delineate urinary
tract anomalies, X-r11) L-S spine.
MANAGEMENT
• onsurgical met11ods - act by imermiuem pressure on
the perineum.
• Frank's nonsurgical method of active dilatation using
graduated 'oaginal dilators of 0.5-1.0 inch diameter and
4-5 inches in length is used to apply constam pressure LO
tl1e vaginal dimple for 20 minutes t.i.d. for 6-8 weeks LO
achieve clinicall y acceptable results. Nonnal sexual
function is possible in over 75% individuals. To main tain
patency, vaginal di lator use shoul d be con tinued until
regular sex ual inte rcourse begins. Other modificatio ns of
Frank's artificia l vagina incl ude Ingram's bicycle seat
stool used for 2 ho urs dai ly to ma inta in co nsta nt peri-
neal pressure. J affe successfully modified Frank's di la-
tion techn ique by using increasing sizes of syringe con-
ta iners. Oestrogen creams he lp in vagina l ep ithelia l
u·ansformation.
• Surgical metl10d of vaginop lasty- to be delayed ti ll the
marriage or until the patient becomes sexually active.
The Mclndoe operation of vaginoplasty using split·
t11ickness skin graft spread over a mould and held in
place in an artificial space created between the bladder in
from and the rectum behind has been successfully
performed and has served functional use. Surgeons have
also successfull> used fresh amniotic membrane graft
to line tl1e 'oaginal space. HIV testing of the donor is
required. Another surgical procedure which is simple
to perfonn has been devised by Williams using labial
69
skin. However, tl1e axis of the artificial vagina poin ts
directly backwards.
• Tissue expansion vaginoplasty using tissue expander has
also been tried with success. Water balloon is employed.
• Shirodkar used a section of the Sigmoid colon LO pre-
pare an artificial 'oagina, but this method was techni-
cally difficult to perform, and the mucus secretion
caused discomfort; hence, this metl10d is not curTently
practiced.
Transveru vaginal uptum can be very easily mistaken for
congenital absence of the vagina. It is a rare condition
having an incidence of I :84,000 gynaecologic visits. The
clinical symptoms will depend entire!)' on whetl1er the
septum is imperfor-ate or otherwise. In case of a perfo-
rated sepwm, mensu·uation occurs and no difficul ty is
suspected until the tim e of marriage when apareunia may
lead the patient to seek consultation, o r at the tim e of
pregnancy. If tl1e seplllm is im perforate, the symp toms of
a menorrhoea and those res ulting fro m mucocolpometra
may call for a tten ti o n . Ul u·asonography helps to arrive a t
the diagnosis. T he co mmonest site for the occ urre nce of
a transverse seplllm is the junction of the upper and
middle tl1ird of tl1 e vagina. Treatment of e ither
manual di latation from the micrope rforation or surgical
excision of the septum. If the sep tum is th ick and wide,
reanastomosis of the upper a nd lower vag ina may be d if-
fintlt; it may require skin grafting to cover t11e intervening
raw area.
syntfroml' - originally described
as testicular feminit.ation S) ndrome- needs to be differenti-
ated from the Mfallerian duct anomaly causing MRKH
syndrome. which also presents with amenont1oea and
absent uter·us. Androgen insensiti,·ity S) ndrome is a geneti-
cally transmitLed androgen receptor defect in a 46 XY indi-
with testes and nonnal testosterone levels. These
present with amenorrhoea, they have no inter·
nal male or female genitalia (absent LllentS), nor·mal female
external genitalia, an absent or shallow vagina, a nonnal
female phenotype with well-developed breastS, and scanty
body h air. Ultrasound/ MRI examination coupled with a
karyotype XY helps to setLle the diagnosis. The abnotmal
gonads are prone to ma ligna ncy, so these sho uld be
removed surgicall y at an early date, soon after sex ual matu-
rit)' has been ac hi eved.
(b) defects - these include partial o r co mplete
dup licati on.
1. Double or vogi1w- th is rna>• occ ur with an en-
tire I)' norma l fallopia n tubes, uterus and cervix, or
with d up lica tion of th e ute rus. T he longitudin al
antero-posterior septum may be partial or com-
plete, extend ing right down to the vaginal o utlet.
Generally, both sides are patent, but in rare in-
stances the septum may deviate from tl1e centre
and fuse with one lateral vaginal wall so tl1at
one side of the "agina and uterus are obstructed
and there is unilater-al haemawcolpos. The asymp-
tomatic longiwdinal sepwm may only come LO
light when the patient complains of soiling her
clothes in spite of using a tampon dur·ing menses.
Examination may re,eal a septum with Mullerian
70 SHAW'S TEXTBOOK OF GYN AECOLOGY
duplication, where in her placemem of the tampon
in one vagina can not prevent egress from the
other side, or it may be detected after marriage
when it ma> be a cause of dyspareunia, or become
apparent onl) at the Lime of labo ur. Symptomatic
septum requires excision. A thick septum can be
vel") vascular.
Complete Nonfusion of the Mullerian Ducts Results in
Duplication of the Genital Tract
2. Duplicatio11 of the --<lefecLS in latera l fusion of t.he
Mullerian dueLS may result in partial or complete dupli-
cat.ion, t.he two halves may be symm eu·ically developed
or asymmet.-icall y formed. These may result in obsu·uc-
tive or nonobsu·uctive ma lfonnations. Symmeu·ical mal-
formations include uterus didelph ys, bicornuate uterus
wi th doubl e or single ce rvix , or a n arc uate uterus
depending o n the exte nt of no nfusio n. Asymmetric
malformations include ute rine duplica ti o n in which
one uteri ne horn is full)' developed a nd rep rese nted by
a hemi ute rus, and the othe r ex hi b iLSva rying degrees of
rudimentary develop ment or may even be totally ab-
sent, cli nicall)' prese nting as a rudim ental")' uterine
horn comm unicating with the main we ll-developed
horn, a non co rnrn u nicating rudimentary functional
horn, a nonfuncLioning rudime ntary horn with consid-
erable disproportio n between the two horns or a t.Lni-
corn uate uterus. \\'olffian duct an o malies often coexist
witl1 MCallerian duct anomalies, hence tl1e importance
in clinical practice to undertake a n in u-avenoLLS pyelog-
raphy or ultrasound in all cases of MCallerian duct
anoma lies to detect presence of any coexisti ng urinary
u-act anomalies.
DETAILED CONSIDERATION OF RELEVANT ANOMALIES
OF THE MULLERIAN DUOS
Classification
Recently, a newer classification for Mullerian duct anoma-
lies has been introduced by the European Society of H wnan
Reproduction and Embryology (ES HRE) (Table 5.2) .
A new classification of the MiJIIerian duct anomalies
was given by ESH itE/ Europea n Society of Gast.rointestinal
Endoscopy (ESCE) in 20 13.
It has the following general characte aisti cs:
1. Anato my is the basis for tl1e sys te ma ti c categorization
of ano ma lies.
2. Deviations of uterine anato my de ai ving from tl1e same
embr>•ological origin are the basis for the design of the
main classes.
3. Anatomical variations of th e main classes expressing
differe nt degrees o f uterin e deformity and being clini-
cally significant are the basis fo r tl1e design of the main
subclasses.
4. Cervical and vaginal anomalies are classified in inde-
pendent supplementar) subclasses.
• Class UO incorpoa-ates all cases witl1 normal uterus.
• Class U I or d)smorphic utertLS incorporates all cases wiili
nonnalute.-ine oUlline but" itl1 an abnonna l shape of the
utea·ine cavity excluding septa.
• Class l is furtl1er subdivided in to tluee categories:
• Class Ula or T-shaped uterus characterized by a narrow
uterine cavity due to thickened late a-al walls witll a con·ela-
Lion of two-tl1 ird uterine corpus and o ne-tl1 ird cervix.
• Class U l b or uterus infanti lis also characterized by a nar-
row uteaine cavil) witl10ut Ia tea-a I wall tll ickening and an
inve rse correlation of one-tll ird uterine body and two-iliird
cenix.
• Class Ul c or oiliers which is aclclecl to include a ll minor
defonnities of the uterine cavity, including t.hose witl1 an
inner indentation at tl1e fundal midline level of 50% of
ilie utea·ine wall tl1ickness.
• Class U2 or septate uterus incorporates all cases witl1
noa·mal fusion and abnormal absorption of the midline
septum. Septate is defined as the utems with nonnal out-
line and an intem al indentati on at the fundal midline
exceeding 50% of the ute rin e wall thi ckness. This inden-
tation is characteri:t.ed as septu m a nd it co uld divide
partly or co mpl e te ly tl1 e utc aine cavity, includ ing, in some
cases, cervix and/o r vagina. Class U2 is furtl1 er d ivided
in to two s ubclasses acco rding to tl1e degree of the uterine
corp us defo nniq•.
• Class U2a or partial septate uterus charac terized by the
existence of a sep wm d ivid ing partly the ute rin e cavity
above ilie level of tl1 e interna l ce rvical os.
• Class U2b or complete sepL<Ile characterized by the
existence of a sep tum fu lly d ivid ing tl1 e uterine cavity up
to tl1e level of tl1e internal cervical os.
• Class U3 or bicorporeal uterus incorporates all cases of
nLSion defects. Bicorporealuterus is defined as ilie utenLS
wiili an abnormal fundal outline; it is cl1aracterized by the
presence of an external indentation at the fundal midline
exceeding 50% of the uterine wall tl1ickness.
• Class U3a or partial bicorporeal utenLS chaa-actea·iLed by
an extemal fundal indentation paa·tly di\'iding t.he uterine
corpus above the le,el of the cervix.
• Class U3b or complete bicoa·poreal lllerus chaa-acterized
by an external fundal indentation completely dividing t.he
uterin e corpus up to the level of the cervix.
• Class U3c or bico•·poreal septate uterus characterized
by tl1 e presence of an absorption defect in addition LO
the main fusion defect In patients with bicorporeal
septate uterus (Class U3c), tl1 e width of tl1 e midline
fundal inden ta ti on exceeds by 150% oflhe ute rine wall
thickn ess.
U3b and U3c defec ts arc assoc iated with reproductive
fa ilure in about 25% of affec ted women. T hese
wo me n ofte n s uffer fro m misca rri ages, preterm
bi rtl1s, in u·a ute ri ne growtJl restrictio n (I UCR) a nd
abnormal feta l p rese ntations such as breech a nd
oblique presen tations. Incide nce of dystocia d uring
labo ur is hi gh, and th e 3rd stage co mp lications, s uch
as adherent p lacenta a nd postpartum haemorrhage,
are more frequenL Unification surgical proced ures
Lllldertake n at laparotomy (Strass man operation,
Tompkins operation or J o nes' wedge metroplasty op-
eratio n) or h)Steroscopic resection of uterine septum
he lp LO imprO\ e obstetric performance in 60%-85%
cases.
• Class U,l or hemi-utenLS incorporates all cases of unilateral
formed utems. Hemi-utenLS is defined as t.he unilateral
 CHAPTER 5 - DEVELOPMENT OF FEMALE REPRODUCTIVE ORGANS AND RELATED DISORDERS 71

Table 5.2 ESHRE/ESGE Class ification for Female Genital Tract Anomalies

Ute rine Anomaly Ce rvical/Vaginal Anomaly

Main Class Sub-class Co-Existent Class

UO Normal
uterus

U1 Dysmorphic
uterus

a. T-shaped b. lnfantilis c. Others

U2 Septate
uteru s co Normal CtJIV/x

C1 $tJI)ISIB CtJtvi X

C2 OoubltJ "no;mar cervix

C3 Unilateral ctJrvlcal aplasia
a. Partial b. Complete
C4 C.-vlt:lll aplasia

U3 Bicorporeal
uterus \II) Notmlll...agna
Longil.ldJnal non-obstltJC!Ing
VI .-gina/ • .,...,
Lon(lll.ldJnal obSirUC•ng
V2 vtlg/nal • .,...,

V3 r,.,._.. soptum
Mti:NOt" lfll)<lriora18 , _ ,
a Partial b. Complete c. Bicorpo<eal septate
V4 lltgonala{Jam
U4 Hemi -uterus

D
a. With rudimentary b. Without rudimentary
cavity cavity

us Aplastic

D ..J

H
a. With rudimentary b. Without rudimentary
cavity

U6 Unclassified malformations

u c v
Assodated anomalies of non-MO/Ierian origin:

Development of uterus llld vagna <k.rring the 1Oth week, tt-e paramesorephric dlcts fuse at tt'er caudal en:ls to a common ctwlnel
llld come in cortact IMth a thickened portion of posteri:Jr urogenital sinus called sirovag1nal bulb. ThiS is followed by devebpmer1 of vaginal
plate. whch ebngates between tt'e 3rd llld 5th morth, llld beoome canalized to form tt-e 1nlenor vagnallunen (Soun::e: Modlied tom
Sader TW. Langman's Medcal Embryology. Baltimore: Wili<:rn ard Will<i"ls, 1985.)
72 SHAW'S TEXTBOOK OF GYN AECOLOGY
uterine development; the conu·alateral part co uld be
either incompletely formed or absen L It is a formation
defect; the necessity to classify it in a different class than
tJ1at of aplastic uterus (fonnation defeCL) is due to tJ1e
existence of a full> developed functional uterine hemi-
cavil).
• Oass U4a or hemi-uterus with a rudimentary (functional)
caviL), charactel'iJ:ed b) the presence of a communicating
or noncommun icating funCtional contralateral horn.
• Class U lb or hemi-utertJS witholll rudimentary (func-
tional) cavity, characte1·i1:ed either by the presence of
a nonfunctional contralateral uterine horn or by apla-
sia of the contralateral part. Presence of a functional
cavity in the contralater-al pan is the only clin ically
important f-actor for complications, such as haemaw-
cavity or ectopic pregnancy in th e rudimentary h orn,
or haemato-cavity and treatm e nt (laparoscopic re-
m oval) are always recomme nded eve n if the h o rn is
co mmu n ica ti ng.
It acco un ts for I %-2% of all ute rovagin al a no m alies
a nd is ofte n assoc iated with a poo r re produc tive per-
fo rm a nce. Spon ta neo us abo rti o n ra tes a re hig h, as
also tJ1e inc idence of prematu rit)'· A tJtird of th ese
pa ti ents have breec h presen ta tions, and a hi g h inc i-
dence of severe IUG R has been recorded. It is worth
noting tltat fe ta l survival has been recorded in o nl y
40% of women with unicornuate uteri. The inc idence
of caesarean sections is high in this s ubgroup of
women.
U4a and b defects need to be investigated by intravenous
pyelograph) (fVP) to detect urinary tract anomalies.
These are gene rail) present on tJ1e side where me Miil-
lel·ian abnormalit) is most pronounced. Renal agenesis
may be present 01· the kidne> ma>' be mal rotated, low
l)ing or peh·ic in location.
• Class U5 or aplastic ute1·us incorporates all cases of uter-
ine aplasia charactel·ited by me absence of any fuUy or
unilaterally dC\·eloped uterine cavity.
• Class U5a or aplastic uterus wiili rudimentary (func-
tional) cavity characterilCd by the presence of bi- or w1i-
lateral functiona l hom.
• Class U5b or aplastic uterus without rudimentary (fun c-
ti onal) cavity characteli:Ged eith er by tJ1e presence of
uterine remnants or by full ute rin e aplasia.
• Class U6 unc lassified includes unde r a no malies.
Prevalence
• About 1.0% in no rma l fe rtil e a nd s ubfe nile wome n
• About 3.3% in cases of recurre nt pregna ncy loss
Background
• Congenital uterine anoma lies resulti ng from the
MCII Ierian duct fusion defects are tJ1e commonest malfor-
mations encountered in clinical practice.
• Septate uterus is most common. About25% incidence of
spon tan eo us first trimester abortions, and 6% second
trimester abortions.
• Implantation inLO a poorl) vasculariJ:ed fibrous sepLUm
might be a conu·ibutOI') factOr (Fedele et al. 1996).
• Bicornuate utei'\IS is not generall)' associated
recun·ent pregnancy losses (Procwr et al. 2003).
Diagnosis
• Combirwd and laf)(trrJS{'Of'Y he lp tO d ifferentiate
between bicornuate uterus and septme uten.IS. The
presence of the uterine fundus suggests a septate utenLS.
• - septate uterus appears as two cavities
without sagittal notching, and the intercornual distance
< 4.0 em. Diagnosis of bicornuate uteniS is favoured if
the funclal midpoint indentation is > 5 mm above me
inte rostia I Iine.
• Hy,terosalpingograplt)' (HSG)- cannot reliably differentiate
between septate and a bicornuate/ arcuate uterus. lf tJte
angle of divergence between the two lllerine cavities is
5.75•, me defect is most likely to be septate uterus. If the
angle of divergence is > 75• but <105•, a diagnosis
cannot be made.
• Mat,>7wtir imaging (MIU)- it is an accurate and
n oninvasive investigation to make a diagnosis of septate
uten.LS. Lf the septum exte nds to <::30% of tJt e septal
cavity, s urgical resec ti o n is ind ica ted.
Adverse Obstetric Outcomes
T he following adverse ol>stetric events have been assoc ia ted
with septate uterus:
• Fi1·st and second trimester pregnancy losses: (between
8- and lt)·week gestation) abortio ns- 25%,
preterm delivery- 14.5% and live births- 62%.
• About two-thirds of abortions occur in tJ1e first trimester.
• It constitutes an important cause of repeated pregnancy
losses.
• Oilier adverse obstetric outcomes include abnonnal
presentation and !UGR.
Surgical Resection of the lntTauterine Septum
(Metroplasty)
hysteroscopic is considf'wd bf'.st as it aVQids
uterine a lUi netxl for elect it'(' caejarnm sf'rtion. Tlte septum is
resectetl wilh or
bulication: Presence of uterine sepwm in association of
adverse reproductive outcome.
PostlljJerat.ive mrmagement: 0 1-al oestrogen for 3 montJ'\S
after completion of Slll'gery has been the accepted practice.
l11Senion of a Foley catheter with its bul b dis te nded with
4-8 mL of s teri le wa ter has bee n used fo r 5-7 days to
keep the uterine cavity ope n a nd preve nt inu·a u1.e 1ine adh e-
s io ns. T his is co up led with th e ad ministra ti o n of a ntib io tics
(doxycycline 100 mg b. i. d. fo r 5-7 days) a nd no ns te ro idal
a nti-in flamm a tory drugs (NSA ID) to co ntro l pain a nd p re-
vent adhesions. Asherman syndrome with ute rin e ad hesions
and ad herent p lacen ta a re the late complications.
Amongst the uterine anomalies, bicorn uate uterus is
seen in 35%-40%, arcuate uterus in 15%, uterus dide lp hys
in 10% and uterine septum in 5 %-10% cases.
Diagnosis of Mullel'ian anomalies: This is based on tJte
following information.
l. Clinical data - famil) histOI'), mei'\Strual history, past
obsteu·ic histof) and detailed pelvic examination.
2. Imaging sciences- hystel·osalpingograph)'• ulu-asonogra-
ph)\ MRI imaging.
 CHAPTER 5 - DEVELOPMENT OF FEMALE REPRODUCTIVE ORGANS AND RELATED DISORDERS
3. Endoscopic examinmion - laparoscopy and hysteroscopy.
Arterio-venous anasLOmosis ca using menorrhagia not
responding to medical therapy and occasional rupture
wiLh inLemal haemorrhage is known. It responds to emboli-
zation of uterine arteries. The diagnosis is made by Doppler
uluaso u nd.
MALFORMATIONS OF THE RECTUM
AND ANAL CANAL
IMPERFORATE ANUS
imperforate anus results from the failure or breakdown of
tl1e cloacal m embr-ane between the anal depressio n and the
terminal intesti ne (Fig. 3. 15). The diagnosis is m ade at birtl1
,,hen corrective su r·gery is required fortlnvith.
ATRESIA RECTI
Au·esia rec ti is a co nditi o n in whi ch t11 e lowe r part of the
rec tum fails to develop. This is a much mo re se rio us situa-
tion than an im perforate an us. M,-uor surgical in terventio n
is called for, and t11 e prognosis is g uarded.
CONGENITAL RECTOVAGINAL FISTULA
Various t)pes have been described; t11ese res ult from the
imperfect separation of the rectum from the urogenital
sinus. ln some cases Lhe anus is represented by a depres-
sion in tl1e expected no rmal position but the rectum
opens on to the exterio r somewhe re else on the perineum.
lL is called a perineal anus, or it opens partly by way of an
anal canal and partly as a fistula in me location of t11e
per·ineal body, or it opens through the lower part of the
Fig11e 5.15 Imperforate anus. Jane C. Rothrock, Ak=!xarder's
Cae of the Patient in Surgery, Pedatric &rgery. Mosl:7i, 2011 .)
73
posterior vaginal wa ll into the navicular fossa just within
the fourchette. This is often termed as vagin al an us. lt is
SLll'prising how man> women witl1 an ectopic anus suffer
little inconvenience a nd acq uire satisfactory bowel con-
trol. DLLring ch ildbirtl1 , however, t11ere is a danger of se-
vere and complicated t11 ird-<legree perineal tear; hence,
these patients are best delivered b) caesarean section. It
should be remembered that if surgical cor-rection of an
ecwpic anus is undertaken, the sphin cte r·ic control of the
transplanted anal canal may not be as satisfactory as in the
previous situation.
WOLFFIAN DUCT ANOMAUES
The upper portion of t11e \Nolflh1n d uct may at tim es dilate
to form a paraovarian cyst, and the lowe r portion forms a
Gartn er cyst (Fig. 5.1 6). The paraova ri an cyst may appear
li ke a n ovarian cysL Its u·ue nature is revealed at laparotOmy
whe n tl1 e ovary is no rm al, and the cyst lies in the broad
ligamenL During its removal, o ne sho uld loo k for the
ure ter, a nd no t inj m e it. A small Ga rtne r cyst can be left
alo ne b ut wi ll requ ire mars upia liza tio n o r excision if it
causes d)•spa re uni a.
RENAL TRACT ABNORMAUTIES
A double ureter is rare!) e ncounte red. Its recognition at
laparotomy is necessal") ifinjul") to it is tO be avoided.
An ectopic ureter sometimes communicates witl1 me
vagina, and tl1 e diagnosis is made b) pyridium test and rvP.
It is performed b) a urosurgeon.
ln a fetus, tl1e kidneys initial!) de,elop in the pelvis. They
migrate upwards as tl1e ureter star·ts growing cranially. ln a
rare instance, tl1e kidneys remain in the pelvis and are
mistaken for a retropel"itonealtumour. IVP should be done
before surgery is planned for the removal of reu'Ope•iwneal
tumour.
5.16 Ga-tner's duct cyst.
74 SHAW'S TEXTBOOK OF GYN AECOLOGY
KEY POINTS
• There is a close and parallel development of
Mi:allerian duct and \\'o llfia n ducts during I UL. There-
fore . anomal> of one S)Ste m ma> coexist with the
anomal) o f o th er S)Ste m.
• Although genital U<lCt abnoamalities are encoLUuered in
ro
on I> I % of naecological a \<aaiet} of anoma-
lies starLing fi'Om aplasia, h) poplasia, au·esia and nonfu-
sion ha\e been descl'ibed. A new classificatio n system
gh en b)' the Ew·opean Society of Obsteu·ics and G) nae-
cology is useful fordescaibing ,w ious t) pes ofanomalies.
• A great m,Yority of anomalies go undiagnosed, as they
do not ca use any interference in mensu·uation or
reproducti on.
• For symptomati c patients, in vesti gations, such as
hysterosalpingography, h ysteroscopy and laparoscop)\
are requi red to confirm and assess th e degree of
uterine ma lform ati on .
• Ultraso und, besides d iagnosing genital trac t malfo r-
matio n, ca n de tect associated renal ano ma lies.
• Some abno rm alities do no t req uire correc tion if the
wo man is asymp to ma ti c. Some a re no t amenable to
correctio n. Sorn e need plastic surge ry LO improve fer-
tilit)', avo id pregnancy loss and solve gyn aeco logical
problems s uch as hae matocolpos and haemaw metra.
• Vaginoplasty to crea te an a rtificial '-agina requi res
surgical expe rtise. It restores sexual func tion.
• A rare condition o f arte rio-,e no us anastOmosis ca us-
ing me no n·hagia. it is diagnosed by Doppler ultra-
sound and responds we ll to e mbo limLio n of utel'i ne
anel'ies if e xcessi'e bleeding does no t respond to
medical treatme nt.
SELF-ASSESSMENT
I. Desnibe anomalies aaising from the fusion defectS ofthe
Mull el"ia n dueLS.
2. What are the val'ious complicati ons wh ich can occur
during pt·egnancy associated with Mullerian an omalies?
3. How would yo u differe ntia te between Mulleri an agenesis
and testi cular femini:t.ation syndrom e (a ndrogen insensi-
ti vity) as the ca use of abse nt vagina?
1. Describe the vari o us t)•pes of vaginoplasty.
5. Describe the investi ga tions that as.s is t in establishing the
diagnosis of Miall e ai an ano ma lies, the ir limitatio ns and
comparative usefu lness.
SUGGESTED READING
Bariar Moh>in S. I Jakim S. Cl al. "fclndoe '"b"n oplasty. J O bsu:t
Gy11ecol India 2002;52: 14:>-6.
Bhadr-a D. S, Pradhan M, ct al. Two unusual cases ofhem atc>-
metr-.t i11 adok-cent girb >imuhaneous m enstruation . J O bstel
Gp1CL'ol India 2002:52:146.
Carril1gtol1 B"l. I lricak I I, ct al. "!iolleri:m duct anomalies: imaging
Radiol<>g> 1990; 176:715.
Ch akra,·any BN. Rc"t:Oll>tructi' e Su rgery in lnfcnility. In: U B,
Rao KA, chattetjcc A (c-<h). and Pr-.tctice of Obstetrics and
Gyr1ecoogy for 2,.., c-d. FOGG! Publication , New Delhi :
J aypce. 2003. p.452.
Dabio-a.hr.tfi II . Bahadori M, et al. Septate u terus: New id ea on the
hi>wlogit feature> of the .cptum in thi> abnonnal uterus. Am J
O b.tel C,necol 1995: I 72: I 05.
Daly DC. Walter. CA. Soto-Albor. C. I l)'>leroscopic meuoplasty:
Smgicalaechnique and ob.tctric outcome. Fertil Steril 1983;39:623.
Eli Reshef. Sanfilippo JS. I l)'>lero><:opic emluaaion and therapy of
atlomalie;. In: Quillig-.tn EJ, Ztt>pan FP (eds). Current
Therapy i11 Obstetric; G)1lCOOIO!,'Y· 5th e d . Philad elphia: W. B.
Sau nders Compan)': 2000. p. 77.
£ ,-ans Tl\. Poland M. Bo\ing RL. malfonnarions. Am J Obstea
Gynecol198 1:14 1:910.
Fedele L, Bianchi S, March ini M, ea al. L'lar-.uanocau o-.tl aspects of
e ndornt:uiurn in infcnilc women '"it h septate urerus . Ferti l Steril
1996;65:750- 2.
Frank RT. Form ation ofaraifidal with out oper.ttion. AmJ O bsaet
Gynecol 1938;35: 1053.
Gre en LK, ll arris RE. Uterin e a n om ali es. Fre qu en cy o f diaj,r nosis
and associated ob;le lric com p licat ion s. O bsae a Gyn ecol 1976;
4 7:4 27.
Griffin JE, Edw·.trds C, Madden JE, cl al. Con genita l absence of th e
v.tgina. The Mayer-Rokiaans ky-Kuslcr-l lauser synd rome. Ann lnt
Med I 976;85:224.
Grirnbizis GF, Gordt> S, Di Spiezio Sard o A, ct al. Th e ESIIRE/ ESGE
consensus on the clas.sifi cation of fe male genital tract congenital
ll um Reprod Oxf En gl. 201 3;28(8):2032-2044.
doi:IO. I093/ hum rcp/ det098.
llorner I !A, Li T C, Gookc ID, cl al. The septate ut erus: A re,ie w of
man agem ent ould reproou cthc ou tcome. Fe nil Stcril 2000;73: I.
Ingram JN. The biqcle >eat>tOOI in the treatmen t of \-agin al agen esis
and >lenO>i>: A preliminary report. Am J Obstel 1982;
140:867- 73.
lso-ael R. Man:h G\1. I l)>tero><.'<>pic incisio n of the septate u terus.
AmJ Ob.tet C,necol 1984;149:66.
Jonc. IIW Jr. Reprooucahe impainncnl :md the malformed u tenos .
Fcrtil Sterill981:36:137.
Joph) R. Padmashi V.Jair-.tj P. Tt:>tkularfcminization srndrome.J O bstet
India 2002:52:165.
JOl\\'alli "fJ· Godbole SV. Bhutc SB, t:l al. Pregnancy in a rare case of
unicom<tate uaenos after '"'b,;nopla>ty. J Obsaea G)11ecol India
2003:53:84.
Raur V, Dhar A. Double Utcnt> with obsanu:ted hernhagina a11d
lpsilaae.-al re11al agenc;,i>. J Ob.tel C,11e<:ol Ind ia 2001;5 1:46.
Li S, Qayyum A. Coakley FV, c1 al. of re na l aj,>e nesis a nd
Mullerian d uct anomalk-..J Com put A<Sisa Tom()!,'T 2000;24:829.
Mcindoe A. The treatment of congenital absence a nd obliaer.Hh·e
co ndition of the BrJ Piasa Surg 1950;2:254-67.
Mull er P, Mussel R. Neller A, c1 a l. State of u ppe r urin ary araca in
patients "i ah ut erine malformations. Study of 133 case::;. Presse Med
1967;75:1 33 1.
Parikh MN. Congenit al absen ce in MRI IK syndnHne.J Obsaet
Gynewl India
J A, llaney AF. Recu rrent fi rst trim t-ster pregnancy loss is
assv<.:iated with uterine septum but not with bkonH1a1e ut erus. Fertil
Saeril 2003;80: 12 12.
Ra g.t F, Sauser C, Remoh i J, e l al. Reprodu ctive im pact of congenital
MO:ollerian anom ali<:s. ll um Reprod 1997; 12:2!177.
Richardson DA, E\"MIS M I, Talerman A, Cl al. Segme nt al absence of the
rnid-ponion of the fallopian tube. Fertil Steril 1982;37:577.
Rock JA, Murph y AA, J onc> II W. Su rgery of th e cervix. Am J O bstel
Gynecol 1992;94: 12.
Rock J A, SchlaiT WD . The obstetric consequen ces of uter(l\'agina l
anomaliL'>. Fertil Steril 1985;43:681.
RockJ A. Surgery for anomalie• of the duas. In: Thompson
JD. Rod JA (ed>}. TeUndc'• Oper.tthe Gynccol<>g>•. 7th ed .
Philadelphia PA.J. B: Lippinmu; 1992. p. 603-46.
Romer T. Lober R. I l)'>lero.copic t'<> rrt>clion of a complete septate
utcnos using a balloon I fum Rcproo 1997;12:478.
 Puberty, Adolescence and
Related Gynaecological
Problems
Introduction 75 Puberty - Anomalies of Gonodal
Reproductive Endocrinology of the Growing Function 82
Girl Child 75 Adolescent Contraception 84
The Newborn Female lnfont 76 Miscellaneous Problems 85
The Growing Girl Child 76 Key Points 85
Common Paediatric Gynoecologic Self-Assessment 85
Problems 77
Puberty and Adolescence 79
INTRODUCTION
It is being increasing!) recogn iLe<l as a fact that gplaeco-
logic disorders can have their origin in childhood disorders
such as congenital d eferu, negleCLed infections acquired in
childhood, failure to diagnose and treat endocrinopathies
in childhocxl, tumours O\erlooked and a general tendency
to belittle ph)'S ical and pS)Chological trauma of sexual
abuse. All these can cast their shadow on future reproduc-
tive health of the individual during adult life.
REPRODUCTIVE ENDOCRINOLOGY
OF THE GROWING GIRL CHILD
Outing chil d hood, tJ1e endocrine changes in the growing
female child are d irec ted towa rds prepa ring her fo r the
matu rati on of tJ1e
axis to ac hi eve full reprod uctive potenti al. T he fetal hypo-
Ulalam us (arcua te nucle us) begins to prod uce gonadotropin-
re leasing hormone (Cn RJ-1 ) b)' tJ1e l Oth week of imrauterine
life, gonadou·opin secretion fo llows, levels of circ ulating
follicle-stimulating hormone (FSJ-1 ) and lu teinizing hormone
(Ll-1) steadily rise up LO tJ1e 20th week of gestation when the
fetal h)pothalarnus becomes ino-easingly sensitive to the
negative feedback inhibition of tJ1e placental steroids result-
ing in a rapid decline in levels of the circulating gonadotro-
pins. With the birth and expulsion of tJ1e placenta, iiS inhibi-
tOf) effect ceases and tJ1 ere is once again a u-ansiem rise in
circulating levels of gonadou·opins and a gradual decline to
nadir by the age of 2-3 >ears. Throughout early d1ildhood
me levels of circulating gonadou·opins continues to remain
low, mere is a minimal piwitary response to administered
CnRJ-1 and the h)potJ1alamic seo-el.ion of CnRJ-1 is
profoLLnc:Uy suppressed.
The u-ansilion to pubert) is charaeteriLed by episodic Ll-1
sea·elion associated with the circadian sleejr\\<tke cycle. The
rise in LH values becomes two to four Limes higher dllling
sleep compared to me waking hours. This change is noted
during the early phase of onset of puberty. C•-aduall)\ L11e
levels of FSH begin to rise and reach a plateau at mid-
puben)\ and the LH levels continue to •·ise even thereafter
until late pubeny. Such changes are observed even in girls
suffering from Tumer syndrome indicating that tJ1ese a•·e not
dependent on the oval'ian steroid hormones but represent
me effects of tJ1e mpidly mawling hypotJ1alam ic-pitui taJ)•
relationship.
T he seq uential changes occuning in tJ1 e growing girl
child ind icate that tJ1e initial developme nt begins witJ1 p ro-
gressively increasing Cn RII secreti o n, whi ch leads to in-
creased p iwitary se nsili viL)' and respo nsive ness to C nRJ-1
stimulati on. T his res ul ts in ri se in levels of circulating go-
nadotrop ins, wh ich p romote follicula r deve lopment in th e
ovaries. The ovaries in response to the above sti mulus pro-
d uce oestrogens that act on tJ1e uterine endome u·iu m to
initiate proliferation and e ndometria l growth, a prelude to
menarche. In Lime, the pulsatile secretion ofCnRH is estab-
lished followed by a cyclic ovarian function and regular
menstrual cycles.
Once Ll1e h)potJ1alamus becomes active, CnRJ-1 may
plime tJ1e pituitar> gonadotrops and increase its sensitivity
1.0 subsequent Cn RH sti mulatio n. A pulsatile panem of
CnRJ-1 secretion slow!) evolves. The fact tJ1aL earlier in me
course of de\·e lopment, the CnRJ-1 manifests as low-
frequency pulses fa,'OUI"S FSI-I secre ti on, explaining why tJ1is
is me fi•-stgonadotropin to register a rise. Later as me CnRJ-1
75
76 SHAW'S TEXTBOOK OF GYNAECOLOOY

CNS pulsatile frequency enh ances, ther·e is a greater t·ise in LH

Heredity surges and establishment of the adult pattern of gonadou·o-
Health pin release. The positive feedback to oesu·ogen develops and
Nutrition the crclic pattern of gonadou·opin release and the normal
mensu·ual C)Ciicitygetestablished (Figs 6.1 and 6.2A).

THE NEWBORN FEMALE INFANT

History and physical e.xamination - the newborn: The best

Lime to begin documen Ling clinical observations is at birt11.
others •• General examination should assess the gestational maturity of
• -4------------ the neonate and document any abnom1al findings such as

8
webbing of the neck, ectopia vesicae, congenital ureteric fis..
tula, im perforate anus, vaginal anus, congenital adrenal hy-
perplasia, the presence of ingu inal hernia, umbilical hernia or
L- --,-- --' abdom inal mass suggestive of a gen ital trac t abnonnalit:y, a
\
·.', •• DHEJ +
Sex steroids
b ulging h)•men (mucocolpos), clitoromegal)' (Fig. 6.2B), am-
.C. 4A ,l. b iguous ex ternal ge nit.alia, heterosex uali ty or true imersex .
OE, Puberty General physica l exa minatio n begins wi th tl1e examination of
Figure 6.1 Neuroendocrlnologlc control of puberty. CASH, the breasts. At b irth the breast nodtJ e can be felt easily, and
cortlcoadrenal-stlmulatlng hormone. on squeezing, some clear to mi lky secreti on can be often seen
from tl1e nipples (witcl1's milk) beca use of in utero feulS ex-
posure tO tl1e high circulating levels of maternal oestrogens
during pregnancy. This effect is u a nsiem and spontaneotlSly
resolves witl1 t11e passage of tim e. The external genitalia
should be examined under a good light keeping tl1e newborn
supine \\itl1 t11e tl1ighs well flexed agai nst tl1e abdomen. Once
again oestrOgen effects on the genitalia at·e apparent. the la-
bia majora appears thick and full and tend to cover the labia
minora, tl1e cliLOtis appears pi'Ominent - the clitoral index
(glans width X length) should not exceed 6.0 an 2• Values
exceeding this call for further investigations as clitoromegaly
PIT may be due to serious unde rl) ing causes such as
congenital adrenal hyperplasia, which demands immediate
attention and treaunen t in co ntrast to other causes such
as tme hermaphroditism and maternal exposure to andro-
gens (teraLOgens - dntgs having androgenic side effectS or
androgen-secreting wmours of tl1e adrenals or ovaries).
On separation of the labia, it is not unconm1on to observe
A a white m ucoid disc harge/ b lood whic h may persist for about
7-10 days. The vaginal orifice ma)' be somewhat difficult to
visualize, pressure on the vestibu le often resu lts in expression
of mucous discharge, whi ch confi rms patenC)' of the outflow
tract; ulu·asound exa mina tio n of the pelvis clatifies the
doubL Assigning the C011·ect sex/gende r at b irtl1 is crucial.

THE GROWING GIRL CHILD

A young prepube rta l girl cl1ild may be brought with com-

Rgure 6.2 (A) Hypothalamic-pituitary-ovarian axis regulatory
control. EHA, extrahypothalamlc areas; VMH, ventral medial
hypothalamus; PIT, pituitary; SER, serotonin; DA, dopamine; NA,
noradrenalin. (B) Abnormal finding of clitoromegaly.
plaintS related to h er private parts such as swelling, itching,
offensive vaginal discharge, bleeding or injuf)'· The exami-
nation of t11e prepubertal child calls for patiem persuasion,
gentleness, reassurance and skill and goes a long way in ac-
complishing a satisfactory examination. Sometimes the cli-
nician may have to resort to sedation or even anaesthesia.
A vaginoscope/ colposcope may be used to inspect the
lower genital u-act. Distension of tl1e vagina with saline can
be accomplished b) ho lding tl1e labia tightly around the
vulval in u·oitus; this ma) allow sufficie nt distension for a
satisfactory inspectio n of the cervix. vaginal vaulL healt11 of
 CH APTER 6 - PUBERTY, ADOLESCENCE AND RELATED GYNAECOLOGICAL PROBLEMS
tl1e vaginal wa lls, detection of any neoplasm or the presence
of any foreign body inserted inadvertently into the vagina.
Endoscopic examination may be a satisfactory alternative to
a difficult clinical examination.
The preschool girl child is best examined supine witl1
her hips well abducted and the feet apposed (frog leg posi-
tion). older child is best examined supine with her legs sup-
ported in stirrups. In ) otmg prepubertal girls, tlle labia
majom appear flatten eel, t11e labia minora are thin and rela-
tively p•·ominent and the clitoris is small. On paning the
labia or drawing tl1e lower parts of t11e labia downwards and
outwards, tl1e vaginal orifice can be well visualized The
vaginal walls appear thin and congested, the transverse m-
gae present in adults a•-e not seen, a midline longitudi nal
ridge may be p•·esent. If vaginal discharge is required for
testing, this should be collected witl1 a moist couon tipped
applicator, rubbing should be avoided as tl1is n ot on ly
ca uses discomfort. but also can be u·auma ti c LO the thin and
delicate vaginal epitl1elium. In the young prep uber tal girl
chi ld, the vagina measures 4-5 em, the ce rvix is twice the
le ngth of th e uterus; th e ova ries a re located h igh up at the
pelvic brim. Endoc rin e ac ti vity of the pitui ta ry, ovaries and
ad rena l glands inc reasingly ma nifest betwee n tl1 e ages of 7
and 10 )'Cars when increases in oesu·ogen effects o n the
genitalia become clinically eviden t. In case of suspected
d1 ild sexual mo lestation or rape, th e child may be better
examined in the knee-chest position. In tl1is position, the
vagina balloons out and the introit.us and hymen are easily
visualiJ.ed, the trauma of forced sexual assault is often ap-
parent as lacemtion or tear of t11e in t.roitus posteriorly. ln
t11is position, it is easier to collect discharge from the vagina
for cullltre and forensic tests. The pelvic examination
should be a\oided in an adolescent girl, but when required,
it is done under sedation of anaestllesia.
The vagina lengthens to 10-12 em in a fully grO\m ado-
lescent, the vagina becomes more capacious, the vaginal
epitllelium is thick with the presence of rugae and cov-
ered with a white acidic discharge and tlle vagina shows
tlle p•·esence of a mixed nora of nonpathogenic o•·ga n-
isms. The cetvix feels like a knob at the top of tl1e vaginal
vau lt and tl1e uterus to cervix r·atio reverses to 2:1. With
approaching puberty, th e ovaries descend into tl1e pelvis
and the ovaries show evidence of commencing follicular
function.
COMMON PAEDIATRIC GYNAECOLOGIC
PROBLEMS
The prepubertal girl child : T he common p roble ms for
whidl med ical opinion is sought broadly include fo llowing:
• Vulvovaginal infections and leucorrhoea
• Vaginal bleeding
• Ambiguous genitalia
• Abdominal neoplasms
• Sexual abuse
• Teenage- sexualit)
The common g) naecologic problems affecting tl1e prepu-
bet1.al girl child for \\hich consultation may be sought usu·
ally invohe vulval pnwitus, 'oaginal bleeding or discharge,
77
developmental anomalies, suspected abdominal lu mp, pre-
cocious or late pubet1.y and suspected sexual assaul t.
Altl1ough the genital su·ucwres are in the resting state
during early childhood, the) are not immune to diseases.
1l1e prepube11.al female gen ita is are delicate and are prone
LO infection and bleeding.
Vulvovaginal infections, pruritus and discharge: l n;tation
or inflammation of the vuhoa ma> result from numerous
causes. infections ( ITWIItucum contogioswn, concl) lomata acu-
minata, herpes genital is and gonorrhoea) may be u-ansmit-
te<l through a sexual or nonsexual close contact witl1 tl1e
child Poor personal h)giene may lead to candida! vulvovagi-
nitis, vulval in·it.ation may follow wonn infestation such as
pin worms or thread wonns secondary to anorectal contaJni-
nation. Poor sexual h)•giene may lead to chronic nonspecific
vulvovaginitis and in·it.ation leading to vulvitis causing labial
adhesions. Exposure to chemicals (deodot-a nts/antisepti cs)
may cause aLOpic de nnatitis leading LOa ch ro nic discharge,
vulvar skin excoriati on and over Lime ca use labial ad hesio ns
or eczemaLo id changes.
Vaginal disdwrge: T h is is ge ne rally th e res ult of infec tio n
caused by no nspeciFic ca uses, ge ne rally resulting fro m poor
hygie ne or as a result of speciFic infections. Some tim es, it is
caused b)' an inadvenenL insertio n of a fore ign body by tll e
child.
Nompecific vulvovaginitis: T h is is best treated by initially
improving perineal hygiene such as warm sitz baths, clean-
ing tl1e perineal area witJ1 a bland olive oil followed by soap
and water, keeping the parts elf) and the tLSe of clean cotton
tmdergarments. Often tJ1ese measures suffice. Vulvar medi-
cations should be prescribed sparingly as tl1e skin of tlle
genital region is \Cf) sensitive in children. ln case of an
unsatisfactOI') response in 2-3 weeks, consider wpical ap-
plication of an oestrogenic c•·eam (Pt-emat·in/ Oienesterol/
Evalon). This b.-ings about a thickening of the vaginal mu-
cosa, lowers the 'oaginal pH and encoumges growtl1 of lacto-
bacilli which in tum helps overcome offending bactetial
infection. Oestrogen also helps lO improve tl1e vulvo,oaginal
vascularity and procluce rapid clinical improvement. Non-
specific vulvovaginitis can sometimes cause a copious foul-
smelling blood-stained discharge secondary to anorectal
contamination with &cherichia coli, Strf'jJlororrns foecalis or by
Shigella organisms or by sud 1 as tl1read
worms or pin worms whi ch respo nd to a ntih elmintllic
d rugs. Finall y, any offensive vaginal d isc harge that follows
re te ntio n of a foreign body respo nds promptly to its removal.
Specific vulvovaginitis: Diagnosis sho uld p recede trea t-
ment. Sexuall y u·ansmiuecl disorde rs req uire a specific
treatmen t. Earl)' d iagnosis and treatment prevent seq uelae.
T hese infections have been speciFied in chap ter on Sexually
Transmitted Diseases. Labial ad hesions ca used by infec tio n
can be effectively managed by man ual separation and local
oesu·ogen cream.
Vaginal bleeding: This can be tJ1 e resu It of simple treatable
causes or be indicative of a more seriotLS underlying cause
requiring tJ1orough investigation and a timely t.reaunem.
Diagnostic approach: A histOI') of t11e nature of bleeding
and a general physical examination are essential to begin
witl1. Smear and cui LUre of t11e discharge if serosanguinous
or purulent blood-stained and offensive are of fundamental
imponance. Smear of the discharge for C) to logic evaluation
is necessary whene,er a neoplasm is suspected.
78 SHAW'S TEXTBOOK OF GYN AECOLOGY
l n difficu lt cases where localization of the cause of b leed-
ing is not possible, a thorough e xam ination under anaesthe-
sia under a good ligh4 and if necessary a direct endoscopic
visualization using a paediatric cystoscope/ hysteroscope
he lps to clear the diagnosis.
Common causes include endocrine causes, trauma, pro-
lapsed urethra and neoplasms.
include transiem neonatal vaginal bleed-
ing as a result. of matemal circulating oestrogens in t.he
newborn. Precocious puberty has been reponed as early as
the age of 6 )eat'S; however, the presence of other endocrine
stigmata helps to resolve the diagnosis. Accident.al ingestion
of th e mother's oral conu-acept.ive (OC) pills result.ing in
bleeding has also been reponed.
Traunw may be accidental; su-addle-type it"\iuries result-
ing from fa lling asu·ide a sharp may result in minor
injuries such as lacet-ati ons, or a blum injury may result in a
vul val haematoma; th e injuries ca used by penet.rating ob-
jects may be serious a nd may result in perito neal trauma
in volving inte rna l viscera requiring lapa rotOmy. Self-
in fl icted durin g p ia)' o r fo ll owing sex ua l ab use may not be
reported b)' the chi ld for fea r of remo nst.ratio n. Examina-
tion under a goocl light co up led wi th a deta iled hisLOry help
to arrive at tJ1 e ca use. Precautions m ust be taken to ascer-
tain and excl ude tJ1 e possibility of foreign body inserted in
tJ1e vagina being ove rloo ked.
urethra may fo llow und ue physical exertion
when tJ1 e child co mplains of painful micturition, vulvar
pain and bleeding. Separation of the labia reveals a
mulberry-like protrusion at the site of tJ1e uretJ1 ral orifice. It.
is possible to pass a soft rubber catJ1eter through the cemre
of tJ1e mass and tJ1e bladder decompressed. The catheter
may be left in situ for a few days, suitable antibiotic cover
and ana lgesics should be presc•·ibed. The oedema to us mass
may subside or undergo necrosis when after a few days it.
can be excised at the line of demarcat.ion witJ1 a cut.ting
cautery knife.
Cond),lonulltt acumi1Will are wany or granular lesions may
bleed at times in a prepubertal child.
Sarconw also kn own as grape-like sarcoma is a
rare and highl y malignant tumour of chi ldh ood can·ying a
serio us prognosis.
Ambiguous genitalia: The recogniti o n of genital abnor-
mali ties at an ea rly age is importa m w detetm ine t.he sex of
rearing of the infan4 a nd to chalk out plans for their correc-
ti o n, long-term managemen 4 prognosis and parental coun-
selli ng.
T he examinati on of tJ1e externa l genita lia is of primary
importance. An enlarged phallus a t birtJ1 raises the first
doubt about ambiguous ge nita lia and the need for proper
assign in g of tJ1e sex of tJ1e child. The commo nest cause of
ambiguo us genitalia (> 90% cases) is adrena l hyperp lasia
which can have a serious prognosis if not promptly recog-
nized and treated. The immediate co ncerns of the clinician
in tJ1e salt-wasting L)'Pe are to prevent rapid dehydration
leading to fluid and electrolyte imbalance. The parenLS
shOLLid be counselled that tJ1e exte rn al genitalia are incom-
plete!) formed and furtJ1er investigations are wan-amed. As
a working clinical rule, tJ1e presence of a midline frenulum
on tJ1e phaiiLLS is strongly indicative of the infant being a
genetic male, whereas pai•·e<l attachment of the labia to tJ1e
phallus suggesLS a genetic female. Clitoral e nlargemem witJ1
ambiguo us genitalia at b irth may be d ue to female pseudo-
hermaphroditism, mixed gonadal dysgenesis, male pseudo-
hermaphroditism and t-arel) true he nnaphroditism. Usually
the more pronounced tJ1e amb igu ity, the simpler it is to raise
the child as a female regardless of its ge netic sex. History and
clinical physical examination often tJ1row considerable light
on the possible cause - for example, history of adminisu-a-
tion of large doses of progestogens to tJ1e mother in early
fit'St u·imester, or a family histOI) ' of sexual ambiguity in ot.her
female relatives or a mate mal aunt or another female rela-
t.ive who suffet·ed from amenOtThoea or infertility witJ1 am-
biguous genitalia is indicative of the possibility of a recessive
genetic disorder. A histOI)' of stu·ge•1' for inguinal hemia in
early infuncy with the unexpected finding of an unde-
scended testis helps to identify tJ1e underlying aetiology.
The importance of exa min ation of tJ1e newborn should
include a rectal examination to dete rmin e tJ1 e presence of
the uten.LS at birth. Visualization of tJ1 e hyme n and testing
its patency as discussed ea di e r is important. In case of
doubt, sex chromaLin studi es a nd karyo type, imaging stud-
ies using ulu·asound o r MRI, horm o ne assays of gonadotro-
pins (FSH and Lll ), 17-ketos te roids and 17 a -hydroxy-
progestero ne (whi ch is e leva ted in 2 1-hydox)'lase deficiency)
are indicated for formu lating a diagnosis. of
serum elec trol)'tes and blood glucose are impo rtant in th e
managemem of tJ1 e salt-wastin g \'lltie ty of adrenal hyperp la-
sia. OtJ1er investigational aids which may be of use include
vaginoscopy, colpogram and laparoscopy. Rarely is an ex-
ploratory laparotomy required for diagnostic p urposes
alone. It is advisable to adopt a multidisciplinary approach
LO tackle the lon g-term management of tJ1 e cl1ild. In the
newbom infant. the diagnosis of tJ1e salt loosing adrenal
h)'Perplasia as earl) as possible is important to institute a
prompt u·eaunent to a'oid a se ri otLS outeome.
An imperfomte h) men needs to be tackled at the Lime of
puberty to forestall h)drocolpos/ haemaLOcolpos. Vaginal
anomalies detected at birtJ1 do not call for immediate surgi-
cal imervention. Let tJ1e child grow up to the age of puben.y.
If pelvic imaging shows the presence of a well-<leveloped
uterus and ova.-ies, then tJ1e consideration for plastic sur-
gery for an artificial vaginal reconstruction (panial or com-
plete) becomes mandatory; however, in case of congeni tal
absence ofthe vagina, in the absence of tJ1e uterus, pos!pon-
ing of the surgical procedure unti l tJ1 e tim e of marri age is
important, as coital freq ue ncy helps to mainta in tJ1e patency
of the vagina.
lL must be rem e mbe red that in tJ1e of suspected
herm aphroditism, tJ1 e undesce nded tes tis in the inguinal
canal or imraabdominal situati o n should be surgically re-
moved at pubett)' as it is prone LOa ma lignant change with
advanc ing age.
Thmours of gynaecological origin in children: The role
of tl1e gynaecologist is tO be aware of the possible occ ur-
rence of tumours in childhood, and to be familiar with tl1e
investigations to arrive at the proper diagnosis and manage-
mem plan. A large \'arieL) of swellings and tumours of eli-
verse o.-igins have been recognit.ed in infancy and child-
hood. Man> of tl1ese are not su·ictl) of gp1aecologic o.-igin
but enter tJ1e domain of differential diagnosis or are seen by
the gynaecologist fi t'S4 hence the need about their aware-
ness. These include sacrOCOCC) geal tumour, cluplicalion
cysts of the gastrointestinal u-act (G I u-act), ut-achal cyst,
 CHAPTER 6 - PUBERTY, ADOLESCENCE AND RELATED GYNAECOLOGICAL PROBLEMS
LUnbilical hernia, Wi lms single pelvic kidney, lym-
phoma, haemangioma, chordoma, neuroblastoma, menin-
gioma and hamartoma. Sarcoma boLryoides is a rare and
highly malignant tumour of childhood, it generally presents
as a pol) poidal of grape-like neoplasm protruding through
the vulva. However, germ cell tumours of ovary are com-
monest tumours seen in this age group. Other common
ovarian tumours are teratoma, )Olk sac tumour, granulosa
cell tumour.
A distended urinary bladder can presem as a swelling in
infuncy and childhood. Ovarian wmours, both cystic and
solid, are known to occur in children, and accoum for
1.0% of all neoplasms in premenarcheal children. Girls
with ovarian neoplasms general!)' present with abdominal
enlargement and pain. In the prepubenal child, the bulk
(greater than 60%) of these tumours are of germ-cell ori-
gin (dennoids are the commonest; however, immature
teratomas, emb ryonal cell tumours, e ndodermal sinus tu-
mours, dysgerminomas, choriocarcinomas and gonadoblas-
tomas have been recogn i)(ed in chi ld hood, many of these
are malignant). Man)' of these tumours secrete s ubstances
such as alpha fetoprote ins, ca rcinoemb r)•On ic antigen and
human chorion ic gonadOLropin hormone wh ich serve as
tumo ur marker-s and help to arrive a t a d iagnosis. With ap-
proaching ado lescence, the incidence of epithelial cell tu-
mours of the ovary begin to make their appearance, so that
in adu lt life epithe lial tumours of the ovary predominate
and account for almost 80% of all ovarian neoplasms. In
India, tJ1e incidence of ovarian neoplasms in people
younger than 20 )ears accounts for about 4%-14% of all
ovarian neoplasms. About a third of the tumours tend tO be
malignant. Bulk of these is the germ cell tumours (dysger-
minomas predominant); endodennal sinus tumours, tera-
tomas and mixed cell t)pes have a dismal outlook. The
survival rates are encouraging in girls u·eated early for the
disease.
Ultrasound examination of tlle abdomen and pelvis and
cr/ MR.l scans are useful in establishing the diagnosis of
ovarian neoplasms and assessing areas of solid and cystic
components. Areas of calcification in degenerated parts of
tllese tumour-s are not infrequent. A rar·e tumour of the
lower genital tract namely sarcoma bouyoides also affects
children; it is a tumour posing a grave prognosis and should
be tackled in a paediatric o ncologic setting.
ln general, all u·eaunents s hould aim at conserving re-
productive potentia l as far as possible without jeopardizing
the patien t's life. T his is im portant to enable the growing
ch ild to achieve mawrity a nd preserve future childbearing
potential. The ova ri an wmours have been derailed in chap·
ter on Benign and Ma lignant Ovarian Tumo urs.
Child sexual abuse: Two basic forms of sex ual ab use are
recognized. The first in vo lves vict.imizat.ion by a stranger; it
may involve any form of sexual activity brought about by
enticement, coercion or force. Such acts are usually re-
ported by the child. This situation must be handled very
ractfull). Appropriate medical examination and tests should
be perfonned, counselling should be offered and efforu
should be undertaken to bring the offender to book. The
second fonn of sexual abuse rampant in society, and under-
reponed is incesL
Incest occurs frequently in families witll social problems
of alcoholism, dr·ug abttse, ph)Sical abuse, broken homes,
79
violence, delinquency, mental retardation and an auno-
sphere of violence. Fatller-daughter relationships are the
commonest. but it rna) involve any close male relat.ive.
Among children of inceswous relationship only 10% have
nonnal ps)chological developmenL Anger, guilt feelings,
mood swings. depression, l)ing, dleating and stealing are
some bad habits these children develop; poor school per-for-
mance often follows and unexplained physical complaintS,
sleep disturbances and agg.·essive beha\'iour are frequem
manifestations. Rape leads to an immediate emot.ional
shock and a feeling of anger all around. Tactful handling
and timely ps)chiau·ic help give the child t11e best chance of
coming out of the experience unscatlled.
Sex education and female sexuality: Fifty years ago,
parental supervision and early marriages prevented young
indi viduals from experimenting with sexuali ty. Changes in
societal behaviour, freer interaction between tJ1e sexes,
influence of the media and greater involvement of women
in the workforce have led to cha nging moral and e tl1ical
values and altered adolescent behavio ur. The fact that
almost 10% of pregnancies occ ur in tee nagers, nearly 5%-
8% of reported medica l terminatio n of pregnancy (MTPs)
are in teenagers and 6% of a ll deaths from unsafe abort.ions
occur in teenager-s emp hasizes the need for impart.in g sex
ed ucation to sen ior school and college-going ado lescentS to
prevent unwamed pregnancies, MTPs, sex ually transmitted
diseases (STDs) and HIV (Mukherjee, 1999).
PUBERTY AND ADOLESCENCE
BIOLOGICAL SEQUENTIAL EVENTS OBSERVED
DURING PUBERTY
Adolescence is the age between 10 and 19 >ears. Puberty is
tlle period ofu-ansition from childhood to adult sexual matu-
ration. lt is the process of biological, pS)Chological and
physical development through which sexual reproduction
becomes possible. Progr·ession occurs through sequential
changes described as tllelar-che-+ adrenarche-+ peak growtll
spurt -+ menar·che -+ ovulation. The interval between the
breast development and menar-che is 2-3 years. Honnonal
events earlier described play a key role in orchestrating tl1is
transit.ion. Profound bodily changes, sexual development
and altered e motional and behavioural changes are observed
duting this malltrational pe riod. Besides endocrinal influ-
ences, genetic, nutritional and ot11er environmental factOrs
play an im portant role during this u·ansit.ional period of life.
Insulin-like g.·owtl1 factors peak level coincides with £ 2
level. lnitiall )' FS!-1 is re leased at night at first followed later
b)' an Ll-1 pulse. The level of growth hormones do ub les
during tJ1is growtl1 period.
Endocrine mechanisms underlying puberty: These have
been highlighted in the following:
• Early in pubert). tile sensitivity of the gonadostat to tile
negative effectS of low estradiol (E2) gradually decreases.
• Late in pubert). mattllation of posit.ive E2 feedback init.i-
ates t11e Ll-1 surge.
• Basal levels of pituitary gonadotropins increase til rough-
out puberty due to an enhanced h) pothalamic GnRH
pulse am pi itude rather than freq uen C)'-
80 SHAW'S TEXTBOOK OF GYN AECOLOGY
Age of onset of puberty: The age of onset is infl uenced
by nuu·itional status, genetic and environmental influences
including racial and cultural background, climate and resi-
dence. Hence a great deal of variations is observed in the
evolution of pubert> changes. Normal age of pubeny varies
between 9 and 13 >ears, and the duration lastS 2-3 years.
Although the beginning of puben> is subtle and cannot be
dated precise!), the end point is menstmation (menarche).
Over the last century, the age of menarche has progres-
si,·ely lowe•·ed; this has been very e'·ident in the developed
world including the West and japan. Also menarche occurs
later in women residing at higher altitudes as seen in Eski-
mos. A critical body mass has to be achieved p•·ior to men-
arche, obesity predisposes to earlier age of menarche (min-
imum of45 kg).
When environmental factors are optimal, puben.y is con-
trolled by genetic facto •'S as wiu1essed by the fact that th e age
interval between the ti mes of menarche in identical twins is
2.2 months that between d i:t)•go ti c twins is 8.2 months.
FAGORS AFFECTING TIME OF ONSET OF PUBERTY
o Gene ti cs
o Race. T he Afri can-A merican e nter p ube rty about
1-1.5 )'ears earlier tJ1an the White American gi rls
o Nuu·itional stallls. Puberty sets in ea rlier in moderately
obese girls and is de layed in malnourished girl. Leptin
(peptide) secreted by the fat cells sti mulate Gn Rh secre-
tion and induce early puberty. Minim um of a 45 kg body
weight is required to induce pubertal changes. Macroso-
mic babies tend to grow obese and have early menarche
tJ1ereb).
o General health stallLS
o Altitude. Dela)ed in Eskimo girls compared to gids living
in tJ1e u·opics
o PS)chological state. Exposure to education, media
o Exposu•·e to light (blind indi' iduals enter pubeny earlier
than sighted individuals)
Growth spurt and menstruation: The starting of the
physical growtJ1 cw·ve is soon followed by a typical sequence
of development of fema le secondary sexual characte.-istics,
which include thelarche, adrenarche, continuing growtJ1
sp un genital o•·gan growtJ1 and mena rche. T hese will h ere-
after be discussed at length.
Tun ner and Marshall desc ri bed five stages of p ubertal
changes - these a re in tJ1 e following seq uences (Fig. 6.3A):
o Physical growth and we ight gain
o Development of breasts
o Pubic and a.xi llary hair
o Development of ovaries and gen ital organs
o Growth spurt and mensu·uation
Gordon et al. (2002) depicted the physical changes oc-
CLUTing during pubert) as follows:
A comparison of tJ1e growth rates in male and female
growing children re,eals a similar curve until tl1e age of
10.5 >ears (the male growth being somewhat ahead til rough-
out, tJ1ereafter the growth spun in tJ1e female child overtakes
that of the male child fo•· 1-2 )Cars before it plateaus out).
However, the gmwth curve in the male child demonstrates
the final spun a couple of)ea•'S later before plateauing. Thus,
the average mean height of a fu lly grown man is greater than
that in woman as shown in Fig. I>. I.
PHYSICAL GROWTH AND BODY WEIGHT
The growtll in the height and weight in the female child
begins on average around tJ1e age of I0.5 years (average of
9-11 years) and is compleLed b) Lhe age of 14 >ears. Dllling
this period, the height gn>\\U1LhaLstabiliLes at 1-IOcm/ year
before puberty doubles during puberty (5-10 ani)ear).
Growth is attributed to g.·owtJ1-promoting honnone of
the anterior pituitary, and also by insulin-like growtJ1 factOr
(IGF-1). The body shape also takes on the feminine configu-
ration. The bone mass dtuing adolescence increases by 50%,
emphasizing the importance of providing adequate calcium,
iron and nutritiona l needs during tJ1e g.·owing years of ado-
lescence. Iron requirement increases by 15%.
SECONDARY SEX CHARACTERS (SSC) -TANNER
CLASSIFICATION Of THE SEQUENCE OF DEVELOPMENT
THELARCHE
T he first sign of p uberty is the development of the b reastS.
Breast b udd ing usual !)' appears between tJ1e ages of9 and ll
)'ears; it is indicative of tJ1e competency of the h ypoth ala mic-
pituitary-ovarian axis. The adolescent breast development is
divided into five stages:
Bl -denotes the prepubertal breast. At1J1is infantile stage
only t11e papilla is elevated.
B2 -denotes thelarche. The breast buds are palpable, are-
ola enlarges and the breast is elevated like a small mound.
B3- tJ1ere is further enlargement of tJ1e breast and itS are-
ola without sepamuon of itS contours.
B1 - preferential growth of Lhe areola and nipple leads to
formation of a secondat)' mound over tJ1e mound of the
breast.
B5- fo•·mation of the mature adult breast. There is recession
of the areola into the general contour of tJ1e breast be-
cause of greater gr·owth of the breast tissue (Fig. 6.3B).
ADRENARCHE
T he adrenals are tJ1e mai n source of androge ns, which are
respo nsible for tJ1e growth of pub ic a nd ax illa •)' hair. Pubic
hair generall y make its appeara nce abo ut 6 months afte r
the larche at the Btl stage. Ax illa•) ' hair ge ne rall y make the ir
appearance 1-2 )'Cars afte r puba rche. Rarely axillary hair
development p recedes pub ic hair deve lopme nt.
PUBIC HAIR DEVELOPMENT
The stages of pubic hair growLh are as fo llows:
PI -prepubertal stage when tJ1ere are no coarse p ubic hair
present. the veil us hair present over the pubic area are
sint.ilar to the ones seen over the abdominal wall.
P2 - pubat·che denotes the appearance of long or slightly
curved and pigmented hair sparse I) over tJ1e labia.
P3- darker. coarser and curl) hair are seen spread over tile
mons pubis.
P4 - the preadult stage when tJ1ick clark growths of curly hair
are seen co,e•ing tl1e area shon of the inverted uiangle.
 CHAPTER 6 - PUBERTY, ADOLESCENCE AND RELATED GYNAECOLOGICAL PROBLEMS 81

Growth
spurt

Breasts

Pubic hair

Axillary hair

A
Menarche
age I
8
I
9
I
10
I:
11 .
I:
12'
I
13 14•
I· I
15
I
16

B1

Iy PH1

B2
{\ f { y PH2

B3
(y l PH3

)\! ( y) PH4

B5
PHS

B
Rgure 6.3 (A) Development of secondary sex characters related to age. (B) Pubertal changes in the breasts and pubic hair.
82 SHAW'S TEXTBOOK OF GYN AECOLOGY

200 Determination of bone age provides a better marker for

190 prediction of the remaining growth potential and the fina l
180 adult heighL
170
160
150 Girls MANAGEMENT
E 140 Although pubert) is a transitional physiological pe•iod, lack
of knowledge regarding 'oarious physical changes and fear
120
of futw·e impose stress and anxiety in these adolescent girls,
110
100 though lately they ha'e acquired a beuer knowledge than
90 before. Psychological and emotional changes need to be
80 taken note of and adequately managed.
70
60 • Sex education is vel)' useful in schools. The knowledge
regarding STD, HlV and risk of pregnancy wi ll dissuade
0 2 4 6 8 10 12 14 16 18 20 them from indulging in premarital sex. Where promiscu-
Age (years) ity prevails, contmceptives should be encouraged. Barrier
Rgure 6.4 Height attain ed grow1h curves for boys and girls show-
method protects against STD, and oral pills pro tect
ing grow1h spurt. against pregnancy.
• Nutrition fro m p ro te in, calcium a nd iro n are requi red
for th e growth and main ta ining hae moglobin; calcium
P5- ad ult inverted triangul ar d isLti b uti o n of thick, coarse, need increases b)' 50% and iro n by 15%.
dark curl )' hair sp reading o ut towa rds the medial aspects • Lately, HPV vacci nati on is stro ngly recommended for
of th e th ighs is evident. adolescents, especia ll y if iJley ind ulge in sex ual ac tivity.
• Q uadrivalent vaccine is given at 0, 2, 6 months.
Increased secretion of dehydroepiandrosteronesulp hate • Bivalent vaccine is given at 0, 1, 6 mon iJls.
(DHAS) is responsib le for growth of pubic hair.

AXIUARY HAIR DEVELOPMENT PUBERTY - ANOMALIES OF GONADAL

The sequence of axilla!") hair develop men Lis as follows: FUNCTION

Al -prepubertal stage. o axillar) hair presenL
A2- appearance of sparse axilla•) hair.
A3- adult distl"ibution of thick, coarse and dark pigmemed
hair.
GENITAL ORGANS
• Vuhoa - vuhoal skin under the influence of oesu·ogen be-
comes keratiniLed and resistamto infection. Fat is depos-
ited in the labia majora.
• Vaginal mucosa becomes mu lti layered with the fo•·ma-
tion of supe•·ficial layer containi ng glycogen and PH is
maintained at 4.5 by Dode rl ein 's bacill us acting on
glycogen.
• T he uterus grows mp idl)', and prep ubertal ratio of uterus/
cervix of 1:1 changes to 2: I o r 3: I .
• T he ovari es start deve loping prim ordi al follicles into
Graafian fo llicles. However, a dominant follicle with ovu-
lation occurs in 50% cases. Rest take 1-2 years fo r ov ula-
tOI")' C)1Cies tO OCC \11:
MENARCHE
The first menstrual period generally follows thelardle by
about2 years, when growth developmem is almost complete
and breast development reaches the adult mature stage.
The initial menstrual C)Cles are generall)' anovulatOry
for about 12-18 months after menarche, presenting with
i1Tegular C) des without dysmenorrhoea.
SKELETAL AGE
Sexual maturation con·elates more with bone age than
chronological age.
Delayed pubert) is defined when the secondary sexual char-
acters do not appear b) the age of 14 and menardle is not
established b) 16 >ears of age ( 10%).
Primary amen orrhoea and delayed puberty: Causes for
these conditions can be broadly divided into h)pogonadal
and eugonadal 'oalieties. Patients with h)pogonadism may
have hypergonadotropism seconda•)' to ova•·ian failure
(Turner) or hypogonadism as a result of Failure of matura-
tion of the hypothalamic-pituitai)'-{)Wrian relationship.
The eugonaclal 'oadety consists of patients with evidence of
steroidogenesis but delayed menarche. In tl1is group the
possibility of prima•)' ame no n·hoea due to other causes
s uch as developmental ano malies leading to o ut-
flow obstn.•ction, less com mon!)• testi cul ar femini zation
synd rome (a nd roge n insensitivit)•), fa ilure of developme nt
of the positi ve feedback mechanism in s pite of adequate
e ndogenous oesu·ogen production and hype rprolac tinae-
mia often resulLi ng from a pitui tary neoplas m (p rolacti-
noma) s houl d be suspected. Ma lnutrition and anorexia
nervosa are o tl1er causes. Details are described in chapter
on Amenorrhoea.
Aetiology of delayed puberty:
• Commonly, it is familial or idiopaiJ1ic (60%).
• Kallmann S)ndrome- 1-l)pOthalamic and pituitary inad-
equacy. Cr. MR1 of sella turcica, FSH, LH level con finn
tlle diagnosis.
• Ovru;;m causes - Tumer S) ndrome, Swyer syndrome, re-
sistant 0\'<11)', autoimmune disease, testicular feminiLing
S)ndrome, high FSH.
• Pol)C)'Stic O\oarian disease.
 CHAPTER 6 - PUBERTY, ADOLESCENCE AND RELATED GYNAECOLOGICAL PROBLEMS 83

• De,·elopmem of secondary sexual charaCLers, but no

menstruation- absent uterus or Ct")ptomenontlOea, ob-
struction in t11e lower gen ita I u-act.
• Mal nutrition, anorexia nervosa, ch ildhood illness and
vigoro us exercise.
• Hypoth)•roidism.

Inves ti gations and managemem - see chap ter on Pri-

mary and Secondat")' Amenorrhoea.
Anorexia nervosa is being increasingly recognized and
u·cated witJ1 the help of a psychiauist. ldemification of the
group ofpatiems who exhibit pubertal maturation bm fuilto
de,elop a positive feedback system for establishing appropri-
ate LH surges required for triggering 0\'ulation. In t.he long
term, t11ese individuals witl1 chronic anovulation are at risk
of de,eloping endo metrial hyperplasia and malignancy.
Approach to diagnosis: All patiems after t11e age of 14 years
manifesting the absence of breast deve lop mem and oestro-
gen effecLS need to be investigated. Besides a detai led his-
Lory and physical examinati on includ ing reco rd of he ight in
ce nli me u·es and weight in ki lograms, tJ1e fo llowing investi-
ga ti o ns are recommended:

I. Serum FSH, LH, PRL and TS H, ster·oid hormone assays

Figure 6.5 Precocious puberty -a girl aged 11 years. Note well -
including androgens marked b111ast development and pubic hair growth.
2. CT scan of me skull
3. Buccal smear for sex chromatin determination
4. Kat")Ot)pe, G-banding, polymer-ase chain reaction and precocious pubeny belong LO Lhis varieL). This is mostly as a
nuorescent y testing resuiL of constitutional facwr or CNS disorders.
5. Ulu·asound to detect uterine anomalies and t11e presence Pseudoprecocious puberty: Elevated level of oestrogen,
of the ovary and other honno nes because of ovarian or adre na l tumours
6. Laparoscop)' in selected patienLS o r inLake of hormone containing Lab leLS resuiLS in pseudo-
precocious puberty. T his varieLy is assoc ia Led witJ1 vaginal
b leed ing and oLher changes b uLLhe re is no cyclical ovula-
TREATMENT OF DELAYED PUBERTY Lio n o r dsk of pregnancy.
I. Treat the cause following investigatio ns an d diagnosis. Aetiological classification of precocious puberty: The va.-ious
2. When no cause found, oest.rogen and progestogen init.i- causes ar·e as follows:
ate menstruation and regJJiar cycles, a llow proper growt11
and height, secondru")' sexual characteristics and also I . OJmplete a) ldiopamic, fami lial or sporadic,
pre,ent osteoporosis. Most respond well and have no genetic (75%)
ad,erse effect o n future reproduction. puberty: b) Congen iLallesions of t11e
hypotlwlamtL5-pilui1ary
Precocious puberty: This is defined as tJ1e appearance of Acquired lesio ns- u-auma, infec-
a ny of t11e secondary sexua l ch aracte tistics before the age tion, neoplasm - LUberculosis
of 8 )'Cars or me occ urrence of me narche before the age of (TB) me ningitis in chi ldhood
10 )'Ca rs (Fig. 6.5). It is not a common cli nical en ti ty. Broad!)' c) PanofaspecifiCS)11drome-
speaking, precocio us p uberty can be d ivided into two types. McC une-AibrighL (5%), von
The first variety (known as u·ue, co mplete or isosexual preco- Rec klinghausen 's new·ofibromatosis
cious pubeny) resuiLS from the premature acti vation of the d) Other ca uses- endocri ne/
endocrine pat11way comp•·ising the hypotllalamic-pituilal")'- metabolic disordet-s
oval"ian axis. In such girls, t11e total gl'O\\th spun and poten- 2. Incomplete a) Premature thelarche
tia l increase in height is not achieved, hence it is necessru1' to b) Premawre adrena•·che
identify t11e possibility early and advocate a prompt treaunem puberty: c) Premawre menarche
to dela) t11e malllration process to enable t11e ell ild to achieve
increase in heighL In conu-ast, the second variety kn0\\11 as 3. Pseu dop TfCOCio u.:. a) FeminiLing ova dan lumours
the pseudo or incomplete precocious puberty is t11e result of puberty: (OnfU-1 (10%) (honnone secreting)
sex steroid stimulation indepe ndent of tJ1e above axis. iudef)('JUlent) b) Adrenal hype rplasia/
True precocious puberty: When tJ1 ere is premature mat- neop lasm - 20%
ura tion of hypo th alam ic-piwi tary axis wi tJ1 increased pro- c) Hypo tJ1yroid ism
d ucti on of Gn RH, it is called true precocio us p uberty. d) Hepa toblaHoma producing
There is cyclical ovulation in tJ1ese girls. Such girls are at a gonadou·opins
.-isk of pregnru1cy and sexual ab use. At least 85% cases of e) latrOgenic-oesu·ogen administration
84 SHAW'S TEXTBOOK OF GYNAECOLOGY
In more than 90% of cases, no organic lesion is detected.
The axis and the adrenal
functions mature early resulting in precocious puberty.
Pregnane> in a )Oung girl aged 6 years has been recorded.
Investigations re,eal t11at gonadou·opins and ovarian steroid
hormones are secreted in adult quantities.
A number of skull problems such as rickets can cause
precocious pubert). Tumours at the base of t11e brain such
as craniopha11 ngioma, pituita•)' wmours, optic glioma,
teratomas and astrOC) to mas ma>' be contributory causes.
Infections such as encephalitis, meningitis and h)drocepha-
lus have also been implicated.
Clinical features of prerocious puberty: The commonest va-
riety termed constitlllional precocity tends to run in fami-
lies. lL must be bome in mind that this diagnosis is one of
exclusion. Long-tenn follow-up is recommended as some of
me cerebral conditions come to light o nl y in adulthood.
Sexual precocity is consistent witJ1 a normal reproductive
function, and is not related to ea rly onset of menopause. In
tJ1ese chi ldren, tJ1e seq uence of eve nts of sexual maturation
fo llows t11e norm al standard pattern. T he growth sp urt oc-
curs at an earlier age, so the re is a transient but short-lived
increase in height. As the epiphysis of tlt e long bones fuse
early under premature oestrogen effects, there is an even-
tual stunting of the height. Intellec tual, psychosex ual and
emo tional development co•,·espond to the chronological
age; hence, tltese youngsters and their fami lies have to face
potentially difficult social and emotional situations.
McCune-Albright S) ndrome affects about 5% of chil-
dren with precocious pubert). Multiple cystic bone lesions
are seen. Cafe-au-la it spots on the skin may be evident at
birm. Mensm.ation sets in earl) independent of t11e custom-
ruy sequence events of thelarche and ad re narc he preceding
menru·che. This is atuibuted LO the autonomous production
of oestrogens by the ovaries. Eventual fertility remains un-
impaired and t11e adult height attained.
ln every case of sexual precocity, the possibility of ru1
underlying functional hormone-secreting tumour of the
ova•y must be entertained and its possibility excluded.
InvestigatiollS: The following investigations are recom-
mended:
l. Radiograph of the wrist to establish bone age.
2. T hyroid function tests- T 4• and TSH. TSH s timula tes
FSH receptors.
3. EEG and CAT/M RI sca n ofLhe s kull.
1. Adrenal function tests LO exclude he te rosex ual precocity.
5. Pelvic sonograp h)' LO exclude pelvic neoplasms.
6. GnRl-1 Lest to exclude aULonomous ovarian cysts from those
secondary to gonadotrOpin stimulation. Gn RH test - i.v.
20 meg/ kg GnRI-1 - estimate LH level 30 minu tes
level > 9.2 IU/ L indicates u·ue precocio us p uberty (GnRH
related).
7. FSH, LH, oesu·ogen levels.
Management: Precocious puberty is a disturbing develop-
ment for t11e parents and child. All efforts must be Lmder-
taken to detect the under!) ing cause. However, t11e cause
may not be apparent and rna> be detected only late•· in life.
Pru·ents should be counselled according!)'· Parents should
be wamed t11at the child is vulnerable to sexual assault and
needs careful supervision.
A proper treatment sho uld be instituted for hypothyro id-
ism, adrenal hyperplasia and surgical intervention for u.t-
mOLll'S of t11e ov;uy, adrenals or of neurological origin.
Drug treaunen t of constitutional precocity includes:
I. l•1i· depot medrox)progesterone acetlue (DMPA) 100-
200 mg. i.m. eve!") 2-4 weeks to induce regression ofmese
chru1ges and cessation of mensu·uation. It is however not
vel)' efficient in inhibiting bone growth. Treaunem de-
presses adrenocortical and h) pomalamic-pituita•)' activi-
ties. Instead of i•1iection, daily or qclical progestogen
avoids i•1iections, but are not convenient.
2. Cyproterone acetate exerts antiandrogenic and antigo-
nadotropin effects. Oral administration of 70-150 mg/
m2 / da)' has been found to be superior to DMPA It also
helps in increase of height and stature. Adrenal suppres-
sion is a known side effect.
3. GnRl-1 agonists ( Buserelin) form t11 e mainstay of the
treatment in present-day practice.
T he month ly adm inistra tion of depot prepamti ons al-
lows p ubertal develop ment LObe a n·ested te mporarily until
the full height potential has been ac hieved and the child
reaches t11e appropliate age for t11 e onse t of pubert)'·
• Buserelin I 00 meg nasal spray daily.
• Leuprolide 7.5 mg montJ1 Iy. A single implant of histrelin-
effect lasts for I year.
• Triptorelin 11.25 mg 3 monthly for I year witJ1 calcium
and viwnin D to prevent osteoporosis 20 meg.
ln precocious pubert), future reproductive capacity is
not compromised and premature menopause is not docu-
mented.
Calcium and ' 'itamin D supplementation is required to
prevent drug-related osteoporosis.
ADOLESCENT CONTRACEPTION
This is a complex subject. Cultu•'<l l, religious, socioeco-
nomic and educational facto•'S impact it. Understanding
adolescent sexuality and the emotio nal need of youth
help in tl1e proper and effective im plementation of tl1is
increasingly importa nt social and healtJt goal. Teenage
sex can be viewed as a norm a l behavio ur development
and mi lestone, or a ri sk be havio ur pauern whi ch may
lead to se rious co nseq uences beyond tlt e ado lescent's
comprehension.
Children from poor socioeconom ic strata of society, liv-
ing in crowded localities, disrupted families and states of
depression and unhappiness as we ll as teenagers from the
affluent classes ;u·e prone to expe timent witJ1 sex.
Premarital sex can end in acquiring STDs and unwanted
pregnancy.
Reromml!1Jded co1Jtraceptive met/rods: Adolescents should
be infonned about sexualit), the importance of self-control
and abstinence until a more responsible age. However,
adolescents resent sermoniLing and are more re-
sponsive when t11eir indh·iduality is respected. lnfonnation
about contraception is necessary to equip them to face real-
life situations.
 CHAPTER 6 - PUBERTY, ADOLESCENCE AND RELATED GYNAECOLOGICAL PROBLEMS
OC are in general preferred as these safeguard Lhe ado-
lesce m girl again.sL any unwamed pregnancies. These O C
pills also confer Lhe advamage of regular pe1·iod.s wiLh mod-
est now, and freedom from discomfort. In case of girls in an
un stable relationsh ip with a male parU1er, insistence on the
add itional use of barrier con u·aception b)' the male partner
is desirab le Lo protect he r aga inst STDs.
Emergenty contmception s ho ul d be made avail ab le in case
of con u·aception failure suc h as condom s li ppage/ condom
bu i'Sting/forgouen use. T he conu·aceptives for adolescems
have been detai led in chapLer on Te mpOl<ll')' and Perma-
nent Methods of Contraception.
MTP seroices. Access LO these back-up sen•ices should be
a' -aila ble to unmarried adolescenLS
MISCELLANEOUS PROBLEMS
Apart from the more pertinem prob le ms disc ussed ea rlier,
adolescenLS are s ubjeCL LO OLhe r hea lth prob le ms whic h will
be discussed brie fly hereafte 1:
I. Puberty metwrrhagia: Soon after the menarche, the early
m e nstrual cycles Lend 1.0 be irregular and often pro-
longed leading LO severe anaemia.
2. Dysmetwn·hoea: In the menstmal C)cles Lend
to be in·egular and anovulaLory LO begin wiLh, however,
in Lh e following 12-18 momhs, with maturing of Lhe en-
docl'ine axis, Lhe cycles become more regular, ovulation
seLS in and the periods become painful. Spasmodic dys-
menorrhoea can be severe enough LO requi1·e med ica-
Lion. Drugs s uch as mefenam ic ac id 500 mg, twice da ily,
he lp to con u·o lthe pain. T hi s drug acLS by vin ue of inhib-
iting tl1e enz)•me prostagland in S)•ntlletase.
3. H inutism: T he causes of t11e mascu li ne disLrib ution of
coa1'Se h air can be psychologica ll y disturbing to the indi-
vidual. The causes can be broadl y classified as follows:
(a) Idi opathic
( b) Q,oarian
(i) Polycystic ovarian disease
(ii ) Plll·e gonadal d ysge nesis
(iii ) Virilizing ovarian tumours such as arrhenoblas-
toma, hilar cell wmour, g)'11androblastoma, li-
poid cell tumo u r
(c) Adrenal
(i) Congenita l ad renal hyperp lasia of the delayed
variety
(i i) Viri li zing adrenal wm ours
(iii) Cushing syndrome
(d) lalJ'Ogenic
(i) Anabolic agenLS
(ii ) Androgenic drugs such as d a n:uol
I. Endometriosis: Thought tO be of mre occurrence in India,
recem investigational ad,-ances suc h as pelvic
ph) and laparoscop)' have revealed that this disease
can also occLtr in adolescence and be tl1e cause of se-
vere dyspareunia, dysmenorrhoea and chronic pelvic
pain.
Acne is common am ong adolescent gi rl s. For trea unent,
refer to chap ter on Diseases of the Oval)'.
85
KEY POINTS
• Pubert) is a Lransition from childhood to adulthood
and in,olves physical, biological, endocrinological
a nd ps)•C ho logical changes.
• Normal age of puberL)' in fema les is 9-1'I )'Cars. Pu-
bCI'l)' is precocio us whe n Lhe seconclar)' sexua l c harac-
te i'S appear before the age of 8 )'Cars a nd mensu·ua-
Lion begins before the age of I 0 )'eai'S. The most
common type of precocious puberty is constitutional,
but otl1er causes should be exclude d. It is desirable to
suppress mensLruation until the appropriate age is
reached to allow the girl to reach tl1e heighL
• Dela)e d puberty is tl1e absence of features of puberty
b) tl1e age of 16 years ma) be familial or idiopalhic,
but requires invest.igaLions.
• Pu bert) menorrhagia can cause anaemia needing
blood transfusion and supportive treaunent.
• Acne ma)' be due to PCO D and s ho ul d be u·ea ted.
SELF-ASSESSMENT
I. Describe the endocrinolog)• of pubeny.
2. Describe Tanner classification of de,·elopmem of female
seconda l') sex cha1-acLeristics.
3. Describe the causes of delayed f>llbert).
'1. Write shon notes on adolescen Lcontraception.
5. Disc uss tl1e problems ofteenage pregnanc ies.
6. Disc uss the ca uses and managementofabnonnal uterine
b leed ing in adolescence.
7. What a re tl1e common causes of hi rsu tism in fema le ado-
lescenLS?
SUGGESTED READING
The American Col k-ge of Obstetricians and Cp1ecologi>ts. lleallh Care
for Adolc.ccms. WashingtOn, D.C., ACOC. 2003 Education Pam-
phlet>.
Ada.>hi EY. llillard PA (eds). On Pubcn). l'\omk'• Gtnaecol-
ogy. 12th Ed. Philadelphia, Williams & Wilkin.>, 1996.
Regulatioll of puberty. lk'.>t Pr.tct Re-s Oi11
Endocrinol Mclab 2002; 16: I.
Droegcmucllcr W, llcrbst AL, Mishdl DR, Slcnchcvcr MA (eels). Pedi-
>llric J.:ynccology. Comprehensive Gynccolof..'Y· l$1 Ed. USA, CV
Mosby & Co. 1987; 231.
Gordon J 0, Spcrolf L. Abllonnal pub<:ny and f..'TOWih problems. I land-
book for Clinical Gynecologic EndocrinoiOJ>'Y & ln fcnili1y. Philadel-
phia, Uppincou-Ra,·cn, 2002; 199.
Kaplo"ill P. Clinical Char.tclerisrics of 104 child ren rcfcrn:d for e\'alu-
ation of precocious pubeny. J Clin Endocrinol 2004;89(8):
3644.
Boepple PA. Variations in timing of pub<.'M). Clinical spec-
lntm •md genetic ill\et.igat.ion.J Clin Endocrinol Mctabol 2001 ;86:
23&1.
SperoiT L. Cia.. Rll. Ka.e l'\G (eds) .l\'onnal and abnomlal>cXtoal de-
\'Clopmcnt. Clinical G}necologic Endo<.Tinology a11d Infertility.
4th Ed. Philadelphia, Williams & Wilkins, 1999; 379.
 Menopause and Related
Problems

Introduction 86 Postmenopausal Bleeding 96

Perimenopouse (Climacteric) 86 Key Points 97
Diagnosis of Approaching Menopause 86 Self-Assessment 98
Menopouse 86

and ca uses rapid metabolism of oestrogen in tl1e liver and

INTRODUCTION
1s, hence an tiestrogenic.
• Counselli ng o n co ntracep tio n wi ll help. Intrauterine con·
Menopause is a physiological and natural event in the life of
a woman. It is cha1·acteti:red by the permanent cessation of u-aceptive devices a nd oral combined pills are not recom-
mended o n account of in·egular bleeding and risk of
menstruation. Most women anticipate such an event as age
thrombosis, respectively. Surgical method is not required
advances. However, few women develop a sense of fear with
for a short period of fertility. Pl·ogestogen-<>nly pills may
approaching menopause thinking that it might lead to a loss
cause irregular bleeding. Banier contraceptive is tlle saf-
of femininity, lack of interest by husband and feat· of ageing.
est metllocl.
The _process leading to the final onset of menopause is
• lf a woman has fibroicls, a shan course of GnRH or Mi-
determmed by the number of oogonia present in t11e ova·
rena IU CD can shrink the fibroid and avoid hysterecLOmy.
ries at binh, the rate of atresia during reproductive years
Drsftmctional ute1·ine bleeding requires investigations.
and the honnonal inte1·play regulated by the hypothalamic-
• The woman needs guidance on menopausal symptoms.
piwitaq-ovarian axis.
The need for hormone replacement therapy (HRT) will
be discussed later.
PERIMENOPAUSE (CUMACTERIC)
Perimenopa1t5e is a petiod of 3-4 years before actual meno-
DIAGNOSIS OF APPROACHING MENOPAUSE
pause is characteli:t.ed by a number of changes in body d ue
1. A fall in the level of inhibin B (not inhibin A) cmLSes a rise
to dec lining levels of hormones produced by the ovary. These
in follicle-stimulating hormone (FSH ) level. FSH> 40lU/ L
ch anges may be in the form of mood changes, hot fl ushes,
is 1-eponed.
generalized weakness and alterations in menstrual pattern.
2. Rise of FSH level a nd leutini:t.ing hormone (LH) level
MCLst women accept these cha nges and an ticipate the onset
e leva ted more than no rm al values.
of ac tual menopause in nea r futw·e. However, for so me
3. A fa ll in the leve l of an ti-M hormone suggests a
women such changes produce anx iety, fear of etc. A
low ova na n reserve and low antm l folli cular co unt.
ca reful and sym pathetic counselli ng by healtl1 care provider
may allay he r fears and prepare her me ntally for approac hing Study of FSH level o n day 2-5 after the last menstmal
A general physical examination, pelvic examina- period detectS p rem e nopausal stage.
uon and comm o n investigations are reassuring for patient.
Peri m enopause is foll owed by I year of amenorrhoea.
This pe1·iod is associated with a mi ld ovarian hormonal
deficiency leading to anovulation and menstrual disorders
MENOPAUSE
especially menorrhagia, and sometimes obesity. '
Menopause is defined as the cessation of O\'<ll·ian function
Apan from general healtl1 check-up to mle out cardiovascu-
resulting in permanent amenorrhoea. lt takes 12 montlls of
lar disorde1; diabetes and h)penension, a pelvic examination
amenoni1oea to confinn that menopause has set in, and
mammograph)\ uluasound, bone density and Pap smear may
therefore it is a retrospecti'e diagnosis.
be ach·isable to asslll-e the woman of her good healtl1.
Climacte1·ic is the phase of \\'<lning O\'<llian activity, and
Management comprises the following:
may begu1 2-3 )Cars before menopalLSe and continue for
• Diet, advice on smoking and alcohol. calciLUn supplementa- 2-5 years after iL The climactelic is thlLS a phase of adjtLSt·
uon and exercise will help. Smoking is toxic to t11e follicles ment between the active and inacti'e ovarian ftmction and
86

occupies several years of a woman's life, and it involves
physical, sex ual and psychological adj LISUllents.
DEMOGRAPHY
Sixt) million women in India are older than 55 yea rs. \Vith
women living longer than before, a majority would spend
one-third of their life in the posunenopausal stage. The
health problems cropping up dllling this period a nd their
relationship to oestrogen deficiency of menopause are now
obvious a nd better understood. It is imponamtherefore to
address all these menopause-related diseases and apply pro-
phylactic measures so that these women ca n lead an eqjO)'·
able and healthy life. An average Indian woman now lives
up to 65 years, whereas in the developed counuies a lifes-
pan up to 80 yea r'S is possible.
AGE
Menopause sets in whe n the fo ll icular number falls below
1000. Menopause norma ll )' occ urs between the ages of
48 and 52 years, tJ1e ave rage age being 49 years. It is not
un common, howeve r, to see a woman menstruate we ll
be)•ond the age of 50 years. This de la)•ed menopause may
be related to good nuu·itio n and be tte r health. Late meno-
patase is also co mmo n in women suffe rin g from uterine
fibro ids and those at high risk of e ndo meu·ial cancer: Me no·
patase seLLing before tJ1 e age of 40 years is known as
premature menopause.
Me nopausal age is not related to menarche, race, socio-
eco nomic status, number of pregnancies and lactatio n or
taking of oral contraceptives. It is however directly associ-
ated with smoking and geneLic disposition. Smoking in·
duces premature menopat.ase. Most reliable predictor of age
of menopause may be tJ1e age of menopause in her sister
and mother.
PATHOPHYSIOLOGY
During climacter-ic, ovarian activity declines. Initially, ovula-
tion fails, no corpus luteum forms and no progesterone is
secreted by the ovary. Therefore, the premenopausal men-
strual cycles are ofte n anovulatory and irregular. Later,
Graafian follicles also fail to develop, oestroge ni c activity is
reduced and endome u·ial atrop hy leads LO amenorrhoea.
T he cessati on ofova ti an activity and a fall in tJ1 e oestrogen
and inh ibin levels ca use a rebo und increase in tJ1 esecretion
of FSH and Ll I b)' tJ1e anterio r pitui ta i)' gla nd. The FSH
level rna)' rise as much as 50-fo ld and Ll-1 three- to fo urfold.
Menopatasal urine has become an important commercial
source of hum an me nopausal go nadotropin (hMG). With
furtJ1er advanc ing yea rs, go nadotropin ac tivity of the pitu·
itary gland also ceases, and a fall in FSH level eventually
occ urs.
HORMONE LEVELS
l11ere is 50% reduction in androge n production and 66%
reducLion in oesu-ogen production at menopause. The
oesu·ogen level ma) r·emain low at 10-20 pg/ mL. Some
oesu·ogen comes directly from the ovai)'• but most of it
is oestrone (E 1) derhed from peripheral conver'Sion of
CHAPTER 7 - MENOPAUSE AND RELATED PROBLEMS 87
androstenedione secreted by tJ1e ovar)', a nd its level varies
between 30 and 70 pg/ rnL. The ovary also secretes a small
amotmt of testosterone which catases mild hirsutism at
menopause. Th e FSI I appears in high co ncenua tion in the
ttrine (more tJ1an 40 I / L). 1::2/ 1::1 ratio maintained greater
man I in the premenopatasal period is reduced tO less man
l after menopatase. catasing an oestrogen deficiency state.
O estroge n level greater tJ1an 40 pg/ mL exertS protective
bone and cardiou·opic effect, but tJ1e level less than 20 pg/
mL may pr·edispose to osteoporosis and ischaemic heart
disease (Table 7.1 ). Low level of gr·owth hormone also causes
ovarian fai lure.
Risk factors for menopause-related diseases are as
follows:
• Early menopa use.
• Surgical me nopa use or radiation.
• Chemotherapy especially alkylating age nts.
• Smoking, caffeine, alco hol.
• Family histo t)' of meno pausa l d iseases (gene tic) .
• Dn.rgs such as GnRI I, he parin, cott icosteroids and clomi-
phene (an ti oesu·ogen) when given over a prolonged period
(more than 6 montJ1s) ca n lead LO oesu·ogen defic ie ncy.
• Diabetes.
ANATOMICAL CHANGES
The genital orga ns undergo atrophy and regression. The
ovaries shrink and their surfaces become grooved and fur-
rowed. The tLLil ica albugi nea tJ1ickens. ll1e menopa tasal
ovary measures less than 2 X 1.5 X I em in size (8 mL in
volwne) as seen on ultrasound. Fifteen years later, it sho uld
not measure more than 2 mL. The plain rmascle in the fallo-
pian tube w1der-goes au-ophy, cilia disappear from tJ1e tubal
epithelium and tlle tubal plicae are no longer prominenL
The uter·us becomes smaller because of a u·ophy of itS
plain muscle, so tJ1at the connective tissues are more con-
spicuous. The endomeuium is represemed by only th e basal
layer "ith itS compact deeply stained su-oma, and a few sim-
ple tubular glancls. The l)'mph oid tissue and the fw1ctional
layer disappear. The cervix becomes smaller and its vaginal
portion is represented by a small prominence at tl1e vaginal
vault. T he cetvical stenosis and pyomeu·a are not uncommon.
Table 7.1 Hormone Levels In a Menopausal Woman
E2 5-25 pg/ml
Oestrone 2o-10 pglml - more In obese
women
FSH > 40miU/mL
Androgen 0.3-1.0 nglml
Testosterone 0.1- 0 .5 nglml
LH 50-100 miU/mL
Androstenedione 800 pg/ml
Growth hormone Low
lnhibin B
Anti·MOIIerian hormone
88 SHAW'S TEXTBOOK OF GYNAECOLOGY
Rgure 7.1 Cytology of senile vagini tis. (Courtesy: Dr Sandeep
Mathur, AIIMS.)
T he vaginal forni ces graduall y d isappear the cervix shrinks
after th e me nopause. The vagina becomes narrow and its
epithe lium becomes pale, th in and dr)' and gets easily in-
fected causing senile vagin itis (Fig. 7. 1). T he vulva atrop hies
and the vaginal o lifice na t,·ows a nd this can cause dyspareu-
nia. The skin of the lab ia mino ra and vestibule becomes
tl1in, pale and dry, and there is considerable reduction in the
amoum offaL cont.'\ined in the labia majora. The pubic hair
is reduced and becomes grey. The red patches see n aroLmd
t11e LLrethra and introitus are caused by senile vulvitis, and
a LLretlua I caruncle ma) form. The pelvic cellular tissue
becomes lax and the ligaments tl1at suppon tl1e utenLS and
vagina lose their tone, and these changes predispose LO pro-
lapse of tl1e genital organs, su·ess incontinence of urine and
fuecal incontinence.
Apan from tl1e atrophy of the genital organs, general
disturbances tl1aL de,elop are almost certainly caused by al-
terations in tl1e endocrine balance maintained during the
childbearing pedod. Fat is deposited around the breasts,
hips and abdomen. Although the mammary glandular tis-
sue atrophies, deposition of fat often makes the breasts
more pendulous. Glandula r tissue constiLULes 30% of the
breast volume, it is red uced to o nl y 5% after the meno-
pause. T he skin wrinkles and hair grow aro und tl1 e chin and
li ps. Hype ttension, ca rdiac irregula riti es a nd tachycardia
are at tim es no ti ced afte r me nopa use. Anhritis and osteopo-
rosis of the verteb ral bones, uppe r end ofLhe hip joint and
wrist are re lated LO oestrogen deficienC)• afte r menopause.
Tooth deca)\ keratocorti unctivitis and cataract are re lated
Lo menopattsal oestrogen defic ienC)'·
MENOPAUSAL SYMPTOMS (Table 7.2)
MENSTRUAL
The three classical wa)S in whid1 t11 e menstrual pedod
ceases are as follows:
• Sudden cessalion
• Gradual diminlllion in the amount of blood loss
each regular period until menstruation stops
• Gradual increase in the inter,oals between periods until
they cease for at least a period of I )Car
Table 7.2 Early Features of Menopause
Hot flushes
Sweating
Insomnia
Headache
Psychological
Cancer phobia
Dyspareunia, decreased libido
Pseudocyesis
lrritabil ity
Depression, insomnia, tiredness
Lack of concentration, loss of memory
Urinary stress incontinence, dyspareunia
Altl10ugh by d efiniti o n, me nopa use is said LO h ave set
in if amenorrhoea lasts for a year, a woman who bleeds
after a gap of 6 months is consid e red LO have posuneno-
pausal bleed ing and sho ul d be thoroughly investigated.
Continuous b leeding, menorrhagia o r irregu la r heavy
b leeding in th e pe rim e nopausa l pe ri od a re considered
abnorma l and sho uld be investigated for malignancy of
th e genital u·acL.
HOT FLUSHES
IL is t11e most common symptom experienced by women
after menopause. Almost60%-70% women go tl1rough their
menopatLSal peliod witl1ouL problems. The rest need guid-
ance and treaunenL The most common and tlle most
noticeable symptoms of hot flttshes and sweating are the
mark of the climacteric in 85% women. Hot fiLLShes are the
waves of \'<ISO<lilation affecting the face and tlle neck, and
these last for 2-5 minutes each. These are followed by profuse
sweating. These flushes occur several times in a clay, but are
more severe during the night, and can disturb sleep. The hot
flushes are sometimes preceded by heaclache. Palpitation and
anginal pains may be felL Mental depression due LO distw·bed
sleep or othemise, irritability and lack of concenu-ation are
noticed. Witl1 tl1e passage of time, the frequency and sevetity
of flushes climinish over· a period of 1-2 years. Hot flushes at·e
caused by nomdrenaline, ,,11id1 disturbs t11e thermoregula-
tory system. Oesu-oge n deficiency reduces hypotl1alamic en-
dorphins, whi ch release more norepinephrine and set"OLOnin.
T his leads Loan inapprop riate heat loss mechanism.
Other causes tl1aL ca n be assoc iated with t11e symptom of
hot flushes include thyro id d isease, epilepsy, pheochromo-
cytoma, carcino id S)'ndromes, autoimmune disorders, mast
cell disorders, pancreatic tumo urs and eve n
le ukaem ias.
The ,oasomotor symptoms are more severe in surgical
menopause than natura l me nopa use.
OTHER SYMPTOMS
Some women develop a condition of pseudocyesis, when
they fear pregnane) and attribute ame norrhoea and in-
creased abdominal girth to pregnancy.
Cancer phobia ma) also de,elop; the woman startS wor-
t')ing over her looks.
NEUROLOGICAL
Vasomotor S) mptoms and paraesthesia may take the fonn of
sensations of pins and needles in the extremities.

UBI DO
Sexual feeling and li bido may increase in some, ifthey feel
happy to get rid of menstrualion a nd fear of pregnancy.
Many however nolice decreased libido after menopause
(15%; lack of orgasm and arousal).
The S) mptoms which develop little later are as follows:
• U1·ina•1 S) mptoms such as d)Suria, stress and urge incon-
linence, recurrent infection (urethral syndrome)
• Genital S)lnptoms such as dry vagina, dyspareunia, loss
of libido
• Faecal incontinence
• Thyroid dysfunction
URINARY TRACT
Oestrogen deficiency can ca use uretlwal caruncle, dysu.-ia,
"1th or without infectio n, urge and su·ess inconlinence. T he
stress incontine nce is caused b)' poor vascularity and tOn e of
t11e internal urinary sp hincter. These urinary symp tOms are
clubbed together un der t11 e term ' urethral syndro me'.
GENITAL
Atrophic vagina red uces vag ina l secretio n, and dry vag ina
can cause dyspare un ia. Loss of lib ido adds to sexu al dys-
function. Rare !)', sen ile vag initis can cause vaginal b leed-
ing (Fig. 7. 1). Pro lapse of genita l u·act and stress inconti-
nence of urine and faeces are moslly menopausal related.
NEUROLOGICAL
Depression, loss of memory, irritability, poor concentration
and tiredness, poor sleep and predementia.
LATE EFFECTS OF MENOPAUSE
Menopausal women witl1 chronic oestrogen deficiency are
liable to develop t11e following:
• Artll1itis, osteoporosis and fracture, backache
• Ou·dio,oascular accidents such as ischaemic h eandisease,
myocanlial infarction, atherosclerosis and hypenension.
• Hypotll )·•·oidism and diabetes.
• Stroke
• Skin ch anges
• Alzheimer disease
• Ano-colonic ca ncer
• Too th decay
• Pro lapse ofgenital tracL, stress incontine nce of urine and
faecal incon tine nce
• Cataract, glaucoma and macu la r degeneration
Locomotor S)'Stem disorders: Menopausa l arthropathy,
osteoarthritis, fibrosilis and backac he ma)' be age related.
Osteoporosis (Fig 7 .2)
lt is an incipien t slowly progressing skeletal disorder charac-
terized by microarchitecwral deterioration of bone mass
resulting in increased fragility and predilection to fracrure
in t11e absence of significant trauma. About 15% of elderly
women suffer from osteoporosis and almost three limes as
man) Sltffer from osteopenia (deficient bone mass). Born
osteopen ia and osteoporosis predispose to fractures. These
COilStitute a significant cause of morbidity such as pain, de-
fonnity and impaired •-espirawry and oilier bodily func-
tions. Hip fractw·es a •-e often associated witl1 a high rate of
mortality. Wrist and hip joints are particularly affected.
CHAPTER 7 - MENOPAUSE AND RELATED PROBLEMS 89
Rgure 7.2 Osteoporosis of t he vertebral column.
With increasing lo ngevit)' of wo me n in Ind ia, th e medical
practitioners will be called upon mo re ofte n LO ca re for
osteoporosis-related proble ms.
Osteoporosis is defi ned as a coodition in which there is a
fall in bone mass exceeding 2.5 Sla ndard deviations (SD)
below tile mea n for )'Oung adul ts. World Health Organiza-
tio n (WH O) has defined low bone as osteopenit• and
on th e basis of axial skeleto n BMD (bone mineral
densit)') to facilitate screening and identification of individu-
als at risk. These definitions apply specifically to T-scores
derived from the use of dual-energy X-ray absorptiometry
(DEXA) of the lumbar spine. WHO defines osteopenia as a
Bl\10 between 1 and 2.5 SO below t11e young adult mean
peak bone mass and osteoporosis as BMD which is 2.5 SO or
more below the standard adult mean \'lllues. These cha nges
begin 2 years before menopaLtse.
Pathophysiology. Bone is not an inensuppo•·ting tissue. &me
re11wdelling takes place constantly. At tile cellular level, bone
remodelling is a balance between bone resorption (osteoclas-
tic activity) and bone formation (osteoblastic activity),
whereas the main functions of the osteoc)•tes and lining cells
a•·e metabolic, subserving t11e nutrilion of bone and the
maintenance of calcium homeostasis. After t11e cessation of
ad ult growth, the skeleton consolidates to reach peak bone
mass (PBM) at th e age of 35-40 >•ea rs. a slow
subsequen t age-related loss of bone mass occ urs in eve•")•o ne
at t11e ra te of 0.4% annuall )•, b ut women a1-e additio nally
exposed to an acce lerated rate of bone during the peri-
menopausal age and tJ1e inilial 5-S )•ears of Lhe early meno-
pause (2% corti cal bone and 5% trabec ular bone). Oestrogen
deficienc)' is tl1e dom inant factor conu·ib uting to osteoporosis
in women. Additional conu·ibuling factors sud1 as calciwn
and vitamin D deficiency also need consideration. At tl1e age
of40 years, bone calcium amounts LO 1200 g. When tl1e level
drops below 750 g. fracture of lhe bone is likely LO occu1:
Fig. 7.:3 shows that women live a third of tl1eir lifespan
after menopause. Elder!) women suffer from vertebral frac-
tuJ-es leading to gibbus formalion, a bent spine and shorte n-
ing of height.
The other high-risk factors for osteoporosis are as follows:
• Family histo•")' of osteoporosis.
• Low calcium intake in diet.
90 SHAW'S TEXTBOOK Of GYNAECOLOGY

on I) if given in the pe•·imenopatLSal age or soon after meno-

pause. Gh·ing honnone later is not effeCLive.
Endocrine System
Mild virilit.ation as seen in me form of hirsutism is probably
because ofadrogens produced from the adrenals and obesity,
depositi o n of fat aro und the hips. ll )'pOt.lly•-oid·
) 22.5 so 1------__;;;:::o....-=1 ism with a low metabolic rate (BMR), hig h c ho lesterol
Inadequate
Ca Intake leve l, dl)'lless of s kin, brittleness of ha ir and lack of concen-
Osteoporosl s
tration a re noticed in some menopausal women.

Pyometra
0 10 20 30 40 50 60 70 80 Years after menopatLSe, a woman ma) de,elop senile pyome-
Age in years
tra catLSed b) cervical stenosis, and needs drainage by cervi-
Figure 7.3 Bone mineral density- age related. cal dilatation under general anaesthesia.

APPROACH TO A MEI'K)PAUSAL WOMAN

• Smoki ng and excess of caffeine and alcohol intake.
• Early m e nopause.
• Low weig ht.
• Surg ical menopause following hysterectomy with or with·
o ut oop horectOmy. lt is now beli eved that even if the
ovaries are conserved, the disturbance in the ir vascu larit)'
may lead tO ovarian atrophy.
• Radiation menopatLSe.
• Woman on GnRH, heparin, corticosteroids, danazol, clo-
miphene.
• Th) •'<>toxicosis.
• Sedentary lifestyle, diabetes.
Diminished BM.D can be assessed by DE.XA and single- or
dual-photon absorptiomeu·y for spi ne, neck of the femur
and radius. T his technique detects bone loss of as little as
1%-5% co mpared to plain rad iograp h)', whi c h s hows a loss
of bone on ly at 30% loss.
• HistOI)' of various symptoms.
• Genem l examination includes blood pressure reco rding,
palpation of t11e breasts, weig ht and hirs utism.
• Pelvic exa mination, Pap s meac
• Blood s uga r, li pid profile, ECG.
• Mamm ograp hy, pelvic ul trasound.
• Bone density study. DEXA is a qttick test with less radiation.
• Oestrogen (E..!) and FSH levels to decide on l11e need of
1-IRT.
• Endometrial biopsy in women on H RT and tamoxifen.
MANAGEMENT
The clinician should adopt a holistic approacl1 tOwards
management of healtl1 problems of menopausa l women
and selectively prescribe hormone therapy accord ing LO the
require me nt. Minimal required dose avoids risks whi le co n-
ferring the beneficia l effects.

Cardiovascular Diseases COUNSELUNG

Oesu·ogen is cardioprotective by maintaining a high level of
high-density lipoprotein (HDL) and lowering l11e low·density
lipop•-otein (LDL) and uiglyce•·ides. Oesu-ogen deficiency
l11erefore predispose to al11erosclerosis, ischaemic hean. disease
and infarctiort Obese women with h) pen.ension
and thromboembolic episodes are likely to expe1ience
to cardiovascular accidents. Oestrogen prevents at11erosclerosis
Uli'OUgll its antioxidant prope11.y.
Stroke
T he incidence of stroke also increases in menopausal
women.
Skin
Collagen con tent is reduced. catLSing skin to wrinkle. The
'feminine forever' thought applies to oestrogen cream to
delay the age-related skin changes. However, it is obser\'ed
that after a few monll1s the skin actually thins out, a nd oes·
trogen cream may be beneficialtempora•ily and only in the
initial phase of treatment.
Alzheimer Disease
It is believed that Alzhe imer disease is precipi ta ted by oes·
u·ogen deficiency at menopatLSe, and hormonal l11 erapy is
beneficial in preventing or dela)'ing its onset. It is beneficial
The woman often develops phobia about pregnancy and can-
cer. lt is the dULy of l11e g)11aecologist to convince her, after
thorough examination and investigations, Ulat all is well wim
her. It is a good practice to document baseline recordings of
pelvic which includes me ovalian siLe and the
endomeuial l11ickness, mammograph)' as well as E2 and FSH
levels, when HRT is considered. Regular counselling may be
required untill11e woman is well settled in menopause.
The advice on co ntraceptives is necessa•) '· Until meno-
pause is well established a nd amenon·hoea has for
12 monl11s, l11e coup le is advised to use baiTier mell1od.
Hormonal pi lls may not be safe from l11e point of view of
thromboembo lism. Progestogen pills or depot i•'!jections
may be l11e alternative, but tl1ey catLSe irregular bleeding
and depression.
Diet should include at least 1.2 g of calcium, vitamin A,
C, £and 100 I. U. of vitamin D. Soya beans a•·e good source
of phytoestrogen (discussed later). Weight-bearing exer-
cises (walking and aerobic) delay l11e onset of osteoporosis.
MILD TRANQUILLIZERS
T hese reli eve woman's anxie ty, sleeplessness and depres-
s ion. AntidepressantS s uc h as s ulpiride ma)' be needed.
Antidepressant drugs- Venlafaxine 30-150 mg dail)\ Par-
oxetine 10-20 mg daily, Gabapentin 300 mg three times a day.

HORMONE REPLACEMENT THERAPY
ot all women require HRT. Besides, HRT does not suit all,
and it may cause complications and can be hannful. How-
ever; it is logical to prescribe HRT and not witl1hold it when
one needs it in the minimal effective dose for t11e shortest
needed duration under supervision.
l!:arlie t; every menopausa l woman was advised to have
as soon as menopause set in, to be taken for several
)'Ca rs. Newer researches and their observations reveal that
onl y a few women need prophylactic and therapeutic HRT.
70%-85% of women remain healthy and need only good
nuu·ition and healthy lifestyle.
Who Needs HRT?
• S) mptomatic women who suffer from oesu·ogen defi-
cienC) (tl1erapeutic).
• High-risk cases for menopause-related complications
such as a cardiovasc ular disease, osteoporosis, stroke, Al-
zheimer disease and colonic ca ncer (proph)•lac t.ic).
• Pre mature menopause, spontaneo us o r following surge•)'
(hysterectomy, tubeCLomy). T he surgica l procedures dis-
turb and compromise t11 e blood supply to t11e ovaries.
Menopause caused by radiother-apy and chemotl1erapy
for cancer, especially alkylating agents (prophylactic).
• Gonadal d)-sgenesis in adolescents (therapeutic).
The l) pe of honnone, rout.e of administration and dura-
tion of Lreaunem depend upon the purpose for which it is
used, i.e. prophylactic or tl1erapeutic.
S}'lnptomatic women who suffer vasomotor symptOms,
urinary S)'mptoms and sex ual disharmony because of dyspa-
reun ia, as we ll as ps)•chosomatic problems need to be
trea ted with HRT on a s ho n.-te nn basis for a period varying
between 3 and 6 mo nths. Most im prove by t11 e end of
6 mon ths after wh ich the woman usua lly gets adjusted and
scules down well in the menopausal phase of life.
The high-l'isk cases for osteoporosis have alread)' been
mentioned. The women with atllerosclerosis, hypenriglyc-
ericlaemia and ischaemic hean disease may benefit from
carclioprotective effect of prop h) lactic oestrogen. However,
HRT is not recommended for women who are already suf-
fering from ischaemic hean disease.
Recently, it was proved that proph)•lactic Htrr may delay
or prevem the occurrence of Alzheimer disease and allow
the woman at risk to lead a comfortable li fe for years.
There are women who are health)' and at no risk of t11e
above diseases. T he)' do however fee l inclined to take Htrr
"1th the belieftllat they will have t11e feeli ng of well-being and
can lead an enjoyable life. These women need a proper sa·een-
ing before prescribing t11e honnones. They should be cow1-
selled regar·ding tlle benefit, side effects and tlle cost, and t11e
need for periodic check-up while on honnones. Certain con-
u-aindicat.ions to be noted for oesLrogen t11erap) are as follows:
• Breast cancer, utel'ine cancer or fa mil) history of cancer
• Previous history of thromboembolic episode
• Liver and gall bladder diseases
• Uterine fibroids- the fibroids may enlarge in size
Hypertens ion, diabetes and smoking are not con u·aindi-
cations, provided t11ey are regularly monitored. Rather car-
diac disease, sLroke and smoking may be the indications for
CHAPTER 7- MENOPAUSE AND RELATED PROBLEMS 91
oestrogen therapy to derive benefit and impro,·e tlleir healtl1
from oestrogen deficiency.
Uses of HRT
• Short term - hot flushes, vasomotor symptoms
• Dyspare unia, libido
• Urethral syndrome
• Long term - os teoporosis
• Cardiovascul ar
• Alzheimer disease
OSTEOPOROSIS
HRT is the cornerstone in the pro ph) lax is and treatmem of
osteoporosis. After menopause, the woman loses on an a\'er-
age 3% BMD every year causing osteopenia and evemually
osteoporosis and fracture of the vert.ebra, femur and t11e
wrisL The Lrabeculated bone is most affected. The morbidity
arising from pelvic fractures is considerable. The benefit of
1-1 RT is proved beyond doubt in preventing or de laying bone
resorption. When to start 1-ltrr remains a controversial
point, altJ1ough earlier it was recomm ended in tl1e peri-
menopausal age or soon after menopause, t11e poor compli-
ance over a long period, t11e cost and the limited benefits
resLrict their use for a short per·iocJ of time. For optimal ben-
efits of HRT, natural oestrogen, progestogen, Libolone and
raloxifene are beneficial in osteoporosis, if prescr·ibed early
in menopatLSe. Osteoporosis occurring late in menopatLSe
benefits from bisphosphonates, as primal') Lreaunent.
It is observed t11at benefit of Htrr lasts while tl1e woman
continues to take Htrr, and the bone loss resumes once she
stops taking drugs. The prolonged therapy beyond 8-10 )'ears
is not beneficial but at Limes harmful, so most gynaecologists
now fo llo,,•up the woman for osteopenia and presctibe HRT
when osteopenia occ urs.
Oesu·ogens dela)'S or protects against osteoporosis in
50% of all skeletal bones, and is not restricted to trabeculru·
bones of spine, wr·ist ru1d upper hipbones.
PROPHYLAXIS OF OSTEOPOROSIS
• O estrogen hormone tllerapy- ERT (hysterectomi.ted)
• Oestrogen + progesterone (Htrr)
• Tibolone
• Raloxifene
• Soya cx u·acts
• Bisp hosp honates for late osteoporosis
• Calcito nin
• Hormone
• Diet
CARDIOPROTECTIVE EFFECT OF HRT
Oesu·ogen deficiency increases tlle r·isk of atllerosclerosis,
ischaemic heart disease ru1d angina in a postmenopausal
woman. OesLrogen is t11erefore cardioprotective in preven-
tion of cardiovasCLtlar disease. It also ina·eases HDL and
decreases LDL, cholesterol and triglycerides. Oestrogen is
most effec tive when taken orall)' far as its effec t on a lipid
profile is co ncerned. Oestrogen and tibolone are strongly
carcliopro tec ti ve in menopausal women. llowever, a wo man
with previous ischaemic h ean disease docs not benefit from
HRT and its tLSe is not recommended.
92 SHAW'S TEXTBOOK Of GYNAECOLOGY

DRUGS, OOSAGE AND ROUTE OF ADMINISTRATION

Table 7.3 Advantages and Disadvantages of Oral
Oestrogen Therapy and Transdermal Route of Oestrogen
Shon-term therapy is required to relieve the woman of hot
Oral Transdennal
flushes, night swealS, palpitations and disturbed sleep. Oes-
u·ogen sh ould however be given in the smallest effective Advantages Advantages
dose for a shon possible period of months. Natural • Cheap • Low-dose oestradiol
oesu-ogens a re preferred. Oral Pre marin (E, - natural • Easy to take • AIA:lids first-pass effect and
• Can be withdrawn quickl y iill9r metabolism
oestrogen) in tl1 e dose of 0.375 mg or
in presence of side effects • Reduces triglycerldes
0.625 mg dail)', increasing to 1.25 mg if necessary, eth in yl
• Good for a II pld profile and • No thromboembolic risk
oestradio l 0.0 1 mg, micronized oestrogen ( 1-2 mg) or Eva- cardiovascular protection or hypertension
Jon 1-2 mg are effective. Progestogen suc h as Duphaswn/ Disadvantages Disadvantages
medrOX) progesterone I 0 mg or Pdmolut N 2.5 mg daily for Higher dose required Costly
I0-12 days each month shoLLld be added to prevem endo- First-pass effect in liver Not tolerated In wann cli-
meu·ial h) pe•·plasia and carcinoma. This t11erapy can still Daily intake mates
cause endomeu·ial hyperplasia in 5% and at) pi cal hyperpla- Tablet contains lactose, and Variable absorption
sia in 0. 7% cases. Because of this, some prefer to give a not suited to women who
combined hormone therapy (Femet) containi ng 2 mg I713- are allergic to lactose
oestradiol and I mg of norethisteronc acetate, which is • High Incidence of side effects
known to cause endometrial au-ophy. Progesterone is not • t Hypertension
req uired in a hysterectom ized woman. C)•Cii cal combined
• t Thromboembolism
IIIU causes cyclical bleeding. Peliod-free H RT can be at-
tained if the combined honnones are taken con Linuo usl)'·
Dyspare unia, urethral syndrome and senile vagin itis re- twice a week. The cost prohibitS many women f1-om tt.Sing
spond well to local oestrogen cream, which is preferred over them. It should be applied away from tl1e breastS, o n tl1e
oral t11erapy. Oestriol base cream I/ 2 g is applied every day a1ms. legs and thighs.
for 10-12 days each momh for a period of3-6 momhs until Gel (I 00 mg contains 60 mg 13-oestradiol) is applied 1.0
the S)lnpto•ns disappear. ESTRI G ('<aginal •·ing) releases the skin for imprO\'ing tl1e collagen content and avoid
5-10 meg oestrogen and is 90% effeCLive over a period of wrinkles (two measures of0.75 mg oestradiol). The plasma
3 months. level is maint.ained at60-80 pg/ mL

Long-Term Therapy. Long-term oestrogen t11erapy is ben-
eficial in delaying osteoporosis and red ucing tl1e lisk of a
ca rd iovascul ar d isease in a postmenopausa l woman. How-
eve•; it is observed that ex tending tl1e medication beyond
8-10 years does not confer an)' furtl1er benefit.
Oral Route. Orally administered oestradiol geLS exten-
sive!) metabolized imo oestrone in the intestine and liver
so that only I0 % reaches the systemic circulation as oestra-
diol. Larger doses t.herefore need to be given orally com-
pared to t.he nonoral route (Table 7.:l). This met.abolism
in the gut and t.he Iiver is known as 'first-pass' effect, and
tl1is also increases cenainliver proteins, alters the clouing
fuctors and increases the secretion of re nin. However,
given orall y, it improves tl1 e lipid profile excep t serum
u·igi)•Ce ride and improves the cardioprotective effect. Very
rece nLiy, however, the controverS)' has bee n raised regard-
ing its protective role in a woman alread)' suffering from
a cardiovasc ular disease, and 1-1 RT is not recommended
for tJ1em.
Tran.sdennal Patch (Estraderm). It avoids Lhe first-pass ef-
fect of Ji,er metabolism, and the hom1one reaches the sys-
temic circulation as oestradiol. The risk of thromboembolic
episode and probable hypertension is eliminated. It reduces
serum u·iglyceride levels as well.
Estradenn patch contains 3-4 mg of oestradiol releases
50 meg per day. T he disadvantage of skin reaction with
alco hol-based patch is now avo ided b)' newer transdermal
S)'Stem, but it cannot be reapp lied after being t.aken off
tl1e skin dt.nin g bath. The patch needs to be changed
Vaginal Cream. Oestriol cream is used in urethral syndrome
and dry vagina. About 1/ 2 g is applied dail)' for a few days
each monLh on a short-term basis. Premarin is also ava ilable
as cream.
Vaginal Ring. Oestrogen supplementation can also be ef-
fectively achieved by inserting a vaginal ring tJ1at releases
0.0075 mg of 1713-oesuadiol daily for 90 da)s. This fonn of
medication should be considered in tlte management of
menopausal '<aginal S) mpwms.
Implant. Implant comaining 25-50 mg oesu-adiol is effective
for 6 month each , and maintains the £ 2 1evel at50-60 pg/ mL
A minor ope ratio n is required for insertion and removal. It is
sui tab le in h)•Sterecwm ized women.
lntm nasa l 300 meg of oestrogen raises tJ1 e level of hor-
mone in 30 minutes, and becomes effective. break-
through b leeding, sneezing and itching occ ur in I %-3%
cases and 55% have stopped the tJ1erapy by tJ1e end of I yea•:
The oestrogen therapy reduces tl1e incidence of fmc LUre
b) 50% at the end of5 years (90% vertebra and 50% hip).
Similar!), cardiovascular complications have been reduced
by 10%-50% with oesu·ogen therapy.
Unfortunately, compliance of long-term use of honnone
therapy is ma1Ted by vaginal bleeding. To overcome this
problem, 'pe•iod-free' HRT is now produced by the combi-
nation of oestrogen and progesterone taken co ntinuously
instead of cyclicall y. Not o nly continuous progestogen sup-
presses oestrogen-stimulated endometrium, iL also allows
a smaller dose of oestrogen and progestogen and lesser
side effects. Even then, vagina l bleeding may occ ur up to

6 momhs of this regi me, followed by amenorrhoea. Any
bleeding after that requ ires investigations.
Risks of H Rl" Usage:
• Endometrial ca ncer
• Breast cancer
• Ov;u·ian cancer
• Thromboembolism
• Lipid profile d) function
• Gall stones, li,er dysfunction
• Vaginal bleeding with continuous HRT (period-free
H RT) is more common if the therapy is staned within
I year of menopause, and may last up LO 6 momhs. After
the first )Car of menopause, there is less risk of vaginal
bleeding. Persistem vaginal bleeding requires endome-
trial biopsy. The bleeding can h owever be avoided by de-
creasing oesu·ogen dose or ino·easing the dose of proges-
togen. Wi th 'period-free' HIIT, 75%-100% women
become amenO IThoeic b)' th e e nd of I year.
Gabapen tin is a no nho rm ona l antico nvulsant th at re-
duces ho t fl us hes b)' 50% if given in a dose of900-2400 mg
da il)'· Dizziness (1'1%) ( 12%), tiredn ess, head-
ac he, b ltu1·ed vision, dry mouth and memory proble m
gradua ll)' disappear after a wee k or so.
• Thromboembolism.
• Endometrial cancer if E2 is taken alone and the risk lastS
for 10 )Cars after stoppage of therapy.
• Breast cancer is due to progestogen if HRl' is taken for
more than 5 )Cars.
• The possibilit) of a co rona11 hea n disease in a woman
with a cardiovascular disease has caused a great concem
regarding the use ofi iRT in these women. HRT is contra-
indicated in these cases.
• lnc1·eased risk of ova1·ian cance1:
Progestogens
Progestogens are used for I 0-12 da)s in each cycle to
avoid the risk of endomeu·ial hype1·plasia and cancer in
nonh)-sterecLOmi t.ed women. The 1·isk of endomeu·ial
hyperplasia is reduced to 4%, if given for 12 days in each
cycle. It does so through e nzyme 17f3-h ydroxy dehydroge-
nase, which inactivates 1!: 2 and conu·ols th e mitotic activity
witl1in the endometrial cells. T hey do red uce the bone re-
sorp ti on, but not tO th e ex te nt seen witJ1 oestrogen ther-
apy. Some of the m have an adve rse effec t o n a lip id profile
(Fig. 7 .'I).
T he drugs used arc Norethisterone 2.5 mg, medroxypro-
gesterone and Duphaston , 10 mg. Progeswgen imp lants are
a lso availab le for tJ1ose imolerant to oesu·ogen. Progesto-
gens cause bloated feel, we ight gain and depress ion and
may adverse ly a lter tJ1 e li pid profile. Medroxyprogesterone
has no adverse effect o n lipids but reduces the bone density.
To avoid the systemic side e ffectS and poor compliance witl1
oral progesLOgen, Mire na IUCD containing levonorgestrel
is inserted for 5 )Cars in HRT programme. Micronized pro-
gesterone is not useful in H RT.
Drospire none, a new progestogen, has no androgenic
and ach·erse lipid effecL A dose of 3 mg combined
30 meg oestradiol (Yasmin,J a nya, Tarana) has been tried in
menopausal women, but more research is needed.
CHAPTER 7 - MENOPAUSE AND RELATED PROBLEMS 93
Implant may
endometrial replace
hyperplasia oestrogen
lmpro\195 bone
minellll density
Rgure 7.4 Role of progestogen In HRT.
Testosterone implant and combined tablet with oestro-
gen are used to improve li bido. T he role of Viagra to im-
prove li bido is con troversial at presenL
Yo himb ine resemb les reserp ine, a n indole alkyl amine
alkalo id derived from the bark of tree R.rmwoifirL It improves
libido. A dose of6-10 mg da ily at night is presc ribed. Toler-
ance develops wi tJ1 th is drug. Risk of hirsutism s hould
be borne in mind. Rece ntl)' Flibanse lin, and serotOnin-2A
antagonist in a dose of 100 mg at bed Li me has been
approved for a loss of libido.
Other Drugs
I. Tibolone (Uvial ) is aS) nt11 etic de1ivative of 19-nortesLOs-
terone and has a weak oestroge nic, progestogenic and
androgenic action. The tablet containing 2.5 mg does
not cause e ndomeu·ial h)perplasia but caLtSes in·egular
bleeding in 15% cases. It also elevates the mood, relieves
the ' oasomotor S)lnptoms, improves the sex ch-ive and re-
duces bone resorption. Its main action is can:lioprotec-
tion by reducing t11e level of trigi)Cel·ides. Side effectS
include weight gain, oedema, tendemess in t11e breast,
gastrointestinal symptoms and vaginal bleed (15%) . The
greasy skin and increased hair growt11 are due LO andro-
genic action. It should be initiated only after I year of
menopause to avoid vaginal bleeding.
2. Raloxifene, a nonste roidal compou nd (Evista), is a se-
lective oestrogen rece ptor mod ul ator (SE RM ), which
red uces tl1e risk of fracture b)' 50%, especiall y in verte-
bra by increasing BMD b)' 2%-3%. It ca uses 10% reduc-
ti on in to tal cholestero l a nd LDL a nd ra ises HDL level.
It does not raise tJ1e levels of trigi)•Ce ri des. It is the refore
cardiopro tec ti ve in long term. It has a ve t)' low risk of
endometrial and breast cancer. It is beneficia l in red uc-
ing osteoporosis and is given 60 mg daily with calciu m
and vitamin D. It is absorbed from tJ1e gastrointestinal
u·act (60%), fo llowing which glucuronidation occ urs in
t11e liver and is excreted in tl1 e faeces. Toremifene 20 mg
daily is effective dose in 60% cases. Side iffects are hot
flushes. cramps, increased incidence of venoLtS tJuom-
bosis and retinopath). It does not co ntrol vasomotor
symptoms. ewe r SI!:RMs: O spe mife ne, Lasofoxifene
and Ar.1:0xife ne are being u·ied. Contraindications are as
follows:
• Venous thrombosis.
• It should not be ghen witl1 oesu·ogen.
94 SHAW'S TEXTBOOK OF GYNAECOLOGY
• Hepatic dysfunction.
• SLOp the drug 72 hours before surgery.
• Not to be given with drugs such as indomethacin,
naproxen, ibuprofen and diazepam.
3. Soya. So)·a beans contain isoflavone (phyLOestrogens,
genistein and daidLein). About II g SO)'a contains 2-4 mg
ph)'lOestrogens, whid1 is strong!) oesu·ogenic, though it is
a nonsteroidal plant producL About45-60 mg SO)'a daily
is proteCLive without the potential •·isk of breast cancer,
liver disease and other side effectS of oesu·ogen. It is a
safe alternati'e to hormonal therapy. It also decreases
cholesterol, LDL and uigi)Ce•ides with a marginal in-
crease in H DL. It also has antiviral, antifungal and ami-
carcinogenic effects. It is also present in lentil and chick
peas.
4. Bisphosphonates such as etidronate and ti ludron ate re-
duce bone resorption th rough the inhi bition of osteoclas-
ti c aCLivity. Eticlronate I 0 mg/kg body weight (approxi-
mately 400 mg o rall y clail )') is given fo r 2 weeks followed
by a gap of2-3 months co urse), and this course
is repeated for I 0 such cycles. T he dn.1 g sho uld not be
give n witl1 calci um, beca use its absorp tion is reduced.
Calciwn shoul d be ta ken in tl1e morning and etid ronate
swallowed (not chewed) in the afte rnoon, on an e mpty
sLOmac h wi tl1 a glass of wate r in t.he upright positio n; stay
upright for ha lf an hotu: T his red uces the oesop hageal
irritation. The tablet sho uld not be swallowed with coffee,
tea or juice. Overdose catLSCS hypocalcaemia. Milk and
antacid can reduce gastric irritation. It is recommended
tl1at Hltr should be prescribed in early menopaLLSai age.
After 60 )ears, osteoporosis should be managed wit11
bisphosphonates. Alendronate is given as eit11er 5 mg
dail) or 35 mg weeki). Overdose causes hypocalcaemia.
R.isedronate has reduced gasuic side effectS and is effec-
tive in a dose of 5 mg daily or 35 mg once a month. Zole-
dronic acid is used therapeutically once a )Car as intrave-
nous infusion of 5 mg over 15 minutes, but osteonecrosis
of me jaw and visual disturbances are t11e major side ef-
fects, t11ough Yery rare. lbandronate sodiwn is given 2.5 mg
daily or 150 mg mont11ly orally or 3 mg intravenously
3 mont11ly. Calcitonin is a peptide produced by t11y1·oid
C cells. It inhibits osteoclast activity and inhi bitS bone
resorption. It is given as a nasa l spray at a single close of
200 IU da il y for 3 months. Nasa l spray ca n cause fl ush es,
rhinitis, allergic reactio n a nd nasal bleeding. It reduces
tl1e incidence offrac wre b)' 30%. Subcutaneous injection
of calcitonin is also ava ilable, but symp-
to ms, anaemia and infla mm ati on of join tS cause poor
compliance, as does tl1e high Teriparatide is there-
combinant formation of paratll)•roicl ho rmo ne. About
20 meg once-dail)' subcutaneous i•1iection decreases ver-
tebral fracture by 65% and ot11ers by 50% if used less man
2 years. Nausea and headache are t11e complications.
Strontium raneL-.te given 1-2 g daily orally increases BMD
by 50%. However, it is very expensive and not easily avail-
able. Clonidine is an imidawline deri\-ative LLSed to treat
hot flt.LShes. It is also effective in hypertensive women not
responding to oesu·ogen. Clonidine lowers blood pres-
sw·e in addition to relieving hot flushes. Dose of0.2-0.4 mg
daily suffices. It acts cenu-ally. Side effectS are ch)' mout11,
diuiness and nausea. Androgens improve libido, but car-
•ies me risk of hirsutism.
SUGGESTIONS FOR HRT
• Not every menopausal woman needs HRT.
• A S)'lnptomatic woman due to oestrogen deficiency re-
quires H ttr for 3-6 monms. The duration and route of
HRT depend upon t11e purpose for which the therapy is
presclibed.
• Total dtu-ation of a prop h) lactic therapy beyond 8-10
years has not proved beneficial, but side effectS may
harm t11e woman.
• The benefit of a therapy should be balanced against the
risks of breast and endometrial cancers and venous
thromboembolism.
• Phytoestrogen is available as 'Femarelle', one tablet to be
taken twice a day.
• Therapy should be individualized according to the need.
Lately, once a mon t11 oral ibandro nate is made available
which im proves bone density (iba ndro nate is marketed as
IDROFOS- 150 mg).
T he d rug increases the 13MD b)' 5%-10% and also pre-
ventS rec urrence of frac ture. Non respo nse is seen in 10%
cases.
Ale ncl ronate is the thi rd genera Li o n of b isp hosp ho nates
(non hormonal) and is 1000 times more po te nt than e tid ro-
nate with no side effectS. It is marketed as Osteofos (5, 10,
35 and 70 mg).
HORMONE REPLACEMENT THERAPY AND RISK
OF BREAST CANCER
• The lisk of breast cancer is not increased up to 3 years
of H RT and 5 )Cars of oestrogen alone replacement
themp).
• Lower risk is seen wit11 use of d)drogesterone in HRT.
• HRT can cause recunence of breast cancer and is there-
fore conu-aindicated in a woman who has been treated
for breast cancer. Tibolone is safe.
• H RT increases the density of breast tissue and impedes
screening prog•-amme of mammography subsequently.
• Breast cancer developing following HRT is of low grade
with good prognosis.
HORMONE REPLACEMENT THERAPY
AND ENDOMETRIAL CARCINOMA
• ERT can cause well-differe ntiated ca rcinoma of endome-
trit.un .
• Minimum of 12 cla)'S of progestero ne added to ERT reduces
the risk of endomeu·ial ca ncer to 2%.
• Co mb ined oesu·ogen and progesterone provides a be uer
pro tec tion against endometrial ca ncec
• T ibolone is a safe drug and does not cause endo metria l
hyperplasia.
• Raloxifene, un like tamox ifen exercises antioestrogen
action on endometrium.
• The lisk of cancer witl1 ERT is close and duration depen-
dent.
PREMATURE MENOPAUSE (PREMATURE OVARIAN
FAILURE)
Premature menopause is defined as O\'alian failure occur-
ring before the age of 10 years. It is clinically defined as

secondary amenorrhoea for aL 3 months with raised
FSH level, raised FSH/ LH rat.io and low E2Ievel in a woman
younger Lhan 40 )Cars.
The incidence is I%. Before t.he age of 30 years the in-
cidence is I: I 000, at 35 iL is I :250 and just. before 40 years
it is 1%.
AETIOLOGY
Some known causes of pt·emawre menopause are as follows:
• Fewer germ cell migration from the yol k sac
• More apoptosis of germ cells
I. Genetic disor·der·s such as chromosomal abnot·malities
are reponed in I 0%-20% of cases involving X
chromosomes. Autosomal dominant sex-linked inheri-
tance is also known. Ovarian dysgenesis is seen in
30% cases.
2. Auto immune diseases a re repo n ed in 30%-60% cases.
Mumps, thyro id d)•Sfunct.io n, hypopara t.hyro id ism and
Addiso n disease ma)' acco unt for a few cases. T he ovar-
ian biopsy shows infi lt.ration of th e fo llicles with plasma
cells and lymphocyt.es. Raised CD" co um and low CD4
co unt suggest an a uLo immune disease. Antiovarian
an tibodies are presen L.
3. Tuberc ulosis of t.he gen it.al LracL invo lving the ovaries
can cause secondary amenorrhoea and ovarian
failure.
4. Smoking is known 1.0 induce premaLUre menopause,
and the age when it. occurs depends upon the degree
of smoldng. It is t.oxic for the follicles.
5. Radiation and chemotherapy can cause premaLUre
menopause, but the effect is reversible and the ovary
may resume ontlation and mensu"l.tat.ion after abouL a
year of amenorrhoea. Alk) lat.ing agenLS are st.rong in-
ducers of premature menopause.
6. 0\'<lnan failure following h)SLereCLOm)' is kn0\111 LO oc-
cur in 15%-50% cases even when ov:u·ies are retained
and is caused by kinking and blockage of ov:ui:m
vessels. Tubectomy can also produce a similar effecL
7. Prolonged GnRH ther·apy may lead to ovarian sup·
pression and fa ilure.
8. Enzyme defecLS such as !?at-hyd roxylase deficiency
and galactose mia have adverse effect o n oocytes, but
more often ca use primary ame norrhoea.
9. Resistant ova ty This te rm ino logy is used less fre-
quen tJ y tJ1ese clays and iLis presumed tJ1at the follicles
fai l to respo nd to gonadotropin SLimulation.
10. Inducti on of mu ltip le ovulatio ns in inferti lity can
cause premawre menopause when the fo llicles get
ex hausted.
PATHOPHYSIOLOGY
Either exhaustion of primordial follicles in ovary or lack
of receptors and presence of antibodies has been described
as a cause of premature ovarian failure.
CLINICAL FEATURES
HoL flushes and sweating occur in 75% cases and may be
more sevet·e tJ1an seen in nawral menopause. Libido is
CHAPTER 7 - MENOPAUSE AND RELATED PROBLEMS 95
diminished in 10%-20% cases. Vaginal dryness and uri-
nary symptoms are less complained.
INVESTIGATIONS
• FSH level: 40 miU/ mL or more
• E2 level: 20 pglmL or less
• Thyroid function, calcium level, chromosomal swdy :mel
Lhrroid antibodies
• Blood sugar
• MRl piwitary fossa for presence of wmolll:
• BMD swdy is not al\\'<I)S necessa•)'
• 0\'<lrian biopsy
• Ultrasound
• Prolactin level
COMPLICATIONS
The risks of osteoporosis a nd ca rdi ovasc ular diseases in-
crease in pre ma ture me nopa use.
MANAGEMENT
1. T he cause of premature menopause sho uld be ascer-
t.ained and should be t.reated. Fo llicular maturation,
ovulation and mensu·uat.ion have been res t.o red fo llow-
ing the treatment of t.he cause.
2. Oophoropexy and ovarian shield during radiotherapy
can protect ovaries.
3. Corticosteroid tJ1erap) is effective in an autoimmun e
disease if antibodies 1.0 sex hormones are present in the
blood. Plasmapheresis has also been attempted.
4. A woman with h)po-oestrogenism may require HRT or
other drugs to prevent osteoporosis. Oest.rogen implruu
oral progesterone o•· Mirena IUCD offers long-
Lerm HRT.
Specific management according to t.he need is as follows:
I. An older woman or a parous woman not interested in
pt·egnanC)' or menstrual functions may requit·e HRT if
sh e develops menopausal symptoms. Sh e may require
prophylactic HRT if she is a hi gh-risk case of cardiac
complicatio n, or osteoporosis.
2. Libido improves with testostero ne a nd E2 therapy.
3. A woman not interested in pregnancy, but requests for
restoration of me nstma l C)•cles, s ho uld recieve combined
oestrogen-progesterone C)•Clical therapy.
4. A yo ung woman inte res ted in pregnancy s hou ld be of-
fered e itJ1er ovulation induct.io n Lherap)' (if an ovarian
reserve present) or be offered donor eggs fo r in vitro
fertilization.
5. ln a yo ung wo man with a d iminished ovaria n reserve,
Dehydroepiandrosterone (O HEA ) 25 mg + folic ac id
(OVOSTOR£) three times a clay for 4-6 months and
stimulation o f ovaq improves the pregnancy rate (30%-
50%) by increasing t.he OOC)Le and embryo quality. It also
reduces aneuploid) in embl) os.
LATE MENOPAUSE
LLis defined as a condition in "hich menst.ruation continues
beyond 52 )eat-s. Late menopause occut"S in women wit.h
96 SHAW'S TEXTBOOK OF GYNAECOLOOY
fibroids and is seen in women \\1lo develop endometrial
cancer. Often it is constitutional. Berond 52 rears, endome-
Lrial biopsy is re<Juired to rule out endomeLrial pathology.
BenefitS of late menopause
• une ageing- better quality of life
• Cardioprotective, delay in osteoporosis
Disadvantages - increased risk of breast., uterine and
ovarian malignancies.
POSTMENOPAUSAL BLEEDING
Postmenopausal bleeding is defined as any bleeding from
genital tract after I year of menopause. Normally a 1-)'ear
period of amenorrhoea after the age of 40 is considered as
menopause. However, vaginal b leedin g occ urring anytime
after 6 months of a me no rrhoea in a menopausal age sho uld
be considered as postmenopausal bleeding and investi-
gated. Even without amenorrhoea or irregular b leedin g, if a
woman o lder than 52 years co ntinues to menstruate, she
needs investigations to rul e o ut e ndomeLrial hyperplasia
and ma lignancy of the genital u-acL Malignancies of genital
u·act remains a cause of concern in woman with postmeno-
pausal bleeding and need to be ruled ouL
CAUSE OF POSTMENOPAUSAL BLEEDING
Several causes account for genital tract bleeding in a poSt-
menopausal woman (Tablt> 7. 1):
1. Vulva - trauma, \'uh itis, benign and malignam lesions.
2. Vagina - foreign bod) such as ring pessary for prolapse,
senile vaginitis, vaginal tumour (benign as well as malig-
nam) and postradiation vaginitis.
3. Cervix -cervical erosion, cervicitis. polyp, decubirus ul-
cer in prolapse and cer-.ical malignancy.
4. Uterus - senile endomeuiLis, wberCLtlar endometritis,
endometrial h)'j)erplasia (10%), polyp, endometrial car-
cinoma and sarcoma and mixed mesodermal tumour.
Table 7.4 Cause of Postmenopausal Bleeding
1. Malignancies: Carcinoma of the endom etrium
Carcinoma of the cervix
Carcinoma of the ovary
Carcinoma of the v ulva and vagina
Sarcoma of t he uterus
2. Benign causes: Endometrial hyperplasia
Endometrial polyps
Flbroids
Decubitus ulcer
3. Infections: Pyometra
Tuberculosis
Senile vaginitis
Senile endometriosis
4. Bleeding from urinary tract or anal canal
5. intake of HRT
5. Uterine polypi and endometrial hyperplasia.
6. Fallopian tube malignancy.
7. O vary - benign ovarian tumour such as Brenner tu-
mour, granulosa and theca cell tumour and malignant
ovarian tum our.
8. Blood dyscrasia.
9. Urinary tract - urethral canmcle, papilloma and carci-
noma of the bladde1· mal be mistaken for genital u-act
bleeding.
10. Bowel - bleeding from haemorrhoid. anal fissLLres and
rectal cancer mal be misleading.
An important reason for postmenopausal bleeding is in-
discriminate or prolonged use of oesLrogen unopposed by
progeswgens, and HRT when app lied cyclically. Tamoxifen
causes endomeu·ial hrperplasia and cancer.
Twenty to thirty per cent of posunenopausal b leeding is
a tuib ULed to ma lignancy of tJ1e gen ital u·act, the most com-
mon being e ndometria l cance1; ce rvical cancer and ovarian
tum ours. Common benign co ndiLions are endometrial hy·
perplasia and poi)'Pi and dysfuncti onal uterine b leeding.
Postmenopa usal bleeding d ue to oesu·ogen and t.amox ifen
are not uncommo n, othen; are rare.
CUNICAL FEATURES
HISTORY
The age of menopause, histOt)' of taking oesLrogen and
t.amoxifen should be elicited. Abdominal pain and foLd-
smelling discha1·ge are noted in malignant tumours.
Urinal)' and rectal S)lllptoms are also important features to
be note<l.
EXAMINATION
I. Blood pressure.
2. General examination includes BMI and obese women
are prone to endometrial cancer.
3. Abdominal palpation will reveal a tumour or ascites.
4. Speculum and bimanual examinaLion may reveal an
obvio us cause in the lower genital tract such as cancer
cervix.
INVESTIGATIONS
Excluding ma lignancy is tJ1e main aim of in ves tigations:
I . Blood co unt and smear wi ll reveal blood dyscrasia.
2. Blood sugar levels.
3. Cervical cytology or ce rvica l biopsy from obvio us lesions.
Endometrial tissue sampli ng.
4. Sonosalpingograph y for endometrial polyp.
5. Ulu-asound- enclomeLrial tJ1ickness of more than 4 mm
indicates the need of endomeu·ial biopsy.
6. CA 125 serum levels.
Several metJ1ods Me now available to obt.ain endometrial
tissue for histological examination. Although many endo-
meLrial benign lesions cause bleeding, the main objective is
tO exclude malignanC):
• Dilation and curettage (D&C) - fracLional curettage
comp1ising of sepamte scmpings of endomeLrium and
endocervix not on I) allows the exact site of malignancy
if present but also detects the extent of spread of the
 CHAPTER 7 - MENOPAUSE AND RELATED PROBLEMS 97

History

!
Pelvic examination Investigations
General examination Lower genital tract inspection, Uhrasound, CT. MAl, 0/C-cytology,
BP. blood sugar, thyroid abnormal Cx, enlarged uterus, biopsy, hysteroscopy, laparoscopy,
adnexal mass cystoscopy, proctoscopy, CA 125

7.5 Flowchart of postmenopausal bleeding.

tumour and staging. The curettage requires general Post menopausal bleeding
anaesthesia and hospitalization.
• Uterine cavity aspiration for endometrial sampling ntaybe
done as an outpatient procedure and h as the additional
advantage of avoiding anaesthesia.
• Hysteroscopy + !::A

Vibra asp irator, Grav lee'sje t Isaac's asp irator and

Pipe lle asp irator are used to obtain e ndomeu·ial sampling. Cervix looks normal
Asp iration is ma in ly employed in sc reening women on
HRT and tamoxifen. D&C is best to rule o ut cancer when
postmenopausal b leeding is reported. • Pap smear
• Transvaginal UIS
None of these me thods are 100% foo lproof, and in some lor endometrial
cases, we may fai l to detect the cause of b leeding. thickness

I. Hysteroscopic visualization: lb improve the predictive

value of endometrial swdy, hysteroscopic inspection and
selective biops} are now considered the gold standard in
the diagnosis of e ndometrial lesion, though l %-3%
false-negati'e findings are reported.
2. Ultrasound, CT and t.IRI. Transvaginal ultrasound is an
to other investigations, in detecting the endome-
trial thickness and in-egularity and pelvic tumour. ln case
endomeu·ial cancer is detected, CT and 1\W are useful
preoperative im·estigations and these detect the extem of
Figure 7.6 Flowchart for investigating post menopausal bleeding.
spread ofthe tumour to the myomeu·ium and the lymph
ET: endometrial thickness, EB: endometrial biopsy.
nodes. Doppler ulu-asound wit11 increased diastolic blood
flow and low 1·esistant index suggest malignam g1·owth.
3. When the genital u-act as a cause of bleeding has been
excl udecl, cystoscopy and proctoscopy may discover the
cause of bleeding in bladder or rectum.
Detec ti on of a ben ign lesion sho ul d not deter further
in ves ti gati ons to ru le out ma li gnan cy of the gen ital tract, as
bo tl1 may coexist. Posunenopausal bleeding is expla ined in
Figs 7.5 and 7.6.
MANAGEMENT
I. Treat the cause.
2. When no cause is found , and if there has been only one
bout of bleeding, the patient should be kept under
observation. About 80% of these cases do not bleed
again. lf tl1e woman co ntinues to bleed, or bleeding re-
curs. it is advisable to perform a laparotomy and hyster-
ectom). An undiagnosed small tumour may be discov·
erecl and d ealt with approp1iate lr Othenvise abdominal
hystereCLomy wit11 bilateral salpingo-oophoreCLomy
should be performed and the specimen should be sem
for h istopatJJOiogical study.
Take a cervical
biopsy and
treat according
to stage
Endometrial • Follow up
biopsy by • EB lor recurrent
O&CJEA episodes
• EB lor higl risk
cases
KEY POINTS
• Normal menopause sets in aro und 48-52 years.
• Prematw·e me nopause before 40 yea rs can cause
menopausal sy mptoms, osteoporosis and ca rdi ovasc u-
lar diseases. Late menopause is a high-risk factOr for
uterine mali gnanC}' a nd breast ca ncer.
• In 20%-30% of postmenopausal b leeding is caused by
genital cancers, and needs detai led investigations.
• Urethral S)'ndrome, dry vagina wi1J1 dyspare unia and
menopausal S) mpLOins require short·tem1 oesu·ogen
t11erapy.
• Long-term HRT is protective against osteoporosis, cardio-
'ascular accidents, strol..e, AILheimer disease and colon
cancer.
• A proper diet, exercise and HIU help in delaying
menopausal diseases. Oesll'ogen o·eam, oral tableiS
wit11 progestogen and sl..in patches are available. The
implants and 1\lirena ha'e recentl} been introducecl in
HRT. Otl1er optional drugs a1-e tibolone (Livial), raJ.
oxifene (SERI\1), ph) toesu·ogens and bisphosphonates.
98 SHAW'S TEXTBOOK OF GYNAECOLOGY
• Not all require 1-1 RT. Rmional thinking and recom-
mendation is 'selective use of 1:-1 liT' with minimal dose
for minimum required period. The side effectS and
contraindications to honnone therapy should be
known. A regular follow-up is necessary in women on
HRT. Proper counselling is mandatOr). The type of
honnone. dosage and route of HRT is presuibed ac-
cording to the need of the indi' idual.
• onhormonal proph)lactic therapy may be used in-
stead of 1-1 liT.
• A woman may spend one-third of her life in oestrogen
deficiency state and this may pose health problems.
1-ligh-.-isk cases n eed monitoring and prophylactic
therapy so that she leads a h ealthy life.
SELF-ASSESSMENT
1. Define menopa use. Dcscli be the a natomical changes
and a ltera ti ons in tJ1e ho nno nal pro fi le th at characterize
menopause.
2. En wnerate the S)'mptoms assoc ia ted with th e onset of
menopause.
3. Describe th e pathophysio logy of postmenopausal osteo-
porosis and its manageme nt.
4. Desctibe the commonly prescribed regimes of HRT. En u-
merate its advantages and limitations.
5. Briefly desc ribe the use o f medications prescribed in tl1e
manageme m of osteo porosis.
SUGGESTED READING
Cauley JA. DG. Enomd K, e t E.trogen replacement therapy
and fr.tctures in older women. wdy of Osteoporotic Fractures
Research Croup. Ann hum Mrd. 1995; 122:9-16.
Cold itt CA. ll:.nkinson SE. llunter 01, et al. The use of estros,-ens and
progestins and the ri;,k of breaM cancer in postmenopausal \\X)men .
NEng]Mrd. 1995:332:1589-1593.
Jazrnann LJB. Epidemiology of the climacteric >)"'drome. In: Otmpbell S,
(cd). Mmwgrmi'nl of tl" Mmofxwst and PosJ.?nmopausaJ Yra?l. Lancaster,
England: Pn."M Ltd; 1976: 12.
LindT, Otmeron EC. l lunter WM, el al. A prospective controlled trial
of six forms of hormone "'placement therapy g iven 10 postrneno-
pausal women. Drj Obstet (;yntltcol. 1979;86: I.
Lobo RA, Picker J II. Wild RA, el al. Metabolic impact of adding me-
droxyprogesterone acetate to conjugated estrogen thc:mpy in post-
menopausal women . The Menopause Study Croup. Obstrt Gynet:ol.
1994;84:987-995.
Newcombe PA, Longnecke r M P, Storer llE, et al. Long-tcnn hormone
replacement therapy and risk of breast ca•"cr in postmenopausal
women. Am] J..pidemiol. 1995; 142:788-795.
Utian WI I, Schiff I. 1A.\1S.Callupsurvey on wom en's knowledge, infor-
rnation, and to menopause and honnonc replace-
ment therdpy. Mtnoptwst. 1994; 1:39-48.
 Breast and Gynaecologist

Congenital Deformities 99 Key Points I 05

Benign Tumours 100 Sell-Assessment I 05
Breast Cancer 102

T he breast is a n essentia l part of gynaecological examina-
tion and should be included in the ge nera l exam ination of
every woman coming witJ1 a gynaecological problem.
A rou tine breast examinatio n may discover a breast lump,
hithe r1.o no t recognized by tJ1 e woman. Breast examination
becomes ma ndatory in an ovarian tumour suspected to be a
metastatic growth. During infe r1.ility work-up, galaCtorrhoea
may poim to h)'Perprolacti naemia as a cause of infertility.
ln prinlary amenorrhoea, ill-deve lo ped breasrs suggest
hypothalamic-pilllitat') cause whe reas well-developed sec-
ondary sex characters indicate a local ge nital cause for
ame norrhoea. Regular breast examinatio n is esse ntial in a
woman on honnonal replacemem tJ1erapy (Figs 8. 1-8.3) .
HORMONAL EFFEOS ON THE BREASTS
Breast tissues, glandu lar, ductal as well as me Sl.11)ma re-
spond to and remain sensitive to ovarian hor·mones through-
out the r-eproducti'e period and also after menopause.
Therefore, excess of ovarian hormones and antihormones
play a major role in breast diseases.
CONGENITAL DEFORMITIES
interferes with tl1e woman's ac uvrues. Chronic mastalgia
is desc ribed whe n pain lasts fo r more tJ1 an 6 momhs, and
requires in vesti gati o ns.
TREATMENT
Treaunent (Fig. 8. 1) comprises the fo llowing:
• Analgesics- nonsteroidal antt-inflammatorrd n.rg; (NSAIDs) .
• Evening primrose oil capsule (Wellwome n capsule) con-
taining gamma linoleic acid or gamole nic acid 3 g daily
relieves pain in 70%. Occasional nausea a nd headache
are tJ1e side effects.
• Oana.t.ol 100 mg b.i.d. produces severe androge nic side
effectS in some, and is expensi,e. Although it is 70% ef..
fective, cost and side effectS ma>• preclude some woman
taking mem. Vitamin B6 benefits few women.
• Bromocriptine 2.5 mg b.i.d.: Nausea, vom iting and giddi-
n ess may occur, and because of these side effects, compli-
an ce is poor with danaLOI and bromocriptine. About45%
success is reponed. Cabergoli11e IIJ11g-arti11g with less side
effects. ( Destin ex 0.25 mg twice a week.)
• Trunoxifen 10 mg has less side effectS, but endomeuial
h yperplasia and in rare cases, ca ncer has been reported.

Congenital deformiti es include an abse m or an extra nip-

ple, supern ume rat)' breasts, ap lasia or hypoplasia, some-
Limes uni latera l.
ln Turner S)'ndro me, and in some cases of primal')' amen-
orrhoea, oestrogen tJ1 crapy may develop breastS and reduce
me risk of osteoporosis.
Trmww mul infectiou are mainly confined to breastfeed-
ing puerperal women. Cracked nipples wi ll be healed wim
Masse a ·eam. Mastitis requires a nalgesic, ho t fomentation
and antibiotics. An abscess will require incisio n and drain-
age.

MASTALGIA
Painful breast seen in )Otmg wome n is ofte n cyclical, but in
older women it is usually ac> dical. C)•clical mastalgia is the
breast pain occun·ing for a few da)S before menstruation. 8.1 Milk-producing structures and ducts in the human breast
Severe mastalgia lasts more than 7 days, requires drugs and (simplified cross-section).

99
100 SHAW'S TEXTBOOK OF GYN AECOLOGY
Figure 8.2 Sell-palpation of breasts.
• Gonadotropin-re leasing hormo ne (G nRH ) analogue
(gosere li n) 3.6 mg as month ly depot it"Uection is effec tive
but in fl uences the menstrua l cycle (ame no n·hoea) and
causes os teopo rosis on prolonged use. Sho n.-term ther-
ap)' is useful, but very expens ive.
• Testosterone uncleca no<lle (Restandol ) 40 mg b.i.d. is
effec tive. Androgenic side effects after 3 months of u·eat-
mem are often Lhe li miting factor in its use.
Noncyclicalma:.lll/gilt is seen in older women and may be a
S)'lnptom ofbreastcancer. This requires investigations to find
out tJ1e tmderl) ing cause. Some women suffer from chest wall
pain (fieue S)ndrome). If tJ1is is tJ1e Olllse, SAIDs LLSually
relieve pain. If not, injection witJ1 an
combination locall) has shown 75% response.
BREAST lUMP
Less than 10% women presenting wim a breast lump have
breast cancer. NevertJ1eless, S)Stematic examination and in-
vestigations are r·equired to rule out maligna ncr Symptom-
aJ.ic lump (pain or growing) requim Sltrgrry.
C)'sti.r swdliug. A single cyst is often benign. Multiple cysts
can become mali gnant. Fine-needle aspiration cytology
(FNAC), and ultrasound wi ll iden tify the cyst.
Buxxt-slitiued fluid, rocummce ajier fl.!pimtion mul multiple cysts
slwnut /Je trnated I n young rwmen, simple tL!piration and
')•tuiJJg)' will be ruietrtwlt!. Bmost (WSI'I'SS is an ac ute disorder affect-
ing women of childbea ring age. It can be e ither lactational or
non lactational. Lac tati onal breast is more common
and ma)' be secondary to cracked nipple or u·auma while feed-
ing the bab)'· Staphylococctl.l attmtl.l is the predominant organism
found in these cases. Nonlactational abscess occ tu·s in women
of older age group as compared to lactational abscess. They
are associated with diabetes and history of smoking in females.
Perit.luctal occurs in older women. Nipple dis-
charge and retracted nipples are clinical features often as-
sociated with smoking, although the catLSe is not clear. Per-
haps it alters the bactetial flora in the dueLS, with a
preponderance of C.. coli and anaerobic organisms, and mis
leads to infection. AnotJ1e1· possibilit)' is direct toxic action
of smoking on me \'l\Scttlar strucwre of ductal epitJ1elium.
Antibiotics and excision of the lesion are required.
Nipp le disc harge ca n be honnonal, but blood-stained
di sc harge is clue to ducta l papilloma a nd perid uctal mastitis,
rare ly due to mali gnanC)'· C)'tology and mammography are
not a lways useful. Resec ti on of the lobe is the recomme nded
treatmenL
GALACTORRHOEA
Galactorrhoea is caused b) h)'Perprolacti naemia and pitu-
itary adenoma. Prolactin level more tJ1an 25 ng/ mL can
caLLSe galactorrhoea, but not all hyperprolactinaemias pro-
duce galacton·hoea. The condition is associated witJ1 ame n-
on·hoea, oligomenot-rhoea and infertility. The macroade-
noma can cause pressure on optic nerve. The management
of galacton·hoea is desct·ibed in chapter on Pt·imary and
Secondaf)• AmenotThoea.
Other causes are h) potJ1) roidism, chest wall i•"Uury, her-
pes .toster, su·ess, and oesu·ogen and dopamine receptor-
blocking agents.
BENIGN TUMOURS
FIBROADENOMA
T his is a benign wm o ur a nd occ urs at a ny age. It is usually
a s ingle tum o ur, ra re ly g rows more tJ1an 5 em a nd ac-
co un ts for 15% of all breas t wm o urs. Befo re the age of
30 years, the wm o ur run s a benign co urse, a nd if the in-
vestigations prove th e be nign nawre of th e tumo ur, it is
safe to leave it be hind. Howeve r, afte r this age the possibil-
it)' of maligna m cha nge ca nn ot be ru led OtH, and excision
biopsy is recommended. If the benign tumo ur in a yo ung
woman becomes tender or increases in size, surgery is a
wise decision.
Fibro(ltl£nrui:. in young women LO clanazol.
Progestogen-on!) pill (mini pill) reduces the incidence
of benign breast disease b) 35%-40% but increases tJ1e risk
of cancer.
Duct jJltjJillo11w causes blood-stained discharge. The C)'LOI-
Og)' of the discharge, mammography and ultrasound locate
the lesion. Ouctoscop)' confirms tJ1e nature of me lesion. It
can turn malignant and requires excision.
 CHAPTER 8 - 8REAST AN D GYNAECOLOGIST 101

(A) With arms at sides. (B) Wkh arms raised over the head,
elevating the pectoral fascia and breasts.

(C) With hands pressed (D) With palms pressed together In front of
fhnly against hips. the forehead. contractilg the pectoral muscles.

(E) Palpation of axHia; (F) Patient supine w kh pillow under the

arm supported as shown, s houlder and with the arm raised above
relaxing the pectoral muscles. the head on the side being examined.

)
(G) Palpation of breast in circular
pattern from the outward.

Rgure 8.3 Breast examination. Positions include patient seated cr standing . (Soiree: Rao, KA Tel<lbook ol (),tnaeoology, lncla: Bsevier, 2006.)
102 SHAW'S TEXTBOOK OF GYN AECOLOGY

+
[ Noncyclical

•
1
Examination
Rule out cancer

l
Tietze syndrome Investigation
, . - - - - _ _ J I , . __ _ _ _---, NSAIDs, anaesthetic+ (cancer)
i>1
Mild requires
assurance and observation
steroid injection
Moderate requires
treatment
l
Treat

Analgesic
l
Evening Vitamin 86
Primrose oil 3 g 100 mg daily
. +
No 1mprovement

Danazol Bromocriptine

1
100 mg bid 2.5 mg bid
- - - ---1 No response L------
. or severe .

+
Goserelin 3.6 mg
l
Testosterone undecanoate
-----.
Tamoxifen
monthly injection 40 mgbid 10 mg daily
Figure 8.4 Treatment of mastalgia.

PREMENSTRUAL MASTALGIA
It is u·eated with toremifene, which is an selective estrogen
receptor modulator and belongs to the tamoxifen group
of drugs; 60 mg dail) is given only in r.he luteal phase.
It improves mastalgia in 60% cases. It has lesser side effectS
as compared to tamoxifen (Fig. 8. 1).
BREAST CANCER
Breast cancer is the commonest can cer in woman and
accountS for 10% of all breast problems presented at the
clinic. Breast car·cinoma is more prevalent in elderly women,
and needs prompt investigations and treatment comprising
surgery followed by rad iothe rapy and chemotherapy, as the
need be. Certain hi gh-risk cases have been recognized and
will need regu lar sc reenin g. These are as follows:
• Fi:nnilifll hiltor:y. A fam il y history of breast cancer in first,
second degree relatives suggest that genetic factor is re-
sponsible for development of breast carcinoma. BRCAl
and BRCA2 genes mutatio ns may be fo und in 3-8% cases.
Presence of these mutations indicates a higher risk of
development of breast cance r in othe r family members.
• A woman with ovaria n cancer is at a high risk of breast
cancer and vice versa. Both malignancies share common
aetiological factors and have common o ncogen s.
• A woman with ovarian cancer sho uld be screened for
breast tumour, as the ovarian wmour could be a metasta-
sis from the breast.
• Agl'. After the age of60 >ears, 50% breastiLUnps prove to be
malignant. In childbea•ingage, 15% ofiLUnpsare malignatlt.
• PariI)'. ullipadty,late first pregnancy (after age of30 yrs)
and nonlactation are the high-risk factors.
• Obese women too have a propensity for breast cancer.
• Early menarche and late menopause with greater num-
ber of menstrual C)cles and shorter cycles expose r.he
breast tissues to oesu·ogen hormones and make them
susceptible to the development of breast cancer. Endog-
enous as well as exogenous oestrogens are carcinogenic.
Lately, p•·ogestogens also ha'e pro,·ed carcinogenic.
• The risk of breast cancer is high in young women on oral
comraceptive pills. The •isk decreases I 0 years after the
stoppage of honnones. However, can cer is well differenti-
ated in these women.
• S11wking. It encow-ages pcriductal mastitis and atypical
growth. It is also immtmosuppressive. Alcohol too may be
a factor.
• Honnoues. It is strongly suspected that combined oral
comraceptives (COC) containing hi gh-potency proges-
togen given for more than 4 )'Ca rs to a woman yo unger
tha n 25 years and befo re he r first pregnancy may predis-
pose her to breast ca nce r at a late r age and the risk is
two- to fivefo ld. One shoul d be ca reful in prescribing
COC to )'Otlllg women. Progestogen-only pill (POP),
while protecting against benign tumours, increases th e
risk in elderly women. T he risk decreases after 10 years
of stoppage of oral conu·aceptive pills. Low-dose COC
may have a lower risk. The risk is related to the d uration
of COC intake. Lately, COC is considered a higher
dsk factor than oestrogen alo ne because of progestogen
content.
Breast cancer is the main concern while prescdbing hor-
mo ne replacementthempy (I IRT) r.o a menopausal woman.
A woman on HRT should be screened regularly for breast
lump, and mammography should be done every 1-2 )Cars.
HRT should not be administered for more than 10 )Cars.

Fortunately, breast cancer following HRT is of low malig-
nant "potential" with good prognosis.
It may be prudent not to recommend HRT to a woman
treated for breast cancer. It is equally important tO carefully
monitor a woman on tamoxifen for breast and uterine can-
cers. It is suggested that vitamin A may be protective. Obe-
sity increases the risk of cancer becattSe of pet;pheral con-
version of oesu·ogen. Raloxifene is safe agai tlSt endomeu;al
cancer but causes thrombosis.
CUNICAL FEATURES
Very often, the fit"Sl thing a woman feels is a lump in her
breast. Nipple discharge and pain come later.
The lump feels firm , irregular and fixed in t11e later
stage. Axillat-y lymph nodes become palpable in the ad-
vanced stage. The ot11cr breastShould also be palpated.
INVESTIGATIONS (Figs 8.5- 8.7)
Clinical fJrtljJat.ion is not I 00% accurate for detec ti ng cancer.
In patients younge r than 40 )'Cars, 50% cases can be missed.
Between the age of 40 and 49 years, accuracy is 80%;
between 50 and 59 )'Ca rs, 90%; and over 60 years, accuracy is
95%. Self-examination increases t.he awareness in a woman
and brings her to the doctor at an early stage for the treat-
ment. Ex amination by physician supp lementsself-examination-
(Figs 8.2 and 8.:3).
Mammography is indicated in the following cases:
• Older and high-risk women.
• To assure nonnalit) when a woman has cancer phobia.
• If a lump is present.
Breast lump
• Clinical examination
• Mammography
• Ultrasound
• FNAC
• MRI (sometimes)
Age <30 years Age >30 years
Observe Excisional
biopsy and
histology
Painful or increase
in size
Resection and
histology
Figt.We 8.5 Investigation and treatment of breast lump.
CHAPTER 8 - BREAST AND GYNAECOLOGIST 103
• Prior to HIIT; Yearly/ 2-yearly screening between the age
of 45 and 60 years is cost-effective.
Contrairulicatiom. Mammography is conu-ainclicated in
pregnane) because of the risk of radiation.
Using onl) mammograph) as an investigation tool is un-
reliable in 50% women below the age of 40 years becattSe of
cletlSe breast tissue. Mammog•-aph) identifies cancer in 75%
cases between 10 and 19 )ears of age, and reliability in-
creases with age. It must be mentioned tllat ime•·pretation
of mammography findings may be difficult if a woman had
previous breast surgeq•. Similarly, HRT also interferes with
mammographic screening. Mammography should include
two views of both breasts: mediolateml obliquf' vinu and cranio-
CtJttdnl view. Regular mammog•-aphy can reduce the mo•·tal-
ity of cancer by 30%. The findings include:
• Altera tion in density of breast tissue
• Microcalcifica ti on
• Thickening of skin
• Presence of fibro us s u·eaks
• Nipp le alterati o n
• Detection of fibroade no ma, lymph nodes, galactocele
• C)•Sts and solid wm o ur.
Ultrmowul using 10-MH:t. probe, is useful in all age
groups, especially before the age of 35 years when mammogra-
phy may not be reliable. Ulu-asouncl differentiates cystic from
solid malignanttumotLr. It is required in young women, pregnant
and lactating woman, and in duct papilloma. Ultrasound, hO\\"
ever. fails to ident.il) microcalcification, which is the hall mark of
!i4alignancy
Excisiona I biopsy and
frozen section
Malignant
Radical surgery.
lumpectomy followed by
radiotherapy, chemotherapy
if required
•
No hormonal
therapy thereafter
•
Follow-up
104 SHAW'S TEXTBOOK OF GYN AECOLOGY
Figure 8.6 CC view- mammography cranlocaudal view.
Rgure 8.7 MLO - mammography mediolateral oblique view.
early cancer. In the cancer of breast, O\'<'lrian screening by ultra-
sound is important, as one ca ncer spreads to the othet:
• Doppler ultraJouud d isplii)'S vasc ul ar pattern of a tumour
and indicates the probabi li t)' of malignancy.
• Computer-aided detecting diognosis (CADD) a nd elec trical
impedance imaging are new techno logies.
• DuctoJCO/J)' tmd cytology when d ueLpapilla is s uspected.
• X•rrl)• dwJ4 CT brain and abdom inalulu·asound for metaStasis.
• MRJ gives tl1 e most acc urate measurement of tumo ur size
of invasive ca ncer, and he lps in staging. It also predicts
t11e response to primary chemothe rapy. It is useful in
yo tm g women and in women who had previous breast
surgery.
• / WAC under or clinical guidance yields the
cellular stud) of lump. Uhmsound/ mammography
should be perfonned prior to F AC becatLSe haematoma
sometimes catLSed b) aspiration can obscure the image
(90%-95% specific).
• Qinical examination, combined with mammography,
F AC and ulu-asound can identifY cancer in 99.5% cases.
• Tru-mt biopsy removes a core of tissue for frozen section,
histology and receptor swdy. A big tumour requires exci-
sional biopsy.
SCREENING
Screenjng is an important tool tO identif} women at higher
tisk of developing breast cancer. It a llo"s for early detection
and timely of modalities of treatment best
suited for the patienL A patiem must be evaluated on the
basis of certain risk factors to determine whether referrals
:u·e needed for genetic testing and for consideration of
chemoprevention and/ or prophylactic surgery.
Major factors used to determine a risk category, based on
a patiem's histOIJ', ar·e as follows:
• Personal histor/' of ovaria n, peritoneal (including tubal)
or breast cancer
• Family h is to r/' of breast, ovarian o r peri to neal cancer
• Genetic predisposition (if the patient's BRCA Status is
kn own)
• Radiotherapy of the chest be tween t11 e age of I 0 and
30 years
AVERAGE RISK
• Age under 40 years - No screening fo r average-risk women
who :u·e younger tl1an 40 years. Among women younger
than 40 yeat·s, the incidence can cer is low.
• Age between 40 and 49 years- For women who decide tO
initiate screening in their 40s, a screening mammography
every 2 ye:u·s is performed.
• Age between 50 and 74 years - Breast cancer screening
with m:unmograph) for avemge-ris k women aged be-
tween 50 and 7 1 )Cars. We t)picall) screen evet}' 2 yeat-s.
• Age 75 years and older - Women older than 74 )'eat'S
should be offered screening on I)' if their life expectat1cy
is at least iO )Cars.
HIGH RISK
As per American College of Obstetrics and G)'naecology
(ACOG) guidelines 2011 , for women who test positive for
BRCAI or BRCA2 mutations or have a lifetime 1isk of 20%
or greater, screening should include twice yearly clinical
breast examinaLion, annual mammography, annual breast
MR1 and breast self-examination.
For women who received thoracic irrad iatio n between the
age of 10 and 30 yeat-s,screeningsho uld include annual mam-
mograp hy, ann ual MRI and screening and clinical breast ex-
amination every 6-12 montJ1s beginning at 8-10 years after
rad iation u·eaunent or at the age of25 )'ea rs.
As per tl1 e Ametican Societ)' of Cancer guide lines 20 15,
women who areal high risk of breast ca ncer based on cer-
tain factors (such as hav ing a parent, sibling or child with a
BRCAl or BRCA2 gene mutation) should get an MRI and a
m:unmogram every
TREATMENT
Treaunent comprises t11e following:
• Excisional biops)' and fmt.en section followed b)' definitive
surger)' as required

• Lumpectom)1
• imple mastecwmy
• Radical mastecLOmy
• Poswperative radiotherapy and chemOLherapy
Lumpec tom>' )'ie lds simila r resulLS as rad ical mastec-
tomy. Ax illary lymp h nodes are re moved in the adva nced
stage.
Rad iotherap)' may be req uired as an aclju nc t in advanced
cases. ReconsLructi ve prosth esis is done in the same sitti ng
or at a later date.
A<ljuvant clumwtherapy reduces the l'isk of recurrence b)'
30%. Tamoxifen 20 mg daily or raloxifene 60 mg daily re-
duces the •·isk of recun·ence in conualateral breast by 50%
for about5 years, but is teratogenic in pregnancy and causes
all'opic vaginitis. AnasLrozole (aromatase inhibitor) is beuer
tolerated tJ1an tamoxifen ( 1-2 mg).
CHEMOTHERAPY
• Four C)'cles of ad ria mycin a nd cyclop hospha mide
• Six cycles of 5-FU, adria mycin a nd C)'Ciop hospha mide
• Six cycles of 5-FU, epirubicin and an thracycl me
Ta.xane improves survival. A woman should not conceive
for 2 >ears after sLOppage of chemotherapy.
PROGNOSIS
Prognosis is based on staging, E2 receptors in tJ1e tissues and
axillary lymph node involvement. Metast."'.Sis is LJ'eated witJ1
chemotJ1erapy.
Ovarian ab latio n may be req ui red to prevent rec u r-
re nce.
HRT and COC are co nu·a ind icated in a woman who is
u·ea ted for breast ca ncer. However, severe menopausal
symptoms may require a low-dose the1-apy. Uncle: supervi-
sion, 1-aloxifene is safe, does not cause endomeLr1al hype•·-
plasia and osteoporosis, although risk of thrombosis needs
to be watched for. Lactation is also conu-aindicatecl in a
,,oman treated for breast cancer because of the 1isk of de-
veloping cancer in the opposite breast.
Breast cancer occurring during pregnane) is known. Sur-
gery and radiotherapy are not conu-aindicated dLtring preg-
nanC)', provided adequate shie ld ing is provided. If, however,
chemo tJ1erap)' is co ns ide red postopera tive!)', terminatio n of
ea rl)' pregnancy is necessa ry beca use of te ratogenicity of the
drugs. Late in p regnancy, che mo th erapy can be delayed
unti l after delivery.
PROPHYLAXIS
Tamoxifen and raloxifene for 5 )elll's:
• Reduce the incidence of conu-alateml breast cancer
b) 50%.
• Prolongs disease-free imerval.
• Reduces tJ1 e risk of rec urrence.
CHAPTER 8 - BREAST AN D GYNAECOLOGIST 105
KEY POINTS
• Examination of tJ1e breastS sho uld fonn part of the
routine examination of all patie ntS undergoing gynae-
cological examinatio n.
• Exa mina tion may reveal co nge nita l deve lopme nta l
ano malies s uch as absen t o r exu·a nipple, hypop lasia,
masta lgia, mastitis in nursing mothers, crac ked n ip-
ples, galac torrhoea of sign ifi ca nce in inferti le
prese nce of benign neoplasms such as free I)' mob1le
fibroadenomas, presence of C)SLS such as galactocele,
i•·regular nodularity in chron ic C)Stic mastitis, hard
indurated nodule suggesti\e of breast cancer or the
p•-esence of blood-stained nipple discharge indicative
of a possible underlyi ng cancer.
• Breast lumps may be be nign or malignant. Mammog-
raph) and ultrasoLmd examination, Doppler studies
and MRl reveal prese nce of solid or cystic neoplasms.
FNAC a nd C)'LOlogica l examination of the aspi rate
mtl)' he lp to establish early d iagnosis of cance•:
• Breast ca nce r ca rlies a wo rse prognosis if it occurs
chui ng pregnan cy and lactati o n because of immuno-
suppressive condition .
• HRT is contraindicated in a woman u·eated for the
tibolone and bisphospho-
cancer of breast.
nates can be offered to pre, em osteoporosis.
• ·nunoxifen is temtogenic.
• lnc•-easing awareness among clinicians oftJ1e importance
ofb reast examination and teac hing patien LS about tJ1e an
of self-examination promote early diagnosis of cancet:
• A baseline mammograp hy in all me nopausal pa tien tS
sta rt ing I-IRT is a desimble p recauti on . Use of oestro-
gens and progeswge ns sho uld be withheld in wo me n
with a strong family histo ry of b reast ca ncer.
SELF-ASSESSMENT
I. Describe the benign lesions of the breast.
2. A 50-)ear-old woman presentS with a lump in tl1e left
breast. How will you manage tJ1is case?
3. A 22-)eai"'id mtllipara presen LS with galactorrhoea. How
will you manage this case?
SUGGESTED READING
BO, Bala>Sanian R, BlairSL, Bul'>tein llj, CyrA,
e1 al. NCCN Guidelines Insights Bre-ast Vcl'>ion 1.2016.] ' all
ComprCtnc Nci\V. .
Mango V, Bryce Y, Morris EA. Gianotti E, Pinker K. ACOG bul-
letin July 0 I 7: brt:""..stcancer risk assessment and t.erccnmg m a•erage-
risk women. Br J Radiol. 2018;24:201 70907. ..
Speroff L, Fri11. MA. Oinical G)'llecologic Endocrinoq,') and lnferulny.
&h Phibdclphia: Lippincou \\'illia111> & Wilkin>. 2011:621-672.
Sule EA, Ehcmade F. Management ofpregrum9 a>>OCi&L-d breast can-
cer hilh chemotherapy in a den;loping country. lmj Surg C:bt: Rep.
2015 ;17:117-20.
 Sexual Development
and Disorders of Sexual
Development
Principles of Sexual Development I 06 Virilism 114
Factors Influencing Designation of Sex I 09 Hirsutism 116
Disorders of Female Sexual Key Points 120
Differentiation 112 Sell-Assessment 120
Masculinization 114
Sex differentiation is a comp lex process comp rising a cas-
cade of even lS that begin with the undifferemiated (poten-
tiall)' bisexual) go nad up to the 6Lh week of inu·auterine life
and end up with the developmem of the specific gonads
and their corresponding in te m al and external genital
organs. Genetic arul lwmwnal injlumces are t!Ut TTUtin determi-
in development of stx, (titlwugh other f(lctnrs TrUly modifj•
its devtiofJment. The environmemal and teratogenic facwrs,
such as ionit.ing radiation, viral infection, chemical agents,
immtmological disturbances, hormones and nuu;tional
deficiencies. pia) a role in sexual differentiation.
ew insights into the biolog) of sexual developmem
and advances in chromosome analysis have encouraged
clinicians to determine sex of the individual at an early
age and institute prompt treaunem of the intersexual state
to enable the individual to lead a more normal life.
The expanding knowledge and recognition of imersex-
ual states have h elped to develop a classification of abnor-
mal sexual development based on gonadal and genital
anatomy, chr·ornosornal nndings and specific identifiable
genetic/metabolic defects.
T he knowl edge of e mbryology is necessa1)' to under-
stand how congenital malformations occ ur in I% offemale
pop ul a ti on.
PRINCIPLES OF SEXUAL DEVELOPMENT
(Fig. 9 . 1)
The deve lopment of no1mal male and female genital organs
and tracts is detenn ined by several factors, all ofwhidl are time
specific during emb1yogenesis. In the 5th week ofinu-auterine
life. the undifferemiated gonad comains cortex and medulla.
The critical period for gonad,·\! developmem is at fr7 weeks of
emb1yogenesis when Y chromosome promotes male gonadal
development. 1l1e external genital organs (phenotype) stan.
developing atiOtJ1 week and read1 completion by 16th week.
The genetic sex is detennined at fei·tiliLation, but the
gonads remain undifferentiated until 6 weeks of intrauter-
ine life. First, the sex chromosomes determine whether the
106
indifferem gonad (w·ogenita l ridge) wi ll differemiate imo a
tes tis or an ovary. Y chromosome develops a ma le gonad
and absence ofY and presence of XX chromosome deve lop
ovaries. lf the gonad is ma le, ge nes associated with the
Y chromosome imeract with other compo nents of the so-
matic cells in the primitive gonad and initiate development
along t11e male lines. The elaboration of the H-Y amigen
complex in tJ1e short arm of Y chromosome, known as
sex-detennining region Y (SRY) , induces testicular develop-
menL Senoli cells in the developing testis produce
Miille iian-i nhibiting substance (MIS) that causes regression
of the Mulledan (paramesonepluic) ducts. In me abse nce
of tvUS, the Mullel'ian ducts de,elop passive!)' to fonn the
fallopian tubes, Lllerus and upper '-agina. Female imernal
organs and external genitalia de,elop partially witJ1out the
need of O\<arian h ormones and differemiate even in t11e
absence of gonads unless interrupted by t11e regressive
influence of MlS. Diffe1·emiation of the Mullerian dueLS pro-
ceeds cephalocaudall y to form the female imemal genital
organs. ln the absence of the masculinizing effectS of dihy-
drotestosterone ( DHT) of testicular o ligin, t11e unclifferemi-
ated ex ternal genital anlage develops along fem inine Ji nes
(vul va). T he genital tubercle develops into tJ1e cl iLOiiS and the
genital folds into the labia Only if tJ1e female fe tus is
exposed to elevated levels of androge n before tJ1e I OtJl LO 12th
week of gestati on, does any degree of masc uline develop-
ments occw: ln such situations, t11e exte mal genitalia may
appear amb iguo us. lf tJ1e androge ns are not elevated until
after me 20th week, t11e on I)' masc uli ne effect is an enlarged
eli to lis as tJ1e extemal genitalia have fu lly formed by that time.
ln Turner's syndrome, t11e ge rm cells fa il to migrate tO
t11e ovary by 6tJ1 week, causing streak O\<aries. Two XX dlro-
mosomes are required for the O\<arian developmenL The
cortex of undifferentiated gonad develops imo ovary.
SUMMARY OF SEX ORGANS DEVELOPMENT
GONADS
I. Formation of testis occurs in the presence ofY chromo-
some (46>..'Y).
 CHAPTER 9 - SEXUAL DEVELOPMENT AND DISORDERS OF SEXUAL DEVELOPMENT 107

Sertoli cells, Anti-Milllerlan (7-9th week) ovary - No role

hormone (AMH), on Mulleri an system and
spe rmatogenesls external genitali a

Development accessory organs

Testosterone - dihydrosterone
{7-8 weeks)
Absence of testosterone

Male external genitalia

(16 weeks)
Female external genitalia
(14 weeks)

Figure 9.1 Development of male and female reproductive organs.

2. Forma tio n of ovary occ urs in the absence ofY chro mo-
so me and in the presence o f second X chro moso me.
XX ch romoso mes are req ui red for ova rian develop-
mem. One X chromosome causes ovarian dysge nesis or
Turner syndrome.
3. Development of the gonads begins between 6 and
7 weeks of gestation.
detemtiiWIII.s: SRY gene of the shon ann (p) of
theY chromosome is the gene involved in testis detenn ina-
Lion. At first, the germ cells appear followed by Senoli cells
that secrete Miillet·ian-inhibiting facLOr (MI F) a nd prevem
developmem of female genital u-acl.
Sen o li cells a lso secrete testos te ro ne-binding protein
tha t b inds to tes toste rone; as a result, tesLOsre ro ne conce n-
tratio n in tl1 e testis is highe r tha n in serum, and this is
necessary for spermatogenesis from primi tive germ cells.
A wee k later (8th week), Leydig cells start secreting
testosterone under t11e inOuence of hu man chorion ic
gonadotropin (hCG) wh id1 has LH li ke acliv ity an d deve lop
accessory organs (\\'olffian duct).
Peripheral comers ion of testosterone to DHT is respon-
sible for male extemal genitalia (male phenot)'J)e); ge ni tal
tubercle enlarges to fot·m penis by 20tll wee k.
Ovaria11 tletermiiWI!I.s: Unless SRY is expressed, ovarian
developmem ensues in the presence of XX kaqotype.
108 SHAW'S TEXTBOOK OF GYN AECOLOGY

Th e ovary has no ro le in th e deve lop me nt of Mi:lile rian by tl1e age of 2-3 years, de tiveclthrough internalization of
sys te m a nd ex tern al ge ni ta l o rgans. cues based on external ge ni ta lia. Patie ntS with 5-alpha-
reductase de ficie ncy or 17-beta-hyd roxystero icl dehy-
INTERNAL GENITALIA droge nase de ficie nC) rna) cha nge the ir ide ntity fro m
Wolffian duelS w1 der the in fluence of teStosterone {testes) ma le to fe male at pubert), suggesting a ho rmo nal ro le
fon n epidid)lnis. vas defe rens and se minal vesicles (male in sexua liatio n. Sexua lit) is infl ue nced by libido dl"ive n
intem al geni talia). MIS from th e Senoli cells suppresses the by testostero ne and in tirnaC) d rive n by oes u-adio l
development of female ime m al ge ni talia from the MUllerian (Table 9.1 ).
duelS. Mull e.-ian d ucts in the abse nce of MIS fonn ful lopian
tubes, uterus and upper vagina (female internal genital ia) .
Mullerian and ll'oljfian drodoj11nmt begins at the same CLASSIFICATION OF INTERSEX DISORDER
period of embr1ogenesis; these are local phenomena
occurring ipsilatera ll y depending on the presence or GENDER IDENTITY DISORDERS ASSOCIATED WITH
absen ce of testoster·one and MIS. NORMAL SEX CHROMOSOME CONSTITUTIONS
Female
EXTERNAL GENITALIA • Adr·enogenital syndrome (testostero ne overproduction
DHT determines th e development of male external geni talia. d ue to adrenoco rti coid insufficien cy)
It is produced in adeq ua te amo unts from 7-8 weeks of gesta- • 2 1-alp ha-hydroxylase dencic ncy
tion until te rm. hCG sti mul ates Leyd ig cells of the fetal testis • 11-be ta-hydroxylase de ficiency
to prod uce increasing amounts of testoste rone, which devel- • Treaun e nt of mo tJ1er witJ1 progestins o r a nd roge ns
ops male o rgans such as vas deferens, e pididymis and se minal • O varian virilizing tu mour
vesicles. Femi nizati on of tJ1e external ge ni talia is co mpleted Male
by 14 weeks of gestati on, whereas masc ulinization is com- • Prima•'}' go nada l defec t
pleted b)' 16 wee ks of gestation. Descen t of the testis is medi- • Testicular regression syndro me
ated b)' testoste ro ne, insuli n-like 3 ligand and itS receptor: • Le) d ig cell agenesis
1

Mascul inizatio n of cloaca occurs on ly if testostero ne is con-
ven ed via 5-alpha-red uctase to DHT ln the absence of this
enzyme, tl1e Wo lffian system deve lo ps normally but external
ge nital ia wi ll be of female pheno type. Similarly, exposure to
and roge n in utero causes masc ulinia tio n of exten1al genita-
lia in a fe male. but the Mi:tlle rian syste m develops no rmal ly.
FACETS OF SEXUAL DIFFERENTIATION
These ca n be broadly classified as follows:
I. Gonadal d e, elopmen t
2. Geni ta l differentiati on
3. Ex.tem al geni ta lia- phenotype.
4. Behavioural differe ntiati on: Sexual/gender identity as
male or female is consciously appreciated by an individual
Defec tive hCG-Iute ini:t.ing ho rm o ne (LH ) receptOr
• Defec t in testos te ro ne synthesis
20,22-desmo lase de ficie nC)'
3-be ta- h)droxylase de h)d rogenase de ficiency
17-alpha-h) dr'OX) lase defi cie ncy
• Male pse udohermaphroditism (testOste rone ins uffi-
cie nc) o n I))
17,20-desmo lase deficie nC)
17-beta-h)d roxysteroid ( 17-ketostero id reductase)
de h) drogenase d eficiency
Defect in the Mi:rll eri an-inhi biting system
End-organ defect:
• Disordered anclr·ogen action (cytosol androgen
receptor·-binding defect)
Androgen insensiti vity syndrome {testicul ar femini-
zati on)

Table 9.1 Chronological Order of Sexual Development

Time In
Weeks Organ Male Female

At fertilization Genetic determinant XY and SRY antigen in the short arm XX or absence of Y chromosome Induces ovarian
(XX or XY) of Y chromosome induce testicular development
development
7-8 weeks Gonads are formed Testes - seminiferous tubules Ovarian cortex medulla-rete ovarll

1()-12 weeks Internal and external Wolffian duct develops into vas, MUllerian duct develops Into fallopian tube,
genitalia epididymis , seminal vesicles and uterus, cervix and upper three-fourths of
external genitalia vagina; external genitalia

At birth Appropriate external genitalia Appropriate external genitalia

Puberty Continuous GnRH releases testoster- Pulsatile secretion of GnRH releases FSH, LH
one secretion and development of and ovarian hormones
male secondruy sex characters Development of secondary sex characters
 CH APTER 9 - SEXUAL DEVELOPMEN T AND DISORDERS OF SEXUAL DEVELOPMENT
Incomp lete androgen insensitivity syndrome (Reif-
enstein S)'lldrome)
• Disorders of testosLerone metabolism
5-alpha-reductase deficiency
GENDER IDENTITY DISORDERS ASSOCIATED WITH
ABNORMAL SEX CHROMOSOME CONSTITUTIONS
Sexual ambiguit)' injrl'qurnt:
• Klinefelter S)ndrome (XXV)
• Tumer S)ndrome (XO)
• XX male
• Pure gonadal dysgenesis (some fonns)
Sexual ambiguity:
• Mixed gonadal (MGD), including
Some forms of pure gonadal dysgenesis
Dysgenetic male pseudohermaphroditism
• True hennaphroditism
FACTORS INFLUENCING DESIGNATION
OF SEX
GENETIC SEX
ln each individual, the n ucle i of hu mans contain a d ip lo id
number of chromosomes, 22 pairs of auwsomes and 1 pair
of sex du·omosomes, making a tota l of 46 chromosomes.
During mawration, a reduction division resultS in each
ovum or spermatozoon containing only the haploid set
of 22 unpaired autosomes and I sex chromosome. ln the
ovum. the sex chromosome is always X, but in the sperm, it
is either X or Y.
The relative number of X- and Y-can·ying spennawzoa
is equal. As the spermatOLOOn can·ies either an X or a Y
chromosome, fertiliLation resultS in a 46-chromosome
paLLern ca1·qing either an XX or XV- a genetic female
or a genetic male, 1-especti,ely. Thus, the o1·iginal diploid
number of ch1·omosomes is restored (22 pairs of autosomes
plus the paired sex chromosomes- 46 in all).
The genetic lex of<m inllivi<ltwl is dPtm11inwL aJ. fertiliwlion.
ln the fertiliLed egg, theY chromosome directS the develop-
ment of the undifferentiated gonads into teSLeS and absence
ofY into ovaries 2 weeks later. T he ovaries do not participate
in sex ual development. Y ch romosome contains on its
short arm l-1-Y an ti gen (surface SRY cell a ntige n), which is
responsib le for the develop men t of testes. T he autosomes
also take parL T his Y chro mosome has no furth er influe nce
beyond th e development of t11e gonads.
T he germ cells arise in t11e endode rmal wall of the
primitive gut near t11e yolk sac, from where they migrate
along tl1e dorsal mesenLery into t11e gonadal s ite. Leydig
cells (interstitial cells) prod uce testosterone that deve lops
t11e Wolffian duel and urogenita l sinus into male genital
organs and external genitalia respectively. The Senoli cells
of the testes also secreLe a nonsteroidal substance known as
t11e MLF. which is responsible for inhibiting the gt·owth of
t11e Mi:1llel"ian S)Stem in males.
The embi")O bearing XX chromosome develops along
tl1e female line and turns the undifferentiated gonad imo
ov;uies. The absence of LeStosterone will cause au·ophy of
the 'v\'olffian duct, and t11e absence of MlF will pennit the
growth of the Mulle1·ian sysLem along the female line.
109
lt must be emphasitedthat it is the absence ofY chromo-
some wit11 itS l-1-Y antigen that directS the gonads and the
MCtllerian system into t11e female pattern. Recently, it has
been reported that it is t11e sex-<letennining region located
on the short arm of Y chromosome (SRY), which controls
the development of testes. Its absence leads LO the develop-
me Ill of female gonads. In a rare case when t11e Senoli cells
fail to secrete MlF, tlte individual will develop Miilleri;m
structures in addition Lo the Wolffian de1·ivatives and grow
as a hel"lnaphrodite.
Similarly, castration of male gonads in early embi)OS will
cause atrophy of the Wolffian duct but will pennit growth of
the Miille1·ian S)Stem along the female lines. Unilateral
casu-ation has enabled one-sided growth of tl1e \Nolffian sys-
tem and growtl1 of the Mi:1llerian duct on t11e castrated side.
The testicular differ·entiation starts at t11e 6tl1 week of
intrauterine life. Fi 1-st, t11e Sertoli cells appear followed by
the seminiferous wbules. Under hCG in fl ue nce, Leydig
cells secrete testos terone (pea k level a t 15-18 weeks). In
abse nce ofY chro mosome, the ovary develops 2 weeks later.
Chro moso mal sex can be determined by the swdy of th e
le ucocy tes or by sim ply ta king a smea r fro m t11 e buccal
mucosa (Fig. 9.2). T he n uclei of fema le cells co n tain a
small stainab le body called tJ1e sex chromatin; hence, fe-
male cells are termed as chromotin p()sitivP. In epithe lial cell
n uclei, t11is small, peripherally situated, darkly staining
nodule is called the 'Barr body'. Male cell nuclei lack this
body and are tl1erefore termed as chromatin negative. This
chromatin nodule has been shown to consist of deoxyribo-
nucleic acid (DNA). lt measures I micron in diameter and
is present in approximate!) 75% of the female cells. A dis-
tinctive and similar t) pe of nuclear appendage shaped like
a drumstick is seen attached to the nuclear substance of
female neutrophils. lL is also possible to detennine sex
from eosinophils. The culture of the fetal cells allows
the chromosomal pauern swdy (Fig. 9.3). The sex of t11e
fetus can be determined in utero by examining feml
Denver system for human chromosomes
13 14 15 16 17 18 19 20 21 22 y
Rgure 9.2 An idealized chromosome set, numbered according to
the internationally agreed Denver system. Note that only one of each
pair is represented. The small figures besides each chromosome
indicate approximately the relative length of the whole chromosome
and the proportion of the total length occupied by the short-term a-m
(Source: By pennission of Dr Bemard Lennox and the Lancet.)
ll 0 SHAW'S TEXTBOOK OF GYNAECOLOGY
• \
• \
9.3 (A) A typical chromatin nodule in a neutrophil leucocyte in female. The nodule measures 1.4 microns and red cells measure
7.3 microns. (B) Typical nodules in the nuclei of the epithelial cells of the skln. The nucleus is 1.6 x 0.9 microns.
desquamated epithelium in the liquor amnii. Chorionic
villus biopsy (CVB) either through cervical route in early
pregnanC)' or transabdominall)' in the second uimester has
rece nLi y become the we ll-est.ablished tec hnique of deter-
mining the fet.a l sex.
The la test noninvasive technique of studying fet.al sex
is polymer·ase chain reaction (PCR) staining offetal cell-free
nuclei in the maternal blood of a pregnant woman.
EXTERNAL ANATOMICAL SEX
The shape of Lhe body comours, the de,elopmem of Lhe
musculature. the d1aracteristics of the bones (notably
the pelvis), tJ1e distribution of hair on the face and body,
breast development and tJ1e external gen italia are strong
presumptive evidence of either sex.
INTERNAL ANATOMICAL SEX
The presence of a recognizable uterus, fallopian tubes and
ovaries is the evidence tllatthe indi vidual is a female. The
rare exception is tlle t.-ue hermaphrodite.
GONADAL SEX
Gonadal sex depends on tJ1e histological appearance
of the gonad from tJ1e study of a biOJ>S) or the removal of
the organs. It is not entirely diagnostic as in the case of
an ovotestis in which both female a nd male e lements are
histologicall)' demonstrated. it is possible to have a
rudim e ntary testis on the one side and a rudimentary ovary
on the other: Such findings are, howeve r; so rare that the
sex of the gonad is a reasonabl y reliable guide to the true
sex of an individual.
•
HORMONAL INFLUENCES
In a female pseudohermaphrodite, an excess production of
androgenic hormone by adrena l cortical h)•perplasia can
modif)' the ex terna l gen italia of a genetic fema le. 1-lypenro-
ph y of th e phallus and fusion of the labia m'\iora may cause
the parents to consider their child to be a male. The virili z-
ing tumours of tJ1e ovary, such as arrhenoblastoma, can
cause hirsutism, hypenrophy of tJ1e cli toris, deepening of
the voice, masculine body comours and amenorrhoea. The
presence of oestrogen in tJ1e male can cause g) naecomastia
(Fig. 9. 1). These are all examples of how honnones, natLU-al
or exogenous, can modify tlle sexual organs and secondary
sexual characteristics.
PSYCHOLOGICAL SEX
Many men and women are psychologically dominated
towards sex ual inversion, a persistence of th e childhood
tendency. Behaviour, speech, dress and sexual inclination
proclaim this fact. Transvestism and effeminate behaviour· are
the most obvious and complete examples wher-e men dress in
women's clothes and assume tJ1at gender role and ,•ice versa.
ENVIRONMENT AND UPBRINGING
Environment and upbringing decide the sex of rearing.
There a re many examples of genetic males and females
being reared b)' their parents in th e mistaken sexual cate-
gory, and who have acq uired over r.he yea rs tJ1e habits and
menta l inclination of the opposite sex to a sufficient degree
LO pass off as me mbers of the opposite sex. Fig. 9.5 shows
the development of gonads and genital organs.
 CHAPTER 9 - SEXUAL DEVELOPMEN T AND DISORDERS OF SEXUAL DEVELOPMENT 111

CUNICAL DIAGNOSIS OF SEX

So me o f tl1 e a bnormalities are seen at b irth, but mos t a re
discovered at p uberty.

EXTERNAL APPEARANCE
Most men look like men, and women li ke wo men because o f
their so-called seconda•) sexual characteristics. A man is broad
shouldered, he is more hirsute, especial I)' about the face and
chin, his scalp hair is coarser, his nature is more aggressive and
robust, his voice deep and his sexual instinctS inclined LO t.he
heterosexual. A woman has nan·ow shoulders, broad hips, is
rarel y hirsute, has fine abundant scalp hair, more deli cately
modelled features, and a typical pauem of pubic hair, u·iangu-
lar, witJ1 tl1e apex downwards and a fl at base at tl1e upper level
of tJ1e mons, her voice is softer, her nature is supposed 1.0 be
less self-assertive and aggressive than tJ1e male and her sexual
instinci.S are heterosexual; a well-developed breast is probabl)'
the strongest external evidence offe minini ty.

Figure 9.4 Gynaecomastia In an otherwise obvious male. (Sou-ce:
https:l/'www ha-leystreetskndlniC.com/en/treatment/gynaecomastia/)
EXTERNAL GENITAUA
In the mal e, the phallus is well deve loped from gen it.altubercle,
the urethra opens in tJ1e glans by I2u1 week, tJ1e scrotum is ru-
gose because of p resence oftJ1e dan os muscle - an almost excl u-
sively male possession - and tJ1e testicles are in tJ1e so ·otwn. In
the fe male, tl1e phallus (clitoris) is mdiment.ary, the t.u·ethra
opens into tl1e tJ1e labia m;yora are smootJ1 and bifid
and do not possess a dartos muscle and a '.agina is presenL

Fifth and seventh week undifferentiated gonad

xo
Ovarian dysgenesis
Turner syndrome and
mosaics

AMH (Sertoll cells +

testosterone
Leydig cells)

Testis+
female genital organs
(uterus and vagina)

Development of male Male pseudo-

external genital organs hermaphrodite
(9-16 weeks) female phenotype

9.5 Development of gonads and genital organs.

11 2 SHAW'S TEXTBOOK OF GYN AECOLOGY

INTERNAL GENITALIA
Bimanual examination discloses the presence of a uterus
and appendages in the female.

SIGNS OF FEMINISM IN THE MALE

EXTERNAL APPEARANCE
Feminine figure , poor musculature, a tendency to obesity,
high-pitched \Oice, absence of hirsutism, feminine person-
ality and sexual inclinations and ID naecomastia (Fig. 9. 1).
EXTERNAL GENITALIA
Hypospadias (urethra opening below the phallus), w1der-
developmem of the phallus, a split scrotum and unde-
scended testicles.
Grey areas exist in the biological spectrum ranging from
pure masculine to pure feminism.

CLINICAL EXAMPLES Figure 9.6 Turner syndrome. Note the marked cubit us valgus. (Sauce:
Neena Khanna, Illustrated Synopsis of Dermatology and Sexuafty Transmtt-
lmersex is classiFiecl as fo llows:
ted Diseases, Sexual Growth and Dewlq:>ment, 4th ed. Bsevler, 2012.)

• Chromosomal ab norma lities

• Gonadal abnormalities
• Masc ulinization of female
• Partial or inco mp le te masc ulinization in a male
DISORDERS OF FEMALE SEXUAL
DIFFERENTIATION
SWYER SYNDROME
This S)ndrome is a male pseudohennaphroclite, a pw·e 46XY
gonadal d)sgenesis wit11 t11e presence of uterus and the
but \lith h) po<>esu'Ogenism and poorly developed breastS.
Undeveloped testes do not secrete testosterone and MIF,
resulting in the dC\·elopment of female genital and
female phenotype. The woman presentS wit11 p•imary amen or·
rl1oea, absence of secondary sex characters and female extemal
genitalia. Cyclical oesu·ogcn and progestOgen can induce men-
stnlation. Conception "1111 in vitro fertilization ( fVF) using
donor eggs is a possibility. The gonads (testes) have 30% risk
to develop malignancy and should be removed.
Turner S)'ndrom e has also been called ovarian agenesis or
gonadal dysgenesis because at laparotOm)' the gonad is fo und
to consist of Lmdifferentiated su·oma with absence of sex cells,
a mere pale su·ip of fi bt'Ous tissue auac hed to the back of the
broad ligament, t11e so- called streak gonad. The follicles grow
up to 20th week of fet.'\llife but become au-etjc due 1.0 absence
of one X sex chromosome. In some, ge nn cells fail to migrate
to the genital •·idge from t11e )Oik sac. These ovaries do not
comain Gmafian follicles, so oesu·ogen is not produced The
patientS are clinicall) of sho•t stature, though not actual
dwarfs, the u·unk is nmscula•·, t11e neck is shon and webbed,
and cubitus valgus is notable. The breastS are not clC\·eloped;
pubic and axillary hair are scanty or absem (Figs 9.6 and 9.7).
Exaggerated epicantl1ic folds may be p•-esent, one of t11e obvi-
ous defectS first noticeable on exllmining the patienL The va-
gina and ute•·us a•-e presem but unclerdC\•eloped. Ot11er gross
congenital abnormalities are p•-esent such as coarctation of
the aorta and defonnities of t11e digitS are also seen. Ot11er
stigma of Turner syndt'Omes includes shield chest, high palate,

TURNER SYNDROME
Incidence of Turn er syndrome is 1:2000 lO 1:5000 live
born girls. About 70%-90% of pregnancies with XO cluo-
mosome abort in early weeks of gestation. In this syn·
drome, e itl1e r th e short arm of X chromosome is de leted
or the nucle us possesses o n ly 45 chromosomes, i.e. 22
pairs of autosomes plus a sex chromosome XO. The ab-
sence of Y chromosome resembles th e female, but these
patientS are, like males, chromatin nega tive, i.e. their nu·
clei contain no nuclear satellite body and no drumsticks
in the neutroph ils. It should be expla ined here that the
presence of a Ba1-r bOd) is dependent on the presence of
the second X chromosome, and if the chromosome pat·
tem is XXX or XXXV, the extra X complement renders
the eccent.-ic chromatin noclule either larger in size or in Rgure 9.7 Turner syndrome. Note the webbing of the neck and
number. aplasia of breasts.
 CHAPTER 9 - SEXUAL DEVELOPMEN T AND DISORDERS OF SEXUAL DEVELOPMENT 11 3

low-set ears, lymphoedema of the extremities at birth and
deafness. The stigma is due to d1romosomal deficiency in the
shon arm of X chromosome and is not always present (seen
in 20%-30%), and the percentage of stigma depends on t11e
percentage of abnormal X chromosome.
The classical case of Turner S)11drome as described
should have a chromosomal pattern ofXO. However, mere
are variants in which mosaicism ofXO/ XX or even XO / XY
produce less clear-cut S)ndromes, e.g. a nonnal-appearing
female apan from gonadal d)sgenesis. 'vVhen a )Oung girl
"ith Turner's S)ndrome presentS with p•·imary amenor-
moea and serum follicule-stimulating honnone (FSH) is
above 40mi U/ mL and E2 is below 25 pg/ mL, osu·ogen
t11erapt with intemlittent progesterone is advised to prevem
osteoporosis. Artificial vagi nil m11y be needed at a later date
for sexual function. Administration of growth hormone
0.05 mg dai ly for 5 yeii J'S near pubeny will improve the
hei ghL A pregnancy Cil n occur with donor egg in fVF pro-
gramme if the uterus is presenL If few follicles persist after
puberty, mensu·uati on and pregnancy is possible ( 15%).
girl presents with primary amenorrhoea. Ovaries and
uterus are absent.
Ultrasound reveals absence of ovaries and uterus. Testos-
terone is presem (> 200 ng/ mL). LH is raised, but FSH is
nonnal. Chromosome sllld) reveals XY chromosomes
(Fig. 9.8A and B).
MANAGEMENT
• Once diagnosed, it is impo•·tam to u-ace me location of
the testes and perfonn gonadectOm)'• because testes are
liable to undergo malignancy in 10%-30% cases. The
conu·ove1'Sial point is as lO when to perform gonadectomy.
lt is prefen·ed to remove the testes in puberty when tl1e
correct diagnosis is made ( 16-18 years).

SUPERFEMALE (TRIPLE X CHROMOSOME)

The presence of an extm X is not uncommon because it is
quite compatible with complete femin ine normali ty. There
is, however, a we ll-recognized u·ip le X syndrome in which
t11e patiem, who is often mentally subn ormal, suffers from
scanty or irregular menstruation and infertility. Clinical
examination ma) reveal hypoplasia of the genital tracL
The importance of chromosomal studies in such a patiem is
obvious. and iLS determination plays an imponam role in
me investigations and management.

MALE PSEUDOHERMAPHRODITE
Testicular feminit.ing S)ndrome, initially described by
No•·ris in 1953, is now designated as eit11er complete andro-
gen insensitivity S)•ndrome (CAIS) or pa•·tial androgen
insensitivity S)•nch-ome (PAIS), and t11is reflectS the aetiology.
incidence is 1:2000 to I :60,000.

AETIOLOGY
The peripheral receptOJ'S for testos•ero ne are absem or are
seamy or they fui l to respond to tes•oste•·one. The external
genitalia are of female phenotype. Chromosome is XY,
and the testes are located along its line of descent in the
abdom inal cavity o r in inguina l ca na l, and are maldevel-
oped. The Wo lffian d uct fa ils to deve lop because of absence
of tes tosterone recepLOrs. Testes prod uce MlF, so the
S)'Stem fai ls to deve lop. However, the lower por-
tion of tl1 e vagina derived from sinovaginal bulb appears
as a dimple of 1-2 em in length. There is often a strong
familial tendency to this disorder, and several cases may
appear in the same family and in different generations,
and tl1e condition is attributed to X-linked recessive
gene.
Unless there is a famil) history, or childhood inguinal
Figure 9.8 (A) Ambiguous genitalia In a child with XY karyotype
hemia comaining the testis, the condition is not diag- and partial androgen insensitivity. (B) Male pseudohermaphrodite
nosed until pu bert). The girl is t)•pically feminine and showing micropenis with labioscrotal gonads. (Source (A): Hack«
tall. The pubic and axillar)' hair are seamy, but the NF, Gambone JC , Hobel CJ, Hacker and Moore's Essentials of Obstet-
breasts are developed because of oestrogen derived rics and Gynecobgy, 5th ed Pl"iladelphia: Bsevier, 2010. Courtesy:
from peripheral comersion of androstenedione. The (B) Dr &mesh kuma-, AIIMS)
114 SHAW'S TEXTBOOK OF GYNAECOLOOY
• These patients will •·equire oestrogen therapy for the de-
velopment of the bt·easts and to prevent osteoporosis.
• If she plans to matT)', vaginoplasty should be done. If
sufficient length of vagina pt-evails, \'llginal dilators may
be effecthe in stretching its length.
absem
The reproducti'e function is not possible
O\'ll t·ies and uterus.
PARTIAL ANDROGEN INSENSITlVITY SYNDROME
ln PAlS, few receptors respond to testosterone, and the
clinical features are variable. Some presem at birth witl1
genitalia, and chromosome study reveals XY
chromosomes. Others presem at puberty with lack of
virilization in a boy, or signs of virilization in a girl with
ptimary amenorrhoea.
The treaLtnent is based on the sex in which the child
is reared, psychological behaviour and t11e amo unt of
virilization. If the chi ld is reared as female, it is best to
perform gonadectOm)' in childh ood to avo id virilization. ln
a boy, tes tosterone will help. T he reproductive function
rema ins poor.
ENZYME ERRORS IN ANDROGEN PRODUCTION
T he production of testosterone from the testes requires
enzymes, the most important of which is 5-alpha-reducrase.
This enzyme converts testosterone into DHT, which is
capable of acting on pel'ipheral target tissues to produce
male phenotype. Absence of this enqme results in female
phenotype and male pseudohermaphroditism.
MASCULINIZAnON
KLINEFELTER SYNDROME
Klinefelter syndrome is seen in I :500 males. The patiem
with this rare disorder external!) resembles a male in gen-
eral body conformity, the penis is smaU or normal in
size; the testes are small, but as a rule are normaUy placed.
Sterili ty is commo n, gynaecomastia is frequently present
(Fig. 9.'1 ), Lh e voice ma)' be high pitched, and me appear-
ance ma)' be e unucho id. The patient is often mentally
defective or deli nquent. Most of tl1ese individuals are sex
ch romatin posiLive li ke females because of t11e extra X chro-
mosome. Genetic ana i)'Sis reveals tl1e ir karyotype to be
47XXY. Tes ti cul ar b iopS)' usuall y reveals hya li ne dege nera-
ti on of the sem iniferous tubu les and overgrowth of Leydig
cells, as a result of whi ch sterility is so often the presenting
symptOm ( Fig. 9.9). Sole-to-p ubic lengLI1 is more than
nonnal. T he pe1'S0n should be bred as male and should n ot
be told about chromosomal abnonnality. Testosterone may
help. The breasts may need surgical excision.
VIRIUSM
Vit·ilism is charactet·it.ed by hirsutism and some of the male
appearances, and au·oph) of tlte breasts.
In patients exhibiting virilism. me chromosomal and
gonadal sex is female and the accessory sex organs of
Some breast
development
Very long
arms
)----.'4- Less-developed
testes
Figure 9.9 Klinefelter syndrome. Note the superficial ly normal male
genitalia, gynaecomastia and feminine distribution of the pubic hair.
Mullerian origin are also feminine. The external genitalia,
however, resemble the male.
CUNJCAL FEATURES
The body conformit) is largel) male wim good tmLSCular
development and broad shoulders. The voice is deep and
the Lll)TOid cartilage is prominent. Hirsutism is present tO a
remarkable degree, wit11 a male distl'ibul.ion of hair. The
psychological sex is often but not invariably male.
The external gen ita lia show hypertrophy of t11e clitotis
and fusion of the labia due to failure of the cloacal
membrane LO divide in congenital \'arieL)'· The vagina is
often absent if t11 e cause is congenital (Figs9. 10 and 9.11).
T he are un derdeveloped. O t11er s igns are frontal,
temporal and vertex baldness, hoarseness of voice, dimin-
ished size of breasts, hirsutism, cli tora l enlargement, acne
a nd ame no rrhoea. Ad re na l wm o ur and male hormo ne
secreting ova rian wmor are respons ib le for viril ism.
CUNJCAL VARIETIES
ADRENOGENITAL SYNDROME
Adrenogenital syndrome occut'S due to hyperplasia of the
adrenal cortex and is of two types. This condition is also
known as congenital adrenal hypet·plasia (CAH).
Congenital or Intrauterine Adrenogenital Syndrome
Congenital or intrauterine adrenogenital S)ndrome (CAS)
is the condition in which the p.-imary defect is a block
in L11e conversion of progesterone to deoxycorticosterone
due to ent.yme failure of21-h)drox)lase. The nonnal adre-
nal conex produces three C21 compounds: hydrocortisone,
 CH APTER 9 - SEXUAL DEVELOPMEN T AND DISORDERS OF SEXUAL DEVELOPMENT
Figure 9.10 Female hermaphrodite showing hypertrophy of
the phallus, masculine appearance of the glans and rudimentary
scrotal sac.
Figure 9.11 Patient with a catheter In the Immature vagina.
corticosterone and aldosterone and in addition certain an-
drogen Cl9 compounds. The production of 17-hydroxypro-
gesterone, which is mildl) androgenic in action, is con-
u·olled b) adrenocorticotropic honnone (ACTH), and
this, in turn. is controlled b) the reciprocal action of
hydrocortisone. If, therefore, the hydroconisone-ACTH
interaction is upset b)• a deficienq• of h)clrocortisone, the
pituitary gland produces an excess of ACTH, whid1 in
turn leads to adrenal co•·tical h) perplasia and excess output
11 5
of androgens, notably 17-hydrOx)'])I'Ogesterone. The main
androgenic activity of 17-hydroxyprogesterone is clue to itS
conversion imo 04-androstenedione and hence to other
onJ1oclox androgens. These androgens are responsible
for phallus of the female pseudohennaphrodite showing
hyperu·oph). the masculine appearance of the glans, and the
persistence fusion of the labia majora to resemble a scronun
(Fig. 9.10). The miniature vagina opens into the w·ogenital
sinus and the external appearance is that of a male
h) pospadias (Fig. 9.11 ). The diagnostic feature is the very
high value of 17-ketosteroids and I7-hyclroxyprogesterone
(>8 mg/ mL) exCI'eted. As expected, the chromosomal
pattern in these girls is XX. Ultrasound should be done to
look for ov;u·ian and ad•·enal tumours. Electrol)•tes should
be monitored, as there is a possibility of hyperkalaemia
and hyponatraemia.
The treaunent of this condition consistS in the adminis-
trati on of cortisone or hydrocortiso ne or the newer syn-
the ti c corticosteroids s ud1 as p red nisone o r p red nisolone
(2.5 mg twice da ily is an adeq uate mainte nance dose for
adu lt and will resto re tJ1e outp ut of 17-kewstero ids to
normal). T he con tinued use of tJ1ese d rugs carries ce11.ain
dan gers of adrenal defic iency d ue to s upp ressio n of ACT H,
and this especially operates at times of such as whe n
a patient needs an anesthetic. At tJ1ese Li mes, cortisone
coverage should be given to tide over the period of stress
(i.e. 1 clay before, on tJ1e day of operation and for 3 days
aftenvarcls). Dose of co•tisone is 0.15 mg/ kg in fo ur divided
doses for child. In a child with salt-losing condition, fludro-
cortisone 50-100 meg dail) witJ1 intravenous (i.v.) saline is
recommended.
The vulval abnormalit) is corrected by a small plastic
operation, and as a rule, it is wise tO amputate the
hype•·trophied eli to .-is between 5 and I 0 )ears of age.
Cliwroplasty with conservation of glans is preferred to
amputation. Fusion of labial folds should be con·ected
at puberty. Mena•·che is often dela)ed and fe•·tility is reduced
in these girls.
Cases of virilitation of the fetus in utero have been
•·eported following tJ1e use of progesterone in the pregnant
mother. Ln fuct. all synthetic progestogens except 17-
hyclroxyprogesterone have some degree of androgen ic
effect. Lf progestogen is to be used in p regnant woman it
should be devoid of any androgenic effec t.
T he effect on tJ1e fews depends largely o n the d uratio n
of th e pregna ncy a t tJ1e tim e of ad ministratio n and th e
dosage emp loyed . Lf p rogestogens are give n before the 12th
1.0 14 th weeks of gestation, tJ1 e neo natal picture may be
similar to that of the inu"ii utcrine ad renogeni tal syndrome,
i.e. enlarged p hallus and imperforate pe rin eal membrane.
T he viri lism is, nonprogressive.
Postnatal Adrenogenital Syndrome
This can be due to excessive output of ACTH from a baso-
phil adenoma of the anterior pituitary gland (Cushing syn-
drome) which gives rise to adrenal cortical hyperplasia. An
adrenal tumour that can be benign or malignam has
the same effect. An adrenal tumour is not depenclem on
influence of piwitaq gland. In an undiagnosed case, initial
accelerated skeletal maw ration is followed b)' early epiphy-
seal fusion and swnted height. Precocious puberty and
increased libido witJ1 aggressi'e beha,·iour is reponed in a
116 SHAW'S TEXTBOOK OF GYN AECOLOGY
few cases. Sterili ty is common. Cortisol th erapy can avo id
t11ese undesirable effects. Males witl1 this syndro me also
present with tl1ese feawres.
VIRILIZING TUMOURS AND OTHER CONDITIONS
OF THE OVARY
The virilit.ing nunours and other conditions of me ovary,
such as arrhenoblastoma, hilus cell ttunour, polycysLic ovary
and h) perthecosis, are cattSeS of ,-ir·ilism and produce a clini-
cal picture somewhat similar to the posmatal adrenogenital
syndrome and are due to excess of testosterone secreted by
me O\'<ll'): In tl1e posu1atal variety of vir·ilism, the genital tract
is nonnal, but tl1e eli to lis enlarges, t11e uterus atrophies wim
me resulting amenoni1oea, t11e voice deepens, hirsutism is
marked and tl1e breasts au·ophy. Excreti on of 17-ketosteroids
is raised only if t11e adrenal is hyper·plastic or neoplastic,
"11ereas with a virili zing ova ri an tumour, it is un altered.
TREATMENT
FEMALE PSEUDOHERMAPHRODITISM
• If the fau lt is an enzym e b loc k a t th e level of 17-
h)•drox)•progeste rone, th e adm inistra ti o n of cortiso ne
or S)'nthe tic co rticoste ro ids will effective !)' co ntro l me
excess prod uc tion of ACT H. T he ex ternal gen ita lia can
be restored to a fem inine pattern by p lastic surgery,
e.g. the formation of a n a rtifi cial vagina by Mcindoe's
operation. Cortisone therapy, if successful, may restOre
menstruation in a patient with ame norrhoea. It is
imponam in such patients to correct any anatomical
defects of tl1e lower gen ital tract in order to obviate me
complications of retained menstrual products such as
haematocol pos or haematometra.
• If tl1e vi r·ilism is due to a tumour, surgical remo,oal is
needed. This also applies to O\oa r·ian androgenic tumours.
• A regular maintenance dose of oesu·ogen is usually
effecth•e in restoring some of the secondat)' sex charac-
teristics, e.g. breast de,·elop ment. Additional intermit-
tent pr·ogester·one therapy prevents breast and uter·ine
malignancy.
• The most effective u·eaunent of facial hirsutism is shavi ng
and cosmetics.
INVESTIGATIONS AND MANAGEMENT
OF AN INTERSEXUAL PATIENT
In the determination of a patient's sex, t11e following inves-
tigations are req uired:
• Gene tic, chromosomal or nuclea r sexing. It is simple a nd
reliab le from a study o f buccal smear, skin biopsy or ne u-
u·ophil examination.
• The external ge nitalia sho uld be examined, preferably
tlllder anaest11esia, when, for example, a vagina may
be discovered concealed by t11 e fusion of labia majora.
Contrast radiograph) is sometimes helpful. Magnetic
resonance imaging (MRI ) is most he lpful in t11ese cases.
• Gonaclal biops) of testes in an apparent male.
• Laparotom)' or laparoscopic-directed gonadal biopsy in
an apparent female pr-o,·ides an opportunity for examina-
tion of intemal genitalia. The presence of rudimentary or
un derdeveloped MCdlerian structures strongly suggestS a
female sex. It is important to note that d t.u·ing a lapar<>·
scopic biopsy of a streak ovar), the ureter that is in close
proximity is vu lnerable to inju ry.
• Ultrasound is an altemative to laparoscopy. It may also
throw light on some accompan) ing Wolffian anomalies.
• Estimation of oesu-ogen, 17-ketosteroid$, testoSLer-o ne and
17-hydroX) pr-ogestemne in the serum or uline may be done.
Deh)ch-oepiandrostenedione (OHEA) level >700 meg/elL
and total testoster-one >200 meg/ elL is abnonnal.
• Estimation of senun elecu·olytes.
• l.v. p)elogram to detect any coexisting renal anomalies,
MRl for suspected adrena l n eoplasm, radiography of the
pituitary fossa and the skeleton.
• Psychological assessment of the patiem's sexuality.
The gynaecologist ofte n n eeds help of endocrinologist
and psychi auist before fin ally declaring the sex of the per-
son, the di agnosis and t11 e u·eaun e nt is best deferred till
puberty when an individual declares, i.e. Ute sex tOwards
wh ich the individual shows grea te r incli nation and atti tude.
During tltis co nsultati on, the parents sho uld be availab le as
the ir cooperation and inte ll ige nt supervision are vital for
the ultima te interest of an intersex individ ua l (Fig. 9. 12) .
HIRSUTISM
Hi rsutism is defined as t11e presence of coarse hair in a
female at sites norrnall) present in males, i.e. upper lip,
chin, chest. lower abdomen a nd thighs. Hi rsuLism may or
may not be associated witl1 menstrual disturbances such as
oligomenor·rhoea a nd amenorrhoea. VililiJ.ation refers LOa
condition of hirsutism associated with ot11er male character-
istics such as temporal baldness, hoarse voice, cliwromegaly
and muscle enlargement as well as such as
amenorriloea and breast au-ophy.
ENDOCRINOLOGY
In a woman, andr·ogens are secreted by the ovaries and t11e
adrenal glands in var-ying proportions. To some extent, t11 ey
are produced by tl1e periphe ral conve rsio n of a ndrostenedi-
o ne in tl1e fat. T he androgens produced are as follows: 25%
comes from tl1 e adr·enal glands, 25% from ova ries a nd rest
from t11e peripheral conve rs io n of androstened ione.
I. Testusteroue, 0.2-0.3 mg da ily - 50% comes fr-o m ovaries
(0.2-0.8 ng/ mL blood leve l) a nd re maining from adrena l
glands.
2. DHill\, 20 meg dail)' (serum level 130-980 ng/ mL) and
rest from adrenal glands.
3. Aru[r().)/enedume, 3 mg daily ( 1.5 mg from ovaries).
4. Delt)'droepiaru[I'O.)/erone sulfJitate (OH EAS), 0.5-2.8 mcg/ mL
(adrenal gland ). 1-1 igher levels sugges t possibility of CAH,
17-hydrox)progesterone >800ng/ d L is present in con-
genital adrenal h)perplasia (CAH ).
Testosterone is bound to serum ho nno ne-binding
globLLiin (SHBG). SHBG production in t11e liver is inhibited
by androgens a nd increased by oesu·oge n and th)-roid
horm one. Low oestrogen and th) roid hor·mone cause fall in
SHBG level, and mis results in some testosterone being
 CHAPTER 9 - SEXUAL DEVELOPMENT AND DISORDERS OF SEXUAL DEVELOPMENT
00 OC CC OC GC O t
ftOIIIN1F. 1'o101111'181F.
Rgure 9.12
The spectrum of sex: possible sexual aberrations in diagrammatic and tabular forms.
released into the blood circulation as free testosterone,
which can cause hirsutism. Similarly, obesity causes fall in
SHBG as well as more peripheral conversion of a ndrostene-
dione to testoster·one.
Ferriman and Gallwey desctibed a scoring system for
hi rsutism in nine body areas on a scale of 0-4 and quami-
fied h air growth. A score > 8 is labelled as hirsutism.
CAUSES OF HIRSUTISM
o Genet.ic and e tJ1ni c.
o Excess androgen o r increased sensitivity of the piloseba-
ceous unit to testostero ne
o Uver disease whe n th e SHBG level drops.
o Ovarian. Polycystic ovarian disease ( PCOD), hype rtheco-
sis, masculini:t.ing ova tian LLtmo urs, e.g. arrh enoblastoma,
hilus cellwmour.
• Adrenal. Congenital adrenal hyperplasia, Cushing
syndrome, adrenal wmour ( I %-2% cases).
• Dntlj,). Androge ns, progestogens witJ1 androgenic effect,
e.g. I 9-norsteroids, and levonorgestrel a nabol ic steroids,
phen)toin, da nuo l and minoxid il.
• 011ten. 0 besi L), h) po tJ1) roid ism, a novula LOry hypo-
oesu·ogenism, idiopathic- 15%, h) pe tprolact.inaemia.
o H imllism occun rarl)• in collgtmitfll ttdwwl h)perplasia,
arou11d puberl)• i11 PCOD a11d in eldl'rly womm aJ. 77Umopause.
11 7
....,
ftOM"'alf. ......
.......
_-
• • ••.. ••
_
.........
>ft.
-.... .. ..
- ----
--
o Idiopathic increased sensitivity of end organ to 5 alpha
reductase.
CUNICAL FEATURES
• PCOD accounts for 80% cases of hirsutism and is char-
acterized by oligomen orrhoea, obesity, hirsutism and
often infertility. Bo th ova ri es are enla rged and covered
with a thi ck, s moo th, fibrotic, pea rly wh ite capsule.
Mu lt.i p le sma ll cysts, 2-9 mm in size, are present at the
periphery of the ova ry, and tJ1 e ovarian s u·oma is
increased due to theca cell hype rp lasia. Ultrasound
reveals tJ1 e ovari a n mo rpho logy clea rl)', and diagnosis
can be acc urate I)' estab lished. LH level is raised even in
the preovulato ry phase of the menstrual cycle, ca using a
high Ll-1/ FSI-I ra tio (mo re tJ1 an 1). This resulrs in
anovulat.ion a nd high oestrogen level, b ut abse nce of
progesterone. About 50% of wome n with PCOD will
show raised leve ls of androgens (testostero ne, a ndro-
stenedione and DH E.A ). Testostero ne level al th o ugh
raised. remains below 200 ng/d L, unlike t11at in ovarian
tumolu· (see also Chapter 24).
• Masculinizing ovarian tu mours callSe defem inization
such as breast au·oph) and amenot-rhoea besides hirsut-
ism, hoarseness of voice and muscular clevelopmenL
Clinical examination may noL always detect small tumour.
118 SHAW'S TEXTBOOK OF GYN AECOLOGY
Laparoscopy. ultraso und and MRI may be required to
locate the tumour. Testoste rone level is raised above
200 ng/ dL Removal of the uamo all' restores u1e men-
strual cycle, but hoarseness of voice and existing hirsut-
ism ma) require appropriate managemenL
• Congenital adrenal hyperplasia is diagnosed a nd u·eated
before pubett). It is due tO deficiency of e nzpne 21-
hydrox) lase. 17-H)drOX) progesterone plasma level is
raised more u1an 8 ng/ mL Coa·tisol deficiency occurs at
times of stress. To diagnose, dexamethasone suppression
test is done by giving I mg of dexameu1asone at nigluand
studying a single plasma conisol level in u1e morning.
The level should be less than 130 nmoi/ L (100 meg)-
u1is test has low fa lse-positive finding. Computed tOmog-
raph)' (CT) scan of abdomen and pituita•)' fossa may be
required.
• Cushing syndrome occurs d ue to overprod uction of
ACTH by pituitary gla nd o r ad renal tum o ur. T he diagno-
sis is estab lished b)' dcxa me u1 aso ne suppresio n test,
ACTH level estim ati on and CT sca n of u1e p ituitary and
adrenal gla nds. DHI.!:A and androste ned io ne levels are
raised in this S)•ndro me.
• Hyperprolactinaemia may be due to e nlargement of the
pituitar)' gland or d ue to a pituit<ll")' tum our. Prolactin
levels exceed 100 ng/ mL An MRI will he lp in me diagno-
sis; mild hyperpro lac tinae mia occ urs in PCOD.
INVESTIGATIONS
HISTORY
The onset and speed of progression he lp tO detennine ilie
cause of hirsutism and viri lism. Change in the voice, breast
au·oph) a nd amenorrhoea indicate defeminization <md
possibility of an O\<at·ian tumour. History of dmg intake
should be ellicited. Infenili t)' ma)' be due to <movulation,
and points towards PCOD.
EXAMINATION
Degree of hirsutism should be noted, including any change
in voice. Breast palpation, search for any abdominal
tumour, clitor-al enla r-gement and pelvic mass by bimanual
examination sho uld be ca rri ed out.
HORMONAL STUDY
T his includes swdy of testoste rone, DHEA and androstene-
dio ne levels a nd that of Ul)•roid horm ones. PreovulatOry LH
and FSH levels need to be estim ated. In PCOD, LH level
exceeds 10 IU/ L; tes toste ron e > 2.5 nmoi/L and SHBG
< 30 nmol/L. Testosterone level > 6 nmoi/ L is seen in
ovarian tumour and hype rthecosis. Noamal prolactin level is
up to 25 ng/ mL. Cortisol level sho uld be < tOO mcg/ mL
In adrenal twnolll; DH E.AS levels are raised > 700-
800 meg/ elL. It is a better estimate u1an 24ho ur urine
estimation of 17-ketosteroid.
17-Alpha h)drox)progesterone > 800 ng/dL is seen
in CAH. and plasma testosterone > 200 ng/dl is see n in
O\'llt·ian and adrenal wmours.
ULTRASOUND SCAN
lunay help tO detect an O\<aa·ian tumoua; PCOD and adrenal
tumour.
CT scan and MRI are needed in case pitui tary or adrena l
tumOLLJ' is SLLSpected.
Lap<troscopic visualization of pelvic organs, dexameula-
sone and ACTH tests are often necessary.
MANAGEMENT
1. Treat the cause. Remo,<al of ovaaian and adrenal tumour
stop furmer hirsutism. Existing facial hair needs
treatmenL Viailil<ltion will cease following removal of a
masculini.t:ing ovat·ian tumour, but hoarseness of voice
may persist. Menstrual cycles are restored and breasts
stan growing. This is preferably done under video pelvi-
scopic vision. Infet·tility will n eed ovulati on induction
drugs, and an older woman sh ould receive cyclical pn>-
gestogen u1 erapy to prevent endometria l h yperplasia
and cancer developing from unopposed oesu·ogen
stimul ati on. Metformin 500 mg t. i.d. for 8 weeks reduces
hyperinsulinaem ia seen in PCOD.
2. Drugs. Dexa me u1asone 0.25-0.5 mg da ily a t night will
conu·o l adre nal hype rp lasia if DI II.!:A is raised. Sometimes
combined om I co nu·aceptive pills (OCI)s) may be needed
in additi on to dexamethasone to suppress androge ns.
Suf>jmssion of wiiJ1 co mbined OCPs not co ntain-
ing androgen ic progestogen such as noreiJ1isterone and
levonorgesu·el will suppress ovarian androgens. Oestro-
gen is not only antiandrogenic b ut by stimulating produc-
tion of SHBG will bind circulating free testosterone to
SHBG. Ullls suppressing its peaipheral ac tion on u1e hair
follicles. Antiandrogens used are ( I) spirono lactone and
(2) C)'Pl"Oterone acetate.
• Spironolactone in a dose of 100-200 mg daily blocks
u1e androgen receptors, reduces its production and
increases its metabolism, and thus prevents hirsutism
in a furmer 60% of cases. It is best given wim combined
oral pills to a,·oid irregular menstruation, and prevents
conception, mlLS preventing possible feminiL.ation of a
male fetus, lest the woman concieves. The side effects
include transient diuresis, menstrual itTegula•·ity (poly-
menonilagia I 0%) and breast enl argement. Occasion-
all y, hyperkalaemia and hyponatraemia may ocelli:
Maintenance dose after 6-12 months is 50-mg spirono-
lactone wi u1 OCPs (sec also chapter o n Ho nn on al
T herapy in Gynaecology). Drospireno ne 3 mg wiu1
30-mcg oesu·ad iol (Yasmin, Janya, and Tarana) used
cyclically for 3 weeks is found very effective in h irsutism
in PCOD.
• Cyproterone acetate is a pote nt progestOgen wiu1
antiandrogenic ac tivity, a syn iJ1etic detiva tive of 17-
alpha-h)'droX)'pl"Ogesterone; it inhibits DHT binding
to its receptors at the periphe ry and has a weak corti-
costeroid effec t. It is given co mbined with oestrogen as
50-100-mg cyproterone da ily for u1e first 10 days of
the menstrual cycle wiu1 30-50 meg of e u1in yl oestra-
diol (EE) for 21 days. After 6- 12 mont11s, a maime-
nance dose of 5- 10-mg C)proterone acetate wiu1 EE
will be effective in preventing recurrence of hirsutism.
The effect becomes apparent after 4 months of treat-
menL Oral co nu-aceptives regulariLe u1e cycle and pre-
vent pregnanq'. Oesu·ogen presem in me pills avoids
menopausal S)tnptoms and also raises me serum
hormone-binding capacity, which bincls me ft·ee
 CHAPTER 9 - SEXUAL DEVELOPMEN T AND DISORDERS OF SEXUAL DEVELOPMENT 11 9

androge ns a nd red uces ins ulin -li ke growth factor. Side
e ffects are we ight gain , nausea a nd headache, rarely
liver da mage.
3. Weight reduction will increase SHBG levels and bind free
testoste rone, thus red ucing its peri pheral actio n o n hair
fo llicles.
<l Cosmetics. Bleaching, waxing, shaving and lase r are
useful in removal of facial hair. Electro lysis is high ly
satisfactOI) ' in treating hirsutism.
5. New drugs ava ilable are
• Hut.amide (nonstero idal) 250 mg b.d. for 3 wee ks
C)clicall y with oral contraceptives for 6 months blocks
tl1 e androgen effec t at th e rece pto r leve l. Side effects
are d ry skin, o ligo rneno rrh oea and live r da mage. It is
faster ac ting than spiro no lacto ne.
• 5 mg dail) for 6 mont11s blocks tl1e conversion
of testostero ne to potent and rogen and is safer than
flutam ide. It red uces conversion of testostero ne LO 01-IT.
• Dutaste•·ide (AVODART), 5-reduetase inhibitor, is
under uial.
Pol)C)'S ti c ova.-ian d isease is detailed in d1apter on
Diseases of th e Ovary. Summa•)' of causes and management
of hirsutism is explained in Table 9.2.

Table 9.2 Summary of Causes and Management of Hirsutism

Cause Mech anism Diagnostic Information Treatment

Ovarian Androgen-producing • Rapid progress • Surgical excision of functioning

androgens tumours (Sertoll, Leydig • High testosterone level tumour
cell, hllar cell tumours) • Pelvic mass present
• Clitoromegaly
Polycystic ovary syndrome • Long -term duration • Oral oontraceptlve pills, antlandrogens
• Mild elevation of testosterone • Weight control
• Elevated LH/ FSH ratio • Metformln
• Anovulation • Changes in lite style
Infertility Laparosoopic ovarian drilling
Irregular menstruation/amenorrhoea Assisted reproductive technology
Obesity (ART) procedures
Luteoma of pregnancy/ On set during pregnancy Conservative management
theca lutein cysts
Adrenal Androgen-producing Rapid onset Remove tumour
androgens tumour High DHEAS
Abdominal mass present
Clitorornegally
Congenital adrenal Elevated serum 17-dihydroxy Gluoooorticoid replacement and
hyperplasia (late onset) progesterone suppression
21 -hydoxylase deficiency
Cushing syndrome • Elevated plasma oortisol Varies as to cause
Exogenous • Honnonal drugs • Methyltestosterone • Withdraw offending drug
androgens • Anabolic steroids
• Danazol
Hair toll icle • Excessive conversion • Long duration • Spironolactone
sensitivity of DHT In hair follicle • Fam ily history • Cyproterone acetate
• Racial t rait • Flutam lde
• Depilatories
• Electrolysis
• Cosmetic treatments - waxing/shaving
Exogenous • Nonhormonal • Phenytoin • Withdraw offending medications
causes of medications • Diazoxide
hypertrichosis • Minoxidil
• Streptomycin
Penicillamine

Pathological states Hypothyroid! sm Treat the cause

Anorexia
Dermatomyositis
Porphyria

Nonnal states Old age Observation

Ethnic trait Cosmetic therapy
Pregnancy
120 SHAW'S TEXTBOOK OF GYNAECOLOOY
ACNE
Acne is a mild form of hirsutism seen in young girls. This
should be treated with Dianette pill containing 35-mcg £ 2,
2-mg C) proterone acetate starling on the first day of cycle
for 21 days in each C)cle. Cimelidine 1.5 mg daily also helps,
but it can cause galactorrhoea and the drug is very expen-
sive. Vaniqa (enornitlline) 11.5% cream is also effecLive;
anLibioLic creams such as clindam> cin I%, erythromycin 2%
and also help. Vaniqa cream is applied twice daily
for 24 weeks - some develop allergic dermaLilis and mild
burning sensation.
• lsou·e tinoin suppresses sebaceous gland secretion.
• Dutasteride (Avoda tt) is 5-alpha-red uctase inhibitor is
under u·ial. It inhibiLS DHT production in 99% cases. It is
con u·aindicated in pregnanC)'·
TRUE HERMAPHRODITE
True hermap hrod ite is an individua l with ovotestes or ovary
on one side and testes on tl1e o tl1er. The uterus and vagina
develop and tl1 e person menstruates. In add ition, tl1e exter-
nal genitalia is of male phenotype. The individual is brought
up as a ma le until puberty, so it may be prudent to retain the
ma le gender and do mastectomy and hysterectomy. TestOs-
terone therapy helps to develop secondary sexual charac-
ters of the male phenot)'pe. Plastic surgery on the phallus
may be required, and sexual function is possible. Fertility,
however, may remain low.
PSYCHOLOGICAL SEX
Homosex ualit), transvestism and transsexuality are ab-
not·mal sexual behaviour. Transsexuality is defined as a
disturbance of gender identit) in which a person ana-
tOmically of one gender has an intense and persistent
desire for medical, surgical and legal change of sex and
lives as a member of the opposite gender. These are psy-
chosexual patienLS and need careful handling and a lot of
co unse lli ng before taking and accepting the individual's
decis ion. lni tia ll)'• hormone therapy fo llowed b)' surgery
will be needed to reconsu·uct the bod)' phenot)•pe of the
desired gende r. Oestrogen for a male and progestogen
for a fema le will red uce th e seco ndary sexual characters
ove r a pe ri od of 1-2 )'Ca rs. Th is makes reconstructive
surge ry easie r, apan fro m th e fac t th a t it g ives the indi-
vidua l LO assert her/ his decision over the change of sex.
KEY POINTS
• Intersexuali ty is a difficult gynaecological problem to
tackle because the condition is extremely rare and the
experience of a g,naecologist is limited.
• Detailed kllO\,iedge on genetic sex, honnonal innuences
coupled \,itJl imestigations are required to make the accu-
rate diagnosis and conduct the appropt·iate managemenL
• Hirsutism is now increasing!)' encownered in )Oung
women as tl1e incidence of PCOD has increased.
Otl1er causes are idiopatl1ic, adrenal, ch-ug adminisu-a-
tion, hrpoth) roidism and h) petprolaclinaemia.
• Ultrasound and hormonal profile stud) are necessary.
• Vatious dntgs used in hirsutism are C) proterone acetate,
spironolactOne, finastetide and combined hotmonal pills.
• Acne is a cosmetic problem and demands treaunem.
• VarieLies of intersex now can be diagnosed based on
chromosomal Sllld). Surgical management allows an
individual to li\e neaNlOnnal life as possible.
• Vitilism requires immediate management; otl1erwise,
certain features wi ll persist despite treat·
ing the cause. These persistent fealtlres are deepening of
voice and baldness.
SELF-ASSESSMENT
I. Describe the phenotypic appearances of individuals with
sex chromosomal abnonnalities.
2. Enumerate tl1e components conuibuting to determina-
tion of sex.
3. What are the common causes of hirsutism? Describe
their managemenL
4. Describe the features of Sw)er S)ndrome, Turner syn-
drome and Klinefeltct· S)ndrome.
5. Define Vit·ilism. Describe iLS clinical feawres, trpes and
managemem of this disorder.
SUGGESTED READING
Ehnnann DA. Pol)'C}">tic o"''"Y syndrome. N Eng J Mc-d 2005;352:
1223-36.
lliorl 0, Birnbaum W, Marshall L. Wtlll>Ch L, R, SchrOder T,
Cl al. of disordct> of sex 1at End<r
crinol. 20 14; 10(9):520-9.
Linden MC, Bender llC, Robin>on A. diagnosis of sex
chromosome aneuploidy. Obstct Cynccol 1996;87:468-75.
Norman comparison with other chcrapit:s in ovulation
induction in polycystic ovary J Clin End()(:rinol Metab
2004;89:4 797.
Ostrer II. Disorders of sex development (DSDs): an update.] Oin En-
docrinol Me tab. 2014;99(5): 1503-9.
Spero!TL, Fritz MA. Oinical Gynecologic Endocrinology and Infertility.
8th ed. Philadelphia: Lippincott Williams & Wilkins, 2011;331-389.
Speroff L, Frit1. MA. ll ir.mtism in Clinical Gynecologic Endocrinology
and In fertility. 7th ed. Philadelphia: Lippincott Williams & Wilkins,
Studdj. PrOj,'T"SS in ObMetric;,and GynaccoiO)O'· 3:197.
 DISORDERS OF
MENSTRUATION

1 0 Common Disorders of Menstruations 13 Fibroid Uterus

11 Abnormal Uterine Bleeding (AUB) 14 Endometriosis and Adenomyosis
12 Primary and Secondary Amenorrhoea 15 Hormonal Therapy in Gynaecology

121
 Common Disorders
of Menstruation
Menstrual Cycle Irregularities 122 Dysmenorrhoea 124
Heavy Menstrual Bleeding (HMB) 122 Premenstru al Syndrome 126
Oligomenorrhoeo and Hypomenorrhoeo 123 Key Points 127
Polymenorrhoea or Epimenorrhoeo 123 Self-Assessment 127
Metrorrhagia 123
MENSTRUAL CYCLE IRREGULARITIES
Mensu·uation is the e nd po int in a series of evenrs wh ich
begins in the cerebral co n ex and hypothalamus and ends at
t11e uterus in t11 e h)'j)Otha lamic-pituitary-ovarian-merine
axis. An y break in this axis creates me nsm..al problems.
Excessive o r inappropriate ly timed mensLruauon and
amenoni1oea are the most commo n co mplainLS for whid1
women seek advice from medical healtll ca re providers.
As described in Chapter 4, no tmal mensu·uauon requires
imegratio n of the h) pothalamic-piLUitary-ov:uian (H-P-0)
axis with a functional uterus, a patent lower genital outflow
u-act and a nonn al genetic kat')Ot)pe of46XX.
Abnormal mensu·uation can be a harbinger of a sinister
pelvic pathology or denote a relatively minor problem;
therefore, a thOt"'ugh investigation into the problem is
called for in eve•')' patient presenting with this complaint.
ln nonnal healt11y women, menard1e occurs between t11e
age of 10 and 16 yea rs, mea n age of menarche being around
12.5 years. Cyclic menSU'U(Itio n persists tJuu ughout the repi"'-
ductive era oflife with an average rll)1.hm of28:!: 7 inclusive
of 1-6 da)s of bleecUng (except pregna ncy and lactati on) . It is
not uncommon for minor valiations to occ ur fi'Om time to time.
24-38 of -9 > 8-10
8
days
VARIOUS TYPES OF MENSTRUAL CYCLE IRREGULARITIES
Except amenorrhea rest are th e disca rded termino logy not
used now a days.
• Amenorrhoea indicates th e abse nce of menstruation. It is
a sympto m and not a disease entity.
• Oligomenorrh oea denotes infreq uem and irregularly
timed episodes of bleeding usually occ urring at intervals
of more than 35 da)S.
• Polymenorrhoea denotes frequent episodes of mensuua-
tion. usuall) occun·ing at ime r·va ls of 21 days or less.
• Menorrhagia denotes •·egularl)' timed episodes of bleeding
thata•·e excessh·e in amou nt (> 80 mL) and/ or duralion of
flow (> 5 days).
122
• Metrorrhagia refers to irregularly tim ed episodes of
b leeding superim posed on norma l C)'Ciical bleeding.
• Menometrorrhagia means excessive and prolonged b leed-
ing thatocctu·s at irregularly timed and frequent intervals.
• Hypomenorrhoea refe rs to regularly timed but scanty
episodes of bleeding.
• Intermenstrual bleeding refers to bleeding (tLSttally not
excessive) that occurs between otherwise no nnal men-
s Lrual cycles.
• Precocious menstruation denotes the occurrence of men-
struatio n before the age of I0 >ears.
• P ostcoital bleeding denotes ' oagina l bleeding after sexual
imercourse.
HEAVY MENSTRUAL BLEEDING (HMB)
The term ' heavy mensLrual bleeding' defined as excessive
blood loss intet·fe.-ing with physical, socia l, emotional
and or material quali ty of life. It is ge nerally ca used by
conditions affec ting the uterus o r its vascula tity, rather
than any di swrbance of functi o n of th e H- P- 0 axis.
Whenever the uterine e ndo me u·ial s urface is e nlarged, the
b leeding surface is increased, conu·ibuting tO excessive
b leeding. Such co nditi o ns preva il in uterine fibroids, ade-
nomyosis, uterine pol)'pS, myo hype rplasia and e ndometria l
h )'perplasia.
HMB is also see n in wome n wi l11 increased uterine
vascularity such as in chronic pelvic innammatO t')' disease
(PIO) and pelvic e ndom euiosis. The uterus is often reu·o-
verted in position with restricted mo bilicy. Such a utenLS
tends to be bulky and co ngested. The presence of an intra-
utedne conLraceptive device (IUCO) ofte n leads to
and prolonged bleeding. Lastl), menorrl1agia may be the
result of bleeding diso rders like Von Wille brand disease or
an arteriovenous aneUI')Sill.
A normal mensuual blood loss is mL and does not
exceed 100 m L. ln menot-rhagia, the me nstrual C)cle is
unaltered, but the duration and quantity of the mensuual
 CHAPTER I 0 - COMMON DISORDERS OF MENSTRUATION
loss are increased. Menorrhagia is essentially a symptOm
and not in itself a disease. It affects 20%-30% of women at
sometime or other with significant adverse effects on the
quality of life in terms of anaemia, cost of sanitary pads and
interference witJ1 da)·to-da) activities. Several causes may
prevail in a few cases and attribute to excess bleeding. ln a
few cases. the underl) ing cause may be difficult to detecL
OLIGOMENORRHOEA
AND HYPOMENORRHOEA
OUGOMENORRHOEA > 38
days
ln some women, the pauem of menstruation extends to
cycle lengths exceeding 35 days without any impairment of
th eir fertility. This is compatible with normal reproductive
capacity within the limits of its own infreq uent ovulation, so
it requires no trea tm ent. lloweve r, if the cycles are very er-
ratic and infreq ue nt, medical auemion is called for. T he
causes and findings of cli n ica l inves ti gati ons are similar to
those of amenorrhoea. Many of these women are obese,
hirsute with poorly deve loped secondary sex ual charac-
teristi cs, gen ital hypop lasia and ova rian s ubfunction.
Amenorrhoea is often tJ1 e contin uu m of o ligomenor-
rhoea. T his condition is often enco untered in women at
the extremes of reproductive life and in some lactating
women . Other causes are genital tuberculosis and poly·
cystic ovarian disease.
HYPOMENORRHOEA
ln some women, mensu·uation lastS for only 1-2 days, and
ilie blood loss is so scanty tJ1atshe ma)' need a change ofjust
one to two sanita•y pads. Scanty menses, which is otherwise
regular, may not be pathological because its regularity pre-
supposes a normal H-P-0 relationship. ln these women,
ilie ute•·ine end organ may be at fuult. A small hypoplastic
uterus, genitaltube•·culosis and panial Ashennan syndrome
also cause hypomenorrhoea and need investigation and
treatment. Oml fJills t1lso cause hypomenoniwea.
Scanty periods may precede menopause.
POLYMENORRHOEA OR EPIMENORRHOEA
Women with polyme no rrhoea (epime no n·hoea) suffer from
shorte ned C)'Cies. Meno rrhagia often goes hand in hand
witJ1 this comp laint. It is more freq ue nt in ado lescent girls
and in perimenopausal women. The exact aetio logy of this
problem is not known. In most of these women, the fo llicu-
lar phase of the cycle is acce lerated, resul ting in shorter cy-
cles. The ovaries often appear hyperaemic and may contain
haemorrhagic follicles. Myohyperplasia of the uterus is a
common accompaniment. The lining endomeu·ium is gen-
erally of nonnal tJ1ickness; however, in women suffering
from pol) menorrhagia, the lining endomeuium may ap-
pear thickened. The caLtSe of ovarian seems to
be the result of a disturbed endocrine axis.
Pol)lnenorrhagia is frequent!)' observed when women
resume menstrual acti,·ity after a delivery. lt is aw·ibuted
to the persistence of the activity of ilie anterior lobe of the
123
pituitary gland initiated d uring pregnancy into the post-
natal phase. The excessive stimulation by the gonadotro·
pins causes frequent ovulation and menstruation. ln a
substantial number of women, associated pelvic pathol-
ogy, such as PI 0, endometriosis and fibroids, is also en-
coLuuered. Treaunent should then be directed LO the
caLlSe. When no definite caLlSe is identified, u·eaunent
with C)•clic honnone therap) restOres the nonnal men-
strual pattem.
METRORRHAGIA
The preferred tenn 'intennensu·ual bleeding' is used LOde-
fine any acyclic bleeding from tJ1e genital tract. ln su·ict
terms, the term should be rcsu·icted LO bleeding atising from
the uterus only. The bleeding may be imennittem or con-
tinuot.lS. It is superimposed o n a norm al mensu·ual cycle.
lnterme nsu·ua l bleeding may be physiological, occ urring
at the ti me of ovula ti on when horm o na l changes u·iggering
ovulati on take p lace. T hese women complain of mid-
menstrual bleeding (Miue lsc hm erz) from a few
ho urs to l da)', a profuse sticky discharge and ime nn ittent
cramping pain of short duration. These episodes coinc ide
wiili ovulation, and this fact can be confi rmed by ba.'\al bod)'
temperature (BBT) charts/ sonograp hy. All that is req ui red
is to provide an explanation to tJ1e patientofthe underlying
cat.lSe and alleviate her anxiet)'· 1\ fnv 1rumths of combined oral
jJills will cure ovulfllion bleed.
Particular!) in elder!) women, postcoital bleeding should
not be bt"LlShed aside lightl). It ma) be the earliest sympwm
of a neoplasm; a meticulous search should be instituted LO
exclude such a possibilit). Besides a tJwrough clinical ex-
amination of tJ1e lower genital u-act, speculum examination
of ilie cen·ix in good light for a pol)p, vascular erosion,
endocervicitis, cancer of the cen ix and ilie presence of an
l UCD should be looked for, along with lower genital tract
ulcers and growths. A Pap l711f'(lr l'xamintJiiQn should be ol>-
tained. A diagnostic h)Steroscopy and an endomeu·ial curet-
tage for histological study of tJ1e endometrial tissue a•·e im-
portanL A pelvic sonog•-aphy to evaluate the pelvic organs is
recommended. Refer to Table I 0. 1 for a brief summ ary of
the types of uterine bleeding.
Table 10.1 Types of Abnormal Uterine Bleeding
Te rms In Clinical
Usage Menstrual Patte rn
Oligomenorrhoea Cycle length > 38 days
Polymenorrhoea Cycle length < 24 days
Menorrhagia Increased menstrual flow/Increased
duration at regular cycles
Hypomenorrhoea Scanty bleeding and shorter days of
bleeding
Metrorrhagia lrregulel' bleeding In between the cycles
Menometrorrhagia Increased menstrual flow as well as
lrregulel' bleeding between the cycles
124 SHAW'S TEXTBOOK OF GYNAECOLOGY

2. Congestive d)•smerwrrlwea manifests as increasing pelvic dis-

DYSMENORRHOEA
DEFINITION
Dysmenon·hoea means cramping pain accompanying men-
su·ualion.
AETIOLOOY
Patients can be classified imo groups for understanding t.he
palhogenesis of this distressing condition.
TYPES
I. Priiii{J')' LO the one that is not associated
"1th any iclent.ifiable pelvic It is now clear that lhe
pathogenesis of pain is aw·ibuted LO a biochemical det·ange-
ment. It affects more than 50% postpubescem women in
the age group of 18-25 )'Cars with ovul a to ry cycles.
2. SecondriYy refers LO the one assoc iated with
the presence of o rga ni c pelvic pathology, i.e. fibroids,
ade nom )•Osis, PID and endome u·ios is. Un ilateral d ys-
menorrhoea occ w'S in a rudimentary ho rn of a bicorn u-
a te uterus. It is also seen in some women wearing IUC D
and in cases of cervical stenosis.
VARIETIES
Dysmenorrhoea is described under three clinical varieties:
I. SfX1S11UXIic d)'S1111!1Wrrlwea is the most prevalent one and
manifests as cramping pains, generally most pronounced
on Lhe first and seco nd da) of mensuuat.ion.
comforL and pelvic pain a few days before the start of men-
ses. Thereafter, Lhe patient rapidly e xperiences relief in
spnptoms. This is commonly seen in PLD, IUCD
wearers. pehic a nd fibroicl5. It is also experi-
enced b) women ha' ing varicosit) of pelvic veins.
3. Membmnous dysme110rrlwea is a special group in which lhe
endomeLrium is shed as a cast at the Lime of mensu·ua-
Lion. The passage of the cast is accompanied by painful
uterine cramps. This is a ra re \>ariety.
AETIOLOGY OF PAIN (Fig. 10.1)
Spasmodic pain is atuibuted to myom euial conu-act.ions due
to ina-eased PGF2a secreted under progesterone elfecL In-
creased peristaltic action is seen in the subendomeu·ial zone
on ulu-asound scan and this ca uses myometrial activity. The
pehic venous congestion as recognized o n Doppler ultrasound
explains congestive ctysme nord1oea. Reli ef from dysmenor-
rhoea foll owing cervical di latatio n and vaginal deli vet)' is at-
tributed to da mage to sympa the tic ne tves around the cervix.
Vasopressin by increasin g sec re Lion in prima t) '
d ysmenorrhoea is a lso he ld responsible. Similarly, endothe-
li n b)• increas in g conLribuLes to d)•smeno rrhoea.
CUNICAL FEATURES (Table 10.2)
Primary dysmenorrhoea is widely prevalent; more than 50% of
teenagers and 30%--50% of mens u·uating women suffer from
varying degrees of discomforL The severe incapacitating type,
which imetferes with a woman's daily activities, affectS only
about 5%-15% of Lhe population. Its is higher
amongst lhe more intellige nt and sensitive working<lass

@Pain
(a) f Ulerine activity
(b) Uterine ischaemia
(c) Sensitization of nerw
terminals to prostaglandins
and endoperoxldes

i Reduced blood flow

(Ischaemia)
0

luteum
'\._ /1
@
CD Progesterone v Increased
myometrial
(Menst7ualflow) contractions

®f Prostaglandins
+
Endoperoxides
+
Metabolite
Rgure 10.1 Postulated mechanism in the generation of pain in dysmenorrhoea. (Souroe: Hacker NF, Gambone JC, Hobel CJ. Hacker and
Moore's Essentials o f O>stetrlcs and Gynecology, 5th ed. Philadeptlia: Bse'wier, 2010.)
 CHAPTER I 0 - COMMON DISORDERS OF MENSTRUATION 125

Tab le 10.2 Differentiating Featwes of Primary and Secondary Dysmenorrhoea

Differentiati ng Featu res Prim ary Secondary

Onset Within 2 years of menarche 2()...30 years, maybe pre· and postmenstrual
Description Cramping -hypogastrium, back, inner thighs Variable dull ache
Symptomatology Nausea, vomiting, diarrhoea, headache, fatigue Dyspareunia, infertility, menstrual disorders
Pelvic findings Normal Variable, depending on cause
Aetiology Excessive myometrial contraction, ischaemia, excessive Endometriosis, PIO, adenomyosis, fibroids,
prostaglandin production pelvic vein congestion
Management Reassurance, analgesics, NSAIOs, antispasmodics, OC Treatment directed to the cause
pills, in rare cases, surgery- Cotte's operation or tap·
aroscoplc uterosacral nerve ablation (LUNA)

women. Both local a nd syste mi c sympwms a re appare ntly ti1e
result of increased levels of prostagla nd ins (F.p) in ti1e me n-
s trua l fluid. T hi s results in ltle rine c ramp ing, na usea, vomit-
ing, backache, di a n·hoea, g idd iness, syncope a nd fainting. it
is respons ible fo r tJ1e hi g hest incide nce of absem eeism, re-
s ulting in loss of work ho urs a nd eco nomic loss.
Primary d)'Smenorrh oea occ urs in ov ulatory cycles;
hence, it makes its appea rance a few years after menarche
with at least 6-12 mo nths of pain less petiods. it is most in-
tense on the first day of menses and progressively lessens
with mensLrual flow. It often lessens with passage of time
and after childbirth. Pelvis findings are normal. Pain may be
accompanied b) nausea , vomiting, headad1e and fainting.
INVESTIGATIONS
ln women suffeting from secondary dysmenot·rhoea, tests LO
confinn the clinical diagnosis and unravel the extem and
type of underi)ing pathology should be canied ouL These
commonly include the following:
• Pelvic sonogt-aphy followed by cr
scan or MR1 scan, if
indicated
• Diagnostic h ysterosalpingogram / sonosalpingogt·aphy
• Endoscopy- diagnostic h yste roscop y/laparoscopy
TREATMENT
11-eaunent inc ludes co unse lli ng, psycho the rapy to mod i£)•
patient's pe rcep ti on of he r proble m a nd a lte r behavio u ra l
a ttitude, medi cal measures a nd s urg ical ime rve m io ns .
MEDICAL MEASURES
Therapy for primary dysmenorrhoea co ns istS of measures to
relieve pain and suppress ovu lation if the woman desires
conu-aception additiona lly.
• Analgesics such as paracetamol 500 mg t.i.d./piroxica.m
20 mg b.i.d.
• Antispasmodics such as h)OSCine (Buscopan) compounds
Li.d./cam)lofin (Anafo•tan) Li.d./drotavet·ine (Drotin)
Li.d., diclofenac Li.d.
• Prostaglandin S)ntheta.se inhibitOrs are C)clooxygena.se
inhibitors. o nsteroidal anti-inflammatorydrugs (NSA!Ds),
s uc h as mefe nami c acid 250-500 mg/ q. i.d., provide
relief in 80-90% cases. I nclom e th ac in 25 mg three to
s ix times dai ly provides re lief in 70 % cases. Naproxen
275 mg t.i .cl. re lieves abo u t 80% cases/ kewprofe n
50 mg t.i.d. is s uccessful in 90% cases. ib uprofen
400 m g 6-8 ho urly is a lso effec tive. T he advantage of
the above reg im es is Lhat med ica tion is restricted to
the symptom days a lone, and it does not interfere with
ovulation. Me lox ica m has no gastric side effectS. The
side effects of these drugs are na usea, vomiting,
blurred vision, nephrotoxicity and gasLric ulcer on
prolonged use.
• Glyceryi u·iniLrate ( niLrogi)Ce rine) , a nilt'ic oxide donor,
relieves pain b) relaxing smooth muscles of the uterus.
• Progestogen-containing I UCD Progestasen)
relieves pain in addition to pro,·iding conu-aceptive mea-
sures and reducing bleeding.
• O ral conu-acepti,es (0Cs) administered C)clical iy sup-
press ovulation and are useful in relieving dysmenor-
rhoea. The advantages of regularity of pe•iods, modest
bleeding and desir·ed conu-aception make this the treat-
ment of choice in many young women. The drugs also
cw·e Miueischm er1. pain.
• Pe lvic endomeuiosis may be u·eated with increasing doses
of dana:wi/OCs/gonadou·opin-releasing honnone GnRH
agonists (ie upro li de, busere iin a nd nafareli n ).
• Vitamin E, 200 mg b.i.d., s tarting 2 days before a nd 3 days
d u ring periods c la ims to red uce dysmenorrhoea.
SURGERY
Su rgeq• is rare I)' unde rta ke n if med ica l measures fail to pro-
vide re lief and in women with seconda r)' d)•Smenorrhoea to
treat the unde rlyin g pelvic pathology. Surg ica l interventions
may be diagnostic to begin with, fo llowed by defin itive treat-
ment based on severity of symptoms, patient's age, desire
for childbearing, rnensu·ual functions a nd the patiem's per-
ception of her problem. Surgical interventions include ti1e
following:
• Diagnostic h)SLeroscOp) followed by dilation and curet-
tage (D&C). excision of pol) p or utetine septum. Dilata-
tion of cenix- it cia mages the nerves.
• Diagnostic laparoscopy followed b)' lysis of pelvic adhe-
sions, m)romectOill)', draining of chocolate cyst, caute•·y or
 LUNA TENS
126 SHAW'S TEXTBOOK OF GYNAECOLOGY
laser vaporization of islands of endomeuiosis, excision of
adnexal masses, laser-assisted uterosacral nerve ablation
(LUNA) for spasmodic dysmenorrhoea.
• Laparotom) followed b) excision of chocolate cyStS, eradi-
cation of endometriosis, m>omecLOmy, excisio n of localized
adenom)oma, presacral neurectomy (Cotte's operation).
• Hysterectom) in elderl) woman is the last reson.
• Tmnscutaneous elecu·ical nerve stimulation (TENS) is
effective in 15% cases.
PREMENSTRUAL SYNDROME
Premensu·ual S)•nch-ome ( PMS), also desc•·ibed as premen-
strual tension (PMT), is a symptom complex recognized
primarily by cyclic changes associated with ovulatory cycles.
It occurs 7-14 days prior to me nsu,•ation and resolves spon-
taneo usly after me nses. It is freq uently en co untered in
middle-aged women. IL is important for two reasons, firstly
because the symptoms of PMT are responsible for socioeco·
no mi c loss, an d secondl)' beca use of assoc iated legal and
wome n's lights issues that have ari se n in co njunctio n with
personal accountab ility d ulin g the premenstrual period. It
comprises physical, psyc ho logical and behavio ural changes
not assoc iated with organic lesion (Tab le 10.3). It is preva-
lent in 5% women.
AETIOLOGY
The exact cause of PMS is not known. It has been poswlated
that it represents aS) ndrome which is the result of multiple
biochemical abnormalities. Amongst these, the following
have been implicated: (i) oesu·ogen excess or progesterone
deficienc> in the luteal phase; (ii) increased carbohydrate
imolerance in the luteal phase; (iii) p)lidoxine deficiency-
this vitamin plays a role in oestrogen S)nthesis and also in
dopamine and serotonin production; (iv) increased pro-
duction of vasop•·essin, a ldosterone, prolactin and systemic
prostaglandins which adversely affect renal fw1ction and
comribute to fluid •·eten lion and bloating; and (v) fluctua-
tions in opiate peptide concentrations affecti ng endorphin
levels. Howeve•; biochemical estimati ons do not bear these
out. He nce, at present it is not yet clear whether P.MS is an
abnormal response to nom1al ho rmonal fluctuation o r a
result of hormonal abnormali ties. A w011tan with hysterectom)'
Table 10.3 Various Symptoms of Premenstrual
Tension
1. Pain Headache, breast pain, abdominal
cramps, muscle stiffness, backache,
generalized body ache
2. Water retention Breast pain, bloating, weight gain
3. Behavioural Low per1ormance, difficulty In concentra·
changes tion, Irritability, depression, forgetful·
ness, low judgement, anxiety, loneli·
ness, feeling like crying
4. Autonomic Dizziness, faintness, nausea, vomiting, hot
changes flushes
but conseroation of nw:y also 1tjJer from PJ\!rJ; suggesting
that the ovarian luroe a rvk in PJ\trJ:
Low level of (neuro u-ansmitters) in tlle
brain and low level of serotonin are probably responsible
for psychiauic disorders. Genetic predisposition is also rec-
ognized in a few cases.
CUNICAL FEATURES
The S)ndrome may be mild, mode•-ate or severe.
Symptoms of PMS are m>•·iad and not associated with
organic lesion in the pelvis. T he classic desc•·iption includes
increasing breast tenderness, abdomina l bloating, head-
ache, sleeplessness, fatigue, emotional lability, mood swings
and depression, it-ritability, fluid retention and weight gain
beginning 7-14 days plior to menses. As menstruation ap-
proaches, psychological abnorm ali ti es such as irri tability
and h ostility increase. T he dom inant symptom in different
gro ups varies from anx iety, to depression, 1.0 fluid retention,
bloa ting, headache and breast pain, to increased appetite
a nd craving for sweet foods. About 5% suffer from seve re
sympwms whi ch influence da il y activity. T he body we ight
increases b)' I kg and breast vo lum e by 20% d ue to oedema
and increased vascu la rity. PMT does not occ ur before
pubert)', during pregnanC)' o r afte r me nopause. It may,
however, occur if the postmenopausal woman goes on
mone replacement therapy (1-1 RT).
DIAGNOSIS
Diagnosis depends on his tO f) and careful questio ning. Tem-
poral con·elation ofs)lnptoms with the premenstrual phase
of the cycle as documented in a menstrual diary helps LO
arrive at a rational diagnosis. o organic pelvic lesion is
detected, and no definite test is available to confinn the
diagnosis.
TREATMENT (Table 10.4)
• For ps)•chological symptoms (psrchotherapy), counsel-
ling and reassw-ance alone suffice for the milder cases.
Vitamin B12 5-50 meg, vitamin Br. 100 mg and vitam in E
200 mg daily help PMS cases.
• For breast symptoms alone, be ne ficial th erapies include
(i) Danazol 100-200 mg in divided doses during the lu-
teal phase. However, adverse mascu li ni zing effect follow-
ing long-term usage is a d rawback. (ii) GnRH analogues
Table 1 0.4 Management of Premenstrual
Syndrome
Psychosomatic Vitamins 8 1 , E
Selective serotonin reuptake
Inhibitor, sertraline, citalopram anxiolytics
Breast pain Oanazol, bromocriptine GnRH
Pelvic pain and Yasmin, primrose
bloated ness Prostaglandin Inhibitors
OC, progestogen
Mirena IUCD
 CHAPTER I 0 - COMMON DISORDERS OF MENSTRUATION
provide relief, but long use causes menopausal (antioes-
trogenic effecLS) and osteoporosis. Besides, the
dntgs are expensive. The following drugs are used:
• Goserelin (Zoladex) 3.6 mg subcutaneously, 4 weekly
• Leuprore lin acetate (Prostap) 3.75 mg i.m., 4 weekly
• ·r.·ipLOre lin (Decapept) l) 3.75 mg i.m., 4 weekly
• Busere lin (Suprefact) 20(}-500 meg daily subcutane-
ous!) three times a da) for 6 months. O estrogen and
progestogen as add-back therapy to GnRH prevenlS
side effecLS of oesu·ogen deficienq•.
• Bromoc.-iptine 0.25-2.5 mg relieves breast tendemess
but has side e ffeclS s uch as nausea, diLLiness, weight
gain a nd swe lling.
• For bloateclness, weight gain, fluid retention and head-
aches (i) salt a nd fluid resui ction and (ii) spi1·onolactones
100 mg and diuretics may help. Buspirin one 7.5-15 mg
daily or drospire none may be used. Yasm in con taining
3 mg of spironolactone and 30 meg of EE2, is used cycli·
call y as combined oral p ills. Eve nin g p rimrose oil (Pri·
mosa) 500 mg t. i.d.; it is no nho rmo nal a nd co n tains
po lyunsawra ted esse ntia l fatty ac ids. It dive rts ha rmful
PGE2 to PG£ 1 and rep le n ishes CNS PGE1. By this, it s up·
presses i11·itab ili t)' and dep ression as well as re duces fl uid
re ten tion and mastalgia. Go ld pli m contains Primosa with
vitam in and mine rals (six capsules a day).
• Plmtagl.mulin Me fe nam ic ac id and naproxen
improve mood and physical symptOms. These drugs cause
gastrointestinal (G I) upseLS and rashes. Cyclooxygenase
inhibitor (cox-2) has fewe r side effecLS than NSAlD. fbu·
pro fen 400 mg 6-8 ho uri) is a lso useful.
• Anxiol)tics (alpra£olam ) 0.25 mg and antidepressanLS ( L.-i·
cycl ics) do pro, ide some re lie ffro m PMS, but the benefilS
of the raP> must be weighed against the side effeclS.
• ')'-Aminobut)I'ic acid (GABA ) suppresses anxiety level in
the brain. Therefore, GABA agonislS are effective. Selec-
tive sei·otonin re-uptake inhibitOrs (SSRl) such as fluox-
etine 20 mg d a ily a nd senraline 50 mg have been benefi-
cial in treating ph)sical as well as behavioural S)1nptoins
(60% curative). Th e side e ffecLS include headache, drows-
iness, insomni a, sexual dysfunction and G I disturbances.
• Sertraline 50-150 mg and citalop.-am 20-40 mg dai ly
are also use d in the premenstrual phase. Vitamin B6
(60-100 mg) and magnesium (200 mg) are cofactors in
tl1e synthesis of neurou·ansmi ue rs serotOnin and dopa·
mi ne. One gram calc ium da ily also he lps to re lieve
neu ro logica l symp to ms. Ven lafax ine is a co mb inatio n of
sertraline a nd norad rena line re u pta ke inh ib itor.
• Micron ized p rogesterone pessa ry 200-400 mg d aily in the
premensu·ua l p hase. M irena IUC D is now used instead of
oral progestoge ns.
• OCs render the cyc les anovu la tory and provide relief.
• Oesu·ogen skin patc h re leasi ng 100 meg daily or 50 mg oes-
u-ogen implant witJ1 100-mg testoSterone is also employed.
• General measures suc h as e xe rcise , relaxation and hob·
bies, meditation a nd >oga are likely LO be beneficial.
127
• Hysterectomy witJ1 removal of ova lies is a last resort. ln a
younger woman, oophorectomy will need in vitro fertil-
ization (LVF ) programme with donor eggs.
• ReassLtrance, counselling, psyc ho therapy and selective
use of drugs help to co ntro l t11e S)lnpLOms.
KEY POINTS
• onnal mensu·uation occurs as a resull of fine coordi-
nation between h) pot11alamus, inte1·ior piwitary gland
and O\'<l.rian functions, resulting in qclical maturation
of endometriwn and finally ilS shedding.
• A number of \'<l.l"iations in norma l mensuuation are
seen due to underlying diseases of u1erus, ovaries, pi·
tuita i}' gland and systemic diseases. T hese symptOms
may be in the form of menorrhagia, polymeno rrl1oea,
polym enorrhagia, meu·orrhagia a nd dysm en orrhoea.
• AltJ1oug h tl1ese te rms s uc h as me norrhagia,
rhag ia, po lyme no rrhoea/ po lyme no rrh agia a re in
comm o n use in c lin ica l p rac ti ce, rece n tl y a newe r
class ificatio n S)'Ste rn fo r ab no rm a l u te rin e bleed ing
g ive n b)' the Interna ti o na l Federa tio n of Gynecology
and O bste u·ics (FIGO) (PAL M-CO EIN) recom me nds
the use of term abnorma l u te rine bleed ing (AU B) in
place of these te11ns.
• Spasmodic d)smenO il"hoea is common in adolescentS
and young women. Congesti'e dysmenorrhoea is of-
ten associated witll PI D. fib1"0ids and pelvic endome-
mosis.
• Secondai] d)smenorrhoea is a manifestation of or-
g;ulic ute1·ine patJJOIOg) sud1 as fibroids and adeno-
m>osis.
• Premenstrual S) ndmm e is a fun c tional disorder found
in eclucated and economicall) well-to·<lo middle-aged
women, and requires u·eaunent.
SELF-ASSESSMENT
1. Describe commonly used te rms for menstrual irregularities.
2. Describe the manage me nt and cli nica l features of pre-
mensu·ual syndrome.
SUGGESTED READING
BonnarJ. Rcccn1 Adv-.JnCc$ in Ob$1C1rics and Cynaccok>!.'Y· 2003; 15: 169.
SpcrofTL, Fritz MA. Clinical Gynecologic EndocrinoiO!,'Y and Infertility.
8th cd. Philadelphia: Lippincou William$ & Wilkin$, 2011: 567.589.
Studdj. Progrc.,., in Obstetrics m1d Cymoc,-oiO!,'YVolume 3, 11:189.
Usshcr JM, Pcrzj. PMS a. a procc"S:I ofnegoiiat.i on: women '$ experience
and management of prcm etutrual P.ychol llealth. 20 13;
28(8):900-27.
Vigod SN, R<h> LE, Steiner M. Under.uu1dingand treatingprernenstmal
dy>phoric di>order: an update for the women"s he-.lith prdtritioner.
Ob>tct Cync'Col Oin !\'orth Am. 2009;36(4):907-924, xii.
 Abnormal Uterine
Bleeding (AUB)
Introduction 128 Abnormal Uterine Bleeding in Reproducfive
Normal Conlrol of Menstrual Bleeding 128 Age and Premenopausal Women 133
Causes of Abnormal Uterine Bleeding 128 Abnormal Uterine Bleeding in
lnvesfigations 131 Adolescents 139
Management 131 Key Points 140
Palm-Coein Self-Assessment 140
132
INTRODUCTION
Mensu·ual irregularities and abnormal heavy mensm1ation
accoum for up to 25%-33% of women attending gynaeco-
logical outpatient deparunem. Although woman of any
age group can be affected with abnormal merine bleeding
(AUB). it is more common I) experienced b)' women of
35-'15 >ears of age. It is also commonly seen among young
girls soon after attaining menarche. There have been a
number of classification systems to classiry causes of AU B
but recently lmernauonal federation of g) naecologisLS and
obsteuicians has suggested newer classification popula!·ly
known as 'PALM-COEI ' classification to define cause of
AUB. Further, AUB is divided imo acute and chronic AUB,
depending on the duration of the problem persisting in the
woman. Chronic AUB is defined as bleeding that isabnonnal
in volume, 1·eguladty and/or timing for the past 6 months.
It does not usuall y require immediate intervention. Acute
AUB is an episode of heavy me nstrual bleeding of sufficient
quantity to 1·equire immediate in ten•entio n tO prevent
fun.her loss. It ca n be seen \\1th existing chro nic AUB.
About 10%-25% of women experience episodes of AUB
at so me tim e chu·ing tJ1e reproductive yea rs of tJt eirlives. lt is
common during tJ1 e ex u·emes of rep rod uctive life, following
pregnancy and d uring lactation. It has been shown that
55.7% ofadolescenLS experie nce abno nnal menstrual bleed·
ing in the first year or so after tJ1e onset of menarc he because
of the immaturity of tJ1e hypotJlalamic-pitui tary-ovarian
{H-P-0) axis leading to anovulatory cycles. It generally takes
18 montl1s to 2 years for regular cydes to be established.
It is not uncommon for a premenopausal woman to
develop menorrhagia, and tl1 is is often due to anovulatOry
cycles in 80% of cases. However, endometrial malignancy
should be ruled out before deciding the type of u·eaunenL
The term 'd)sfunctional uterine haemoni1age' was
specificall) used when meno1-rhagia was not associated
To \iew the k-cturc note> :.can the >pnbol or log in to rour account on
128
with an)' genital u·act abnorma li ties, general or endocrino-
logical diseases. In this case, a ho rmona l imbalance is
considered the root cause of of the endome-
trium that causes menorrhagia; this often happens in an-
ovulatory cycles wiLI1 excessive or unopposed influence of
oestrogen on the endometrium. This term is now replaced
by Abnonnal utel'ine bleeding.
ln some cases. abnormal endometrial haemostasis is tl1e
cause ofabnonnal excessive bleeding.
NORMAL CONTROL OF MENSTRUAL
BLEEDING
Once the mensuual bleeding starts, the platelet aggregation
fo1·ms dots in the opened vessels. Prostaglandin F2a ( PGF2a)
causes myometrial conu-actions and constricts the endome-
trial vessels. The repair and epithelial regeneration begin on
the tl1ird and fourth day of period, by tlte growtl1 of epiL11elial
cells from the open e ndomeuial glands aided by tlt e vascular
e ndotJ1elial, epidermal and fibroblast growtll factors.
H- P-0 axis is intac t, b ut e ndometrial changes get altered. PGI
In excessive b leedin g with regul ar mensu·ual cycles, the Phiz >
It is observed tJ1 at, in these cases, (p rostacyclin),
which is a local vasod ilato t; is increased compared to PGF2a
in the endometrial tissue.
CAUSES OF ABNORMAL UTERINE BLEEDING
(TABLE l 1.1)
The causes can be di' ided into following: (i) tl1ose due tO
general diseases. (ii) those which are local in t11e pelvis,
(iii) tJhose caused b) endocrine disorders, (iv) conu-acep-
tives and('') iatrogenic. The new classification of causes of
AUB is shown in Fig' 11.1- 11.1.
 CHAPTER II - ABNORMAL UTERINE BLEEDING {AUBI 129

Table 11.1 Aetiology of Menorrhagia

General Causes Pelvic Causes Contraceptive Use HormonaVAUB

Blood dyscrasia PID, pelvic adhesions IUCD Ovulatory: Irregular ripening

or Irregular shedding

Coagulopathy Uterine fibroids, endometrial hyperplasia Posttubal sterilization Anovulatory: resting

Adenomyosis endometrium - 80%
Metropathia haemorrhagica

Thyroid dysfunction Feminizing tumour or the ov;ry Progestogen-only pills

Genital TB Endometriosis
Pelvic congestion, va-icose veins in the pelvis

Coagulopathy
Po lyp
Ov ulatory dysfunction
Adenomyosis .I Submucosal I Endometrial
L eiomyoma 'I Other I Iatrogenic
Mali gnancy & hyperplasia Figure 11.1 Basic FIGO classification system for causes of
N ot yet classified AUB in th e reproductive years. Th e system Includes four cat-
egories that are defined by visu ally obj ective structu ral cri teria
(PALM : polyp, adenomyosis, leiomyoma, malignancy or h yper-
p lasia); four unrelated to structural anomalies (COEI: coag u ·
lopathy, ovulatory dysfunction , endometrial, Iatrogenic); and
one (N) that Includes entitles not yet classified . (Source: From
Figure 1. Malcolm G Munro: Obstetrics and Gynecology Oinics.
Vol 38(4): 703- 731, 20 11 .)

Coagulopathy
Polyp

Ade nomyosis 0 111Jiaklry dysfunction

"\.I St.brrucosal
Endome1rial
Leiomyoma

Maliglancy & hyperplasia

v1 Other
Iatrogenic

Not yet dassified

SM · Submucosal 0 Pedmc.Aated i ntracaV11ary

Leiomyoma
subclassification 1 < 50% Intramural
2

---
system Intramural

0 · Other 3 Contacts e ndome trium; 100% Intra mural

3 4 4 Intramural
2- 5
5
(j\ ( 1 --::::;l Subserosai :.SO% Intramural

6 Subserosa! < 50% Intramural

6 I 2
5
-
7
7
8
Subserosa! pedunculated
Other (specify e.g. cervical, parashlc)

Hybrid l'Wol'ltll'ltl&f's areletedeepat'atedby 11 t\'lflotn. Bycaweni Ot\ ,,.. hffll

M rs IG it'e re&atoneNp\MI\ IN floeaeeord rei&rt iO
leiO"'IOmaS he retlt.onet'lipiO bNow
(impact both
endometrium SUbmucosalandsuboeiOsal, eachwllh loss
and serosa) 2-5 than half the diameter In I he endometrial
and perhoneal cavhies, "'spectlvely.

Figure 11.2 FIGO classification system Including the leiomyoma subclassification. The classification of leiomyomas categorizes the submucosal
(SM) group according to the Wamsteker system 12 and adds categorizations for intramural, sub serosal and transmural lesions. lntracavita-y lesions
are attached to the endometrium by a narrow stalk and a-e classified as type 0, whereas types 1 and 2 require that a portion of the lesion is intra-
mural, with type 1 being 50% or less and type 2 more than 50%. Type 3 lesions a-e totally extracavlta-y but albut the endometrium. Type 4
lesions a-e intramuralleiomyomas that a-e entirely within the myometrium with no extension to the endometrial surface or to the serosa. St.bserosal
(types 5-7) myomas include type 5, which are more than 50% intramural; type 6, which are 50% or less intramural, and type 7 being attached to the
serosa by a stalk. Lesions that a-e transmural a-e categorized by their relationships to both endometrial and serosal surfaces. The endometrial rela·
tionship is noted fist, whereas the serosal relationship is second (e.g. type 2-5). An additional category, type 8, Is reserved for myomas that do not
relate to the myometrium at all and indude cervical lesions, those that eXist in the round or broad ligaments without a direct attachment to the uterus,
and other so-called pa-asitic lesions. (Soutte: From Figue 2. Mak::olm G Munro: Obstetrics <11d Gynecology Onic:s. Vol38(4): 703-731, 2011.)
130 SHAW'S TEXTBOOK OF GYNAECOLOGY

Rgure 11.3 FIGO classification system for causes of abnormal uterine bleedin g in the reproductive years. FIGO. International Federation
of Gynecology and Obstetrics. (Source: From Figure 1. Malcolm G Munro, 00 and ian S Fraser. American Journal of Obstetrics
and Gynecology. Vol 207(4): 259-265, 2012.)

Rgure 11.4 Notation for FIGO classification system. FIGO, International Federation of Gynecology and Obstetrics. (Source: From Figure 2.
Malcolm G Munro, Hilary 00 Critchley and ian S Fraser: American Journal of Obstetrics and Gynecology \bl 207(4): 259-265, 2012.)

GENERAL DISEASES CAUSING HEAVY MENSES
General diseases caus ing heavy menstrual blood loss are as
follows:
• Blood dyscrasia, i.e. leu kaemia, coagulopa thy, thrombocy-
topenic purpura, severe anaemia; coagulat..io n disorders
are seen in 20% of adolescenLs; Von Wille brand disease.
• Th) roid d) fw1ction- H) poLil) ro idism and h) pe•·Lil)TOidism
in Llle initial SLages.
• General tuberculosis may cause me no rrh agia initially, but
in the advanced staLe, ame norrhoea e ns ues.
LOCAL PELVIC CAUSES
These include following:
• Uterine causes: te.-i ne fib•·oids, fibroid pol) p, adeno-
lll) OSis, endometl"ial h)perplasia.
 CHAPTER 11 - A BNORMAL UTERINE BLEEDING IAUB) 131

• Ovarian causes: Chocolate C)'Sl, ova•·ian fem inw ng LUmours,

poi)C)Stic ov;uian disease (PCOD), endomeuiosis. INVESTIGATIONS

Tubo-ovarian causes: Salping<rOophoritis, pelvic infla m-
maLO ry disease (PLD), genital TB, varicose ve ins in t11 e pelvis
(Fig. 11.5).
• Arteriovenous malformations : Ute ri ne arte liove nous
fisu Ja and va licosity of vessels (ra re) - T his may be
co nge nital, but q ui te often it is tra umati c following dilata-
ti on and curettage (D&C) .
• Imm edi ate puerperal a nd postabortal periods.
• lau·ogenic causes: In·egula r use of oral con traceptive pills
and o ther honnonal conu-aceptives.
INTRAUTERINE CONTRACEPTIVE DEVICE
lnu·aute line co ntraceptive device (IUC D) has provided yet
ano Lhe r aetiological factO.: Abolll 5%-10% of women
wea ring the dev ice suffe r me no rrhagia in the first few
mon ths. Poststeriliza tio n me no n·hagia is repon ed in 15% of
cases, b ut th e ae ti ology is not clea r.
No obvio us cause is seen in 40%-50% of the cases. In the
past these cases were labelled as dysfuncti onal uterine bleeding
(D 13).
AUB patien ts sho t.tld be co mpletely in ves tigated. Besides
physical examinatio n, tl1e fo llowing tests are advised:
• Comp le te hae mogram.
• Bleed ing Lime and clotting time .
• T h)•ro icl profile as indicated.
• Pelvic sonography.
• Diagnosti c h)'Steroscopy.
• Enclomeuial tissue sampling by D&C or endometrial
aspi•-ation .
• Diagnosti c laparoscopy.
• Sonosalpingography can delineate a submucolts fibro id
clearl).
• Pelvic angiography is required when th e cause of meno r-
rh agia is no t de tected by o tl1e r means. This shows v;uicosity
and an eriove not.ts fistula .
IMANAGEMENT
Man agement consists of the following ( Fig. 11.6):
• Gen eml measures to improve th e health status of the
patien L Achice regarding prope r d ieL, adequate rest
d uring menses, o ral adminisu-atio n of haematinics,
vitamins and pro te in supple men ts and to maintain a
me nsu·ua l calenda r no ting du ration and extent of blood
loss.
• Trea t the cattse.

In wome n suffering from meno n·hagia, consider th e

following:

• In ovul atory crcles, ora l nonsteroidal anti-inflammatory

drugs (NSAIDs) such as mefenami c acid 500 mg Li.d.
along with a ntaci ds. Other drugs in this category include
11.5 Laparoscopic v iew of varicose uterine vessels. nap•·oxe n. and ibuprofen. Blood loss is red uced b)r 30%-
(Courtesy: Dr ViJek MaiWah, New Delti.) 40%. These drugs ;u·e e ffective in ovulatO I) bleeding a11d

M enorrhagia

Rule out cancer

Cont raception not desirable
if concept ion desir ed
• Ethamsylate, NSAIDs
• Tranexamic for 3-4 months
Cont raception also desired-
pregn ancy not desired
• Combined o ra l
contraceptive pills
• Progestogens and other
hormones
• M irena
• GnRH 3-4 mont hs
and uterine pathology
+
Normal uterus (DUB) Uterine path ology present
• Medical therapy
Comb ined oral contraceptive !
Surgery
pills contrai nd icated over 40 years,
progestogens and others

+
I !
No response
Effective Fails Hysterectomy with removal
+
Continue f or 6- 9
• Min imal invasive
surgery
of ovaries after SO years
{No minimal conservative surgery)
month s as required • Hysterectomy w ith
and follow-up con ser vation of ovaries
Figure 11.6 Management of menorrhagia.
132 SHAW'S TEXTBOOK OF GYNAECOLOGY
in LUCD users. They are an tiprostaglandins and inh ibi t
cyclooxygenase activity. They deo·ease the menstrual
bleeding, but have no effect on the duration of mensl.l'ual
bleeding. These drugs should be taken only during men-
struation, which is an advantage, over cyclical ho nno ne
therap).
• Tranexarnic acid is currenLI) L11e most commonly
presnibed drug for the control of excessive mensu·ual
bleeding. Given in a close of 500- 1000 mg two or Lluee
Limes a day du.-ing the phase of heavy menses, Ll1is drug
reduces blood loss by 35%.
• Cyclic oral contraceptive pills.
• Progestogens in endometrial hyperplasia.
• LUCD.
• Minimal invasive stwgery includes endomeu·ial L11ermal
ablation, endometrial resection and others (see later).
• Hysterectomy in selected cases.
• GnRH ana logues: They are not effective in immediate
con u·ol of bleedin g; however, L11e ir use can induce
amenorrhoea. In wome n manifestin g obvio us pathology,
corrective measures for the sa me are called depend-
ing on her age and the desire for retaining me nsu·ual and
childbearing functions. The rape utic measures include
fo llowing:
• Removal of an IUCD, if medical th erapy fails.
• M)'OmeCLomy/ hys te recto my fo r ute rine fibroids.
• Adenomyomectomy/ hyste rec tomy for adenomyosis of
L11e uterus.
• Laparoscopic lysis of ad hesions for chronic PLD.
• Electrocautet') or laser vaporiLation of endo meuiosis and
drainage of chocolate C)SLS in pelvic endomeuiosis.
• Hysterectom) with or wiLI10ut removal of L11e adnexa
according to the age and L11e individua l needs of the
patient.
• In patients suffering from bleeding disorders, a haema-
tologist's opinion should be sought.
• Utet·ine anery emboliLaLion in varicose vessels.
• Von Willebrand disease; intravenous desmopressin.
AUB is of two following types:
I. Anovul atory cycles (80%)
2. Ovulatory cycles (20%)
PALM-(OEIN CLASSIFICATION
DUB was coined to describe abnorm al heavy menstrual
bleeding whe n no SU1tCLUral gen ita l trac t abno rmality or a
general cause was detected, in a woman of reprod uctive age
in the absence of pregnancy. This condition is clue tO several
causes that make L11 e sta ndard me thods of investigations
and management inco nsistent and diffic ult Several causes
may be attributed tO AUBin an individual, whereas none
may be detected in some. In some, the lesion detected may
not be Ll1e real cause of A UB, i.e. an uterine fibroid may be
a coincidental finding, aS) mpLOmaaic and not the U'ue cause
of AU B.
For this reason, FICO in 20 1I came fonvard with the
new nomenclawre of A B instead of DUB, and a new
classification system to define its cause. This classification
is named 'PALM-COEI ' S)Stem. It stands for polyp,
adenomyosis, leiomyoma, malignancy, coagulopathy, ovu-
laLOry dysfunction, endomeu·ium, iatroge nic and nonclas-
sified. The first four are related to visually objective
structtLral merine abnormalities that can be measured
visually with imaging modalities a nd b) a hisLOpatJwlogical
study. The others are nonstrucwral and att.-ibuted LO
coagulation disorders and hormonal d)Sfunction. sta nds
for not yet specified.
PALM-C0£1 classification is fut·ther subdivided imo
secondary and tertiary subclassification according to t11e
findings detected.
Contrat')' to the PALM group, the COEIN group cannot
be detected by imaging and histopathol ogy. This category
refers to coagulopaLI1y, ovarian steroid dysfunction, either
endogenous or by administration of hormones, for various
conditions (oral conu-acepLives, IUC D, drugs).
AUB mrry be acute or chronic. Acute bleeding may occur
sporadicall y de novo or may be s uperimposed o n chronic
AUB, and requires an immediate trea un e nt Chro ni c AUB
is described as abnorma l me nstrual bleeding rela ted to vol-
um e, timing, regt Ja tity and duration of bleed ing that lasts
for 6 mo nths (minimum 3 mo nths), a nd req uires tho rough
investigations.
AUB does not include L11 e bleeding caused by lesions in
the lower gen ita l tract
PAlM-cOEIN CLASSIFICATION
The classification is stratified into nin e basic categories t11at
are arranged according to L11e ac ron)'ln PALM-COElN
(polyp. adenom)Osis, leiOm)Oma, malignancy and h)perpla-
sia e ndomeu·ium. coagtJopath), ovulaLOry disorders, endo-
meuium. iau·ogenic and nonclassified).
POLYP- (AUB·P)
l t is categoriled and defined by ulu-asound, saline sonogt-a-
phy, hysteroscopy with or without histopathology.
P category is subdivided accordi ng tO number, size,
location and histology.
ADENOMYOSIS (AUB·A)
It is diagnosed by ulu-aso und and MRI. MRI is expensive
and not available in many ce ntres. In such cases, ulu·asound
alo ne is used for the diagnosti c purpose. The category is
s ubdi vided depencUn g on the clep L11 of endometrial myo me-
trial invasio n. It is impo rta nt to remember that man y cases
of adenomyosis are as)'mpto ma Lic and on ly d iagnosed on
hysterectOmy specime ns.
LEIOMYOMA (AUB·L)
Man)' le iom)'Omas are coinciden ta l findings and are not the
cause of AUB. Because of Lhe different locations
and size, t11is gro up is divided in to primary, secondary and
tertiary group.
The primary classification reflects only t11 e presence or
absence of leiom)omas as determined by ull.l'asound. ln
the seco ndat') classification, it is necessary LO distinguish
myomas that imo lve L11e uterine caviL), as t11ese are t11e ones
t11at are like I) to caLLSC AUB- L11e ones away from L11e endo-
metrium are unlikely to do so.
The tertiat')' classification involves submucosal growths.
l t also includes number, si1.e and location of m)omas.

MALIGNANCY AND PREMALIGNANT LESIONS (AUB-M)
This gro up is ra re in the rep roductive age, but may
occur in a woman with a PCOD and chronic anovulation.
The diagnosis is b) hisLO path o logical examination of
the endometrium (D&C, biopsy) o r by hyste roscopic
biops).
COAGULOPATHY (AUB-C)
It consists of a specu·um of systemi c disorders of haemostaSis
that can cause AUBin arou nd 13o/o-20% women of repro-
ducli,•e age. The most common is von Willebrand disease.
However, many of these may be asymptomatic and not
related to AU B.
OVULATORY DISORDERS (AUB-0)
About 80% are anovulatOt)' cycles with unpredictable,
irregular mensu·ual cycles, some ,,1th heavy bleeding. About
20% are ovulatorr but nHI)' be a conseq uence of 'lu teal-o ut-
of phase' (LOOP) events "1th de fic ie nt p rogestero ne. Some of
t11ese are caused by h)'POth)•roidism o r hyperprolactinae mia
ENDOMETRIAL CAUSES (AUB-E)
The mechan ism regulating local endome u·ial ' haemostaSis'
secondat)' to abnormal sec retion of prostagland ins is as
explained earlie r. In rare cases, it is d ue to tuberc ular endo-
meu·itis or infection , particularly chlamydia] infection.
There are no tests availab le, except for infections, to esti-
mate tl1 e local causes, and the case is placed in this category
by exclus io n of ot11er causes.
IATROGENIC (AUB-1)
This is caused b) stero ida l ho rmo nes administered as
conu-aceplives, especiall) in low dose, IUCD, copper-T
may cause WlSChecluled ' breaktluough bleeding' or menor-
rhagia. The <h-ugs that are responsible are anticoagulants,
phenothiat.ine and triC)Ciic a ntidepressa nts which affect
dopamine meta bolism.
NOT CLASSIFIED (AUB-N)
Rare causes not well defined or diagnosed are aner-iove-
nous malfor·mati o ns, va ri cose veins of tl1e uterine vessels
or myohyper·plasia. In othe r-s, no ca use is discern ible by
tl1e existing investi ga tions. T hey a re all clubbed in this
group of unc lassified AUB. As a nd whe n be uer in vestiga-
tions become ava ilab le, they may be allocated to a new
category in fulllre.
ABNORMAL UTERINE BLEEDING
IN REPRODUCTIVE AGE AND
PREMENOPAUSAL WOMEN
The menstrual cycles, which are painless in most cases, are
anovulatory cycles. One point to be e mphasized here is that
D&C and e ndometria l study are impo rtant in premeno-
pausal women to rule out e ndometrial carcinoma. In
younger women, D&C is done when medical tl1er-apy fuils.
Instead of D&C, uterine aspir-ation o r hysteroscopic biopsy
is chose n b)• some to study the e ndo meu·ial lining and 1.0
detect small pol) pi tllatcan be missed on ultrasOund and to
diagnose tubercular endomeu·itis.
metopathia hemorrhagic
CHAPTER II - ABNORMAL UTERINE BLEEDING {AUBI 133
Type I
Type Ill
Figure 11.7 Menstrual history In cases of metropathla haemor-
rhagica. Continuous uterine bleeding Is the most constant symptom,
and most frequently this Is preceded by amenorrh oea of about
8-10 weeks' duration. Sometimes, the bleeding follows upon a nor-
mal period, while at other times, the continuous bleeding may be
preceded by menorrhagia.
METROPATHIA HAEMORRHAGICA
It is a specialized fonn ofanovulaLOry AUB, seen in women
between <10 and 45 )Cars. It is not related to parity.
The S) mptoms are L) picaI. The woman develops continuous
painless "aginal bleeding, sometimes starting at tl1e onset of
menses, or preceded b) 6-8 weeks of ame noni1oea (Fig. 11.7).
Occasionally, the woman reveals a history of menon·hagia be-
fore this. The Ulerus is slightly bulk)'· This condition may simu-
late abortion and ectopic pregnanC)•, if amenoni1oea precedes
bleeding, but pain is conspicuously absenL
PATHOLOGY
A mi ld degree of myohyper·plasia with the uterine \va ll mea-
su ring up to 25 mm, and a unifo nn ly e nlarged uterus is seen
in metropathia haemorrha gica. T he e ndome u·ium is thi ck,
polypoidal, and th in sle nder pol)•pi p rqject in LO tl1e uterine
ca\'ity (Fig. 11 .8). T he e ndom e u·iu m s hows charac teristi cs of
cysti c gland ul ar hype q) ias ia (Figs I 1.9 and I 1.10). T he Swiss
cheese pauern is anotJ1er na me given to desc ribe this endo-
metriu m. The seco nd feature is th e absence of secretary
endomeu·ium wi tl1 tl1 e absence o f coc k-screw glands. Areas
of necrosis as seen during me nstrua tion can be seen in the
superficial surface. One or both ova ties may contain a cyst
not larger tl1an 5 em, but co rpus lute um is absent.
INVESTIGATIONS
• A histor) of tl1e onset, duration and amotmt of bleeding
should be noted Antecedent causes sucl1 as IUCD, pills, preg-
naJlC)\ abortion. drug t11erap) are also pertinent in tl1ese cases.
• General examination, with special reference to ru1aemia
ru1d th) roid function, blood count, coagulation profile, is
carried ouL Peh ic examination is done.
134 SHAW'S TEXTBOOK OF GYNAECOLOGY

A
Rgure 11.8 (A) Metropathla haemorrhaglca. Note that the right ovary is cystic and that the endometrium shows diffuse polyp due to
hyperplasia. (B) Cut section of the uterus showing thickened myometrium (myohyperplasia) and thickened polypoidal endometri um.

Figure 11.9 Endometrial biopsies of normal proliferative endometrium. (A) Simple endometrial hyperplasia without atypia. (B) Complex
endometrial hyperplasia with (C) cellular atypia. (Courtesy (B): Dr S<Wldeep M athur, AIIM S. (C): Hacke' NF, Gambone JC. Hobel CJ, Hacker
and Moore's Essentials of Obstetrics and Gynecobgy, 5th ed. Philadelphia: Elsevier, 2010.)

• UIU'aSOund to study pelvic o•·gans and tO rule out pelvic

organic disease.
• Endometrial Sllldy by cureu age, Ulerine aspir·a tion or
h ysteroscopic biopsy is mandatory in premenopausal
women, and necessa ry in a few younger women suspected
to have endometria l tube rculosis.
• Doppler ultrasound to study endometrial vascularity may
help in the diagnosis.
• Hysterosalpingograph)' and sali ne salpingograp hy may be
e mp loyed, if hyste roscopic fac ilities are not ava ilable.

History, Examination (H/o Hormones/Drugs, Rule Out

Pregnancy)
l
Investigations
l
Blood Test Structural Histology
Rgure 11.10 Metropathia haemorrhagica Endometrium showing
• Complete abnormalities • Dilatation and
superticial necrosis. This necrosis resembles that seen on the fll'st blood cell curettage
• Ultrasound
day of menstruation. The glands, however, do not show any secretory count • MAl as needed • Hysteroscopic
change (x 11 0). • Coagulation • Hysteroscopy endometrial
profile biopsy
• Endometrial
aspiration
biopsy
 /
-30mg day smglday day smgld
20
10 } -6m

CHAPTER II - ABNORMAL UTERINE BLEEDING {AUBI 135

TREATMENT OF ABNORMAl UTERINE BLEEDING
• Treat tl1 e cause. Me norrhagia witl1o ut any organic or
ge ne ral disease should be treated as follows:
A wide varie t>of treaune nt modalities are now available. The
u·eaune nt should be based on tJ1e age o ft.he woman, her
desire 1.0 retai n fertiliL), previous treaunent and se,ericy of
menorrhagia.
• Anaemia should be u·eat.ed simult.aneously. The fi rst line of
treaJmen t is medica l thl'ra/J)'. If that. fails, D&.-<: may be help-
ful mainly for di agnostic pu•·pose, but. a few women may
benefit from it therapeutically. If honnonal u·eaunem
ca uses side effects, many n ow prefer to insen a
IUC D. Failing tl1is, decision h as 1.0 be taken regarding a
conservative sw-ge•)' or hysterectomy. Lately, conser\'ative
surgeries have •·educed t11 e number of hysterectOm ies for
AU B, and are cost-effective witl1 qui ck recovery.
CONSERVATIVE TREATMENT
Lf tl1e menorrhagia is not heavy and the wo ma n is no t an ae-
mic, me nstrual chart fo r a few mo ntJ1s sho uld be observed.
Spo ntaneous cure is possible and ca n be awa ited. Anae mia
ca n be u·eated appropriately, if it exists.
HORMONE THERAPY (Tobie 11 .2)
1. Oesu·ogen tl1 erapy alone is no t recommended because of
the risk o f endo metrial and cancer. Oral combined
pills are effective in o nly selec t women and not safe after
the age of 35 years, in smokers and obese women.
2. Progeswgens are tl1e main ho nnones used in AUB. Proges-
togen induces oestradiol I rogenase wh ich convens
oestradiol to weak oesu-one which in Lum suppresses re-
ceptors. DNA S) ntJ1 esis and has antimit.otic Thus,
p•-ogestogens cause endomeu·ial au·oph)'· A high initial dose
of 10-30 mg a day should a11·est bleeding in 24-48 hours,
after whid1 5 mg daily is given for 20 clays. Witl1c;lrawal bleed-
ing occurs 2-5 days after stopping tl1e dmg, and nonnal
blood loss is expected. A f·urtJ1er course of 5 mg daily for
20 days is staned on tl1e second or tl1 ird day of tl1e pe nods
cyclicall) montJ1S (given at. night. 1.0 reduce side ef-
fecl.S). D)drogeSLemne ( 10 mg) does not. suppress ovulation
in wome n who d esire pregnanC), and it. does not. influence
lipop•-ot.e ii1S. Pmgestoge•1S used common I)' are noretllist.er-
one, D) cb·ogeSLei'One, OM PA o r newer p•-ogestins. Ge.stri1W 1111,
a de•i,oative of 19-non estOSLei'One, is effective in an oral dose
of2.5 mg t\\ice \\eeki)•Or 5 mg vagi nalmbleLS tJ1rice \\eeklyfor
6 months. Instead of a :heek C)dical tJ1erapy, giving p•-oges-
togen only in tl1e luteal phase is not. effective.
Th•·ee-monthly Depo-Provera is also now recommen ded
to reduce tl1e number of mensu·uations in a year.
Instead of cyclical adm inistratio n of pmgeswgens,
con ti nuo us oral progestogens daily for 3 mo mhs with
a break of I week reduces tJ1 e num ber of menstrual
cycles to fo ur in a yea r whi ch many wome n welco me.
Fibruplant imjJ!Jmt. rtdeo.1ing 14 mtg d(tily of levonorgtst-rtl is
nruler trial.
3. Danazol has a limited ro le whe n oral co m racepLives
and p •-oges togens are not sui ted LO a woman . IL has an-
d roge nic side effec ts. Oa nazo l 200 mg daily for 3-4 cycles
is reco mme nded.
4. Clomiphene is advocaLed , if pregna ncy is des ired.
5. £tJlatl1SYlate reduces capillary fragi lit.y, 500 mg fo ur tinles a
day from 5 da)S before anticipated period, up lO 10 days re-
duces menorrhagia b) 50% (Tahle 11.2) in ovulaLOry cycles.
6. SAIDs take n during menstn mtio n for 4-5 days control
menorrhagia b) 70% in ovulaLO•) cycles, post.-IUC D atld
posLS te •ilitation me norrhagia. These drugs inhibit. cyclo-
OX)genase and prostaglandin produ cti ons.

Table 11 .2 Medical Therapy

Drugs Dosage Si de Effects

Com bi ned oral 2Q-30 meg EE2 - progestogen mont hly Nausea, headache, hyp ertension, hyp erglycaemla, thrombosis,
contraceptives seasonale - 3 mont hly (4 cycles in a yea-) li ver and gall bladder d isease, breast cancer

Progestogens 5- 10 mg tablet (1o-30 mg daily) for \Neight gain, depression, headache, acne, abnormal lipid profile,
3 w eeks cycli call y breast tumours
• Continuous 3 m onthly
• 3 mon thly Injections
• Implant

Gestrinone 2.5 mg twice weekly Acne, hirsutism , weight gain, reduced high density lipoprotein,
Danazol 10Q-200 mg dally cholesterol

GnRH analogues 4 weekly In]ectlons Menopausal symp toms, osteoporosis, loss of libido

Tranexamlc acid 1 g, 6 hourly Nausea, vomiting diarrhoea, headache, visual disturbances,

intracranial thrombosis

NSAIDs M efenamic acid 500 mg t.i.d . Nausea, vomiting, dyspepsia, gastric uloer, diarrhoea,
thrombocytopenia

Ethamsylate 500 mg four times daily Nausea, headache, rash

Mirena IUCD 52 mg levonorgestrel Less than those of oral progestogen - because its action is bcal
resllting in endometrial suppression: however, it takes 2-3 mooths
to reduoe menorrhagia and the effect lasts b' 5 years

Ormeloxifene 60 mg twice weekly

 136 SHAW'S TEXTBOOK OF GYNAECOLOGY
7. Antifibrinolytic age nLS - Tranexamic acid, 1-2 g fot.u·
times a day for 6-7 days eluting mensU'l.tation is effec-
tive in 50% of the cases. Ethamsylat.e combined with
250 mg tranexamic acid is a lso advocated. Combined
u-anexamic acid with mefenamic acid is now available
(Trapic-MF).
8. GnRH is emplo)ed, if the above fails. Depot injection
16-6 3.6 mg gi,en monthl) for 4-6 months or 6.6 mg
3.6mg my
implant is nearly 100% successful. A longer duration
money of u·eaunent with its antioesu·ogenic action causes
menopausal symptoms and osteoporosis. This ca n be
counteracted by 'add-back thet-apy' by giving 5-
10 mg norethisterone (not Medroxyprogest.erone
acetate si nce it is not bone protective) or tibolone,
and this allows longer adminisu·ation ofGnRH (more
than 6 months). Gn RH ta kes 4 weeks LO act and is
th erefore not effective in ac ute episodes of bleeding.
9. SERM (selective oestrogen receptor modulatOr) - A
new drug onn eloxife ne, no nho rm onal ce mchroman
60 mg twice weeki)' for 12 weeks to 6 mo nths and there-
after wee kly, is 50% effective. It does no t ca use breast or
uterine cancer beca use of iLS a nti oestroge nic effect. It is
also agonist to tJ1e ca rdiovascular S)'Ste m and bone pro-
tec tive. It some tim es lengthe ns tJ1 e fo llicular phase and
dela)'S mensu·ualion. It can cause a functional cyst, dys-
pepsia and headache at tim es.
10. When oesu·ogen is not co nu·aind icat.ed and a woman
also needs contraception , a new drug Seasonale (co m-
bined oestrogen and progestOgen) is used daily for
84 da)S with a gap of 6 days in a 3-monthly treaunent.
Mensu·uation occurs during tJ1e tablet-free petiod. It is
welcomed b) women because of infrequem pet;ods.
MIRENA
To avoid side effects of honnonal thet-apy, Mirena IUCD is
now emplo)•ed to control menon·hagia. It directly sup-
presses endometrium witJ1 minimal side effects. It has no
action on the ovaries; therefore, E2 and progesterone levels
remain nonnal (Fig. 11 . 11 ). It reduces blood loss by 70%-
90% in 3 months, and acts as a conu-aceptive for tJ10se who
do not desire pregnancy.
E
E
Figure 11.1 1 Mirena IUCO.
Mirena can be retained for 5 years. However it may cause
itTegt.darbleeding eluting tJ1e first3 montJ1s, and the woman is
advised to persevere retaining Mirena and not get it removed
on t11is account. About25% of women become amenorrhoeic
at the end of I >ear. A quick retum of fenility is noted folio"•
ing iLS removal. About80% conceive b) 12 montllS. Mirena is
also useful in women witJ1 menon·hagia and d)smenot-rhoea
associated with uterine fibroid, adenom)OSis.
Disadvantages of Mirena
The following a•·e the disach<antages of Mirena:
• Slightly difficult to itlSerL
• Takes 3 months before it becomes effective.
• Amenorrhoea occurs in 20%-25%, which is not desit-able
in younger women.
• Ectopic pregnancy is repo rted in 0.2 per I 00 women.
• Hysterectomy is req ui red in 25% by t11 e end of 3 years
because of recun·e nce of me no n·hagia.
MINIMAL INVASIVE SURGERY (MIS) (Table 11 .3)
• D&C a nd endo metri al s tud)' are req uired, ifgen ita ltuber-
culosis or endome u·ial ca ncer is suspected or t11e medica l
therap)' fails. Tho ugh main ly perfo rm ed for a diagnostic
purpose, 30%-40% a re re lieved of menorrhagia at least
for a short period of Lime.
Ablative Techniques
The idea of e ndomeu·ial ab latio n arose from oligomenor-
rhoea occurring in Asherman S) ndrome due to synechiae.
These procedures are safe, effective witJ1 lesser morbidity
than hysterectom). as well as cost-effective wit11 quicker re-
covery. Hysterectom> is avoided in man> cases. The endo-
meu·ium is destro)ed upto the basal la)er.
Fertility is tWI possible Jollmuing themp)'- Therefore,
these procedures are mainly suitable for women who wish to
preserve the uterus, a'•oid hysterectomy, but are not inter-
ested in pregnancy.
The method should desu·oy 2-3 mm of myomeuium, if
recurrence of menonhagia h as to be avoided.
Vatious procedw-es have been dC\•eloped. These are as follows:
• First generation- Hysteroscopic endometrial abla tion by
resectoscope, loop, rollerball coagulatio n a nd lase r (tran-
scervical endo me u·ial resectio n [TCRE ))
• Second genera ti on - Racl iofreq uency-ind uced the rmal
ablation, Cavate rm balloo n tJ1e rapy, microwave endome-
trial ablati on (MEA), lase r the rapy
Ta ble 11.3 Minimal Surgical Methods of Treating
Menorrhagia
Ablative technique
First generation
Hysteroscopic ablation endometrium resectoscope,
roller ball laser (TCRE)
Second generation
RITEA, balloon therapy, microwave ablation
Uterine tamponade In acute bleeding
Bilateral uterine artery embolization

• Utet·ine tamponade
• Bilatera l uterine arter-y embolitation
Hysteroscopic Endometrial Ablation. These procedures
should be performed soon after the mensu·ual pe•·iod or
the endometrium is thinned out by giving progestOgens,
danaLol or GnRH for 1-6 weeks before the procedure. The
patient needs to be selected and contraindications are as
noted below:
• Uterine siLe > I2 weeks ( 12 em) (voiLUne > 30 mL)
• Uterine fibroid
• Sca•Tecl uterus (previous surgery)
• Young woman desirous of pregnancy
• Adenomyosis- TCR£ can cause dysmenorrhoea
• Geni La l infection
• Uterine ca ncer or preinvasive at)•p ical h)•pe•plas ia
TC RE un der ge ne ra l anaesthesia using hysteroscope de-
su·oys 4-5 mm e nclomeuium and forms uterine synec hiae.
T he ea rli er monopolar e lec trode is rep laced b)' a bipolar
eleCLrode (VE RSAPO I NTTM).
Complications arc as follows:
• Anaesthetic complications.
• Fluid imbalance with Auid overload (glycine 1.5%),
pulmona•-y oedema, hypertension, hyponatremia, ana-
phylactic reaction with dexu-an, haemolysis and at times
death.
• Uterine, bowel and bladder i•'\iury with burns and vaginal
fiswla.
• Embolism, infection and haemorrhage.
• Menorrhagia •·ecurs in 25% cases b)>the end of 3 years
and needs repeat TCRE or h)sterectomy.
• Dysmenorrhoea in a few women. and haematOmeu-a due
to cervical stenosis.
Radio frequency-Induced Thermal Endometrial Ablation. lt
is a blind procedure using radiofrequency electromagnetic
thermal energy which destroys tl1e endometriLUn at 66°C.
A 0.6-mm metallic probe is inserted u-anscervically tmder
A B
Figure 11.12 Gavaterm balloon. (A) Balloon inside the uterus. (B) Using the syringe, fluid is Injected through the catheter-inflating balloon.
CHAPTER 11 - ABNORMAL UTERINE BLEEDING (AUB) 137
geneml anaesthesia and •·otated over 360° fo•· 20 minutes.
About85% get cured and 30% develop amenonhoea by the
end of I year. It is cheaper compared to TCRE, does not
require hysteroscope and complications of distending
media are a'oicled. Conu-aindications and complications
are similar to those ofl'CRE.
Advantages of RITEA
• Less skill required to perfonn tl1e procedLu·e. Hysteros-
copy not required.
• Less risk with tl1 is procedure.
An occasional uterine perfor-ation, vaginal heat leading
to vesicovaginal fiswla has been reported.
Cava term Balloon Therapy (Fig. 11.1 2). First invented b)'
Ne uwin.h in 1994, this insu·ument comprises a central
comp ULer S)'Stem, battery and a disposable silicon rubber
balloon cathe te r 5 m m in d ia me ter. Under local anaesthe-
sia, th e catheter is inserted transcervicall y in tO the uterine
cavity, and t11e ba ll oon is d is te nded witl1 15-30 mL sterile
solution such as 5% glucose o r 1.5% gl)•cine. T he hea ting
element in the balloo n raises the temperature to 87°C
( 187°F) and this tempcrawre is maintained for 8 minutes
over a pressure of 160-180 mm Hg to exert a tamponade
effect. The catheter h as an inherent safety design related to
time, pressure and temper-attu·e, and it gets automatically
deactivated to avoid complications. About6 mm of endome-
u·ium gets clestrO)ed, so preoperative endometrium thin-
ning is not required. Approximately, 70%-90% resume
nonnal C)cles ancll5% become amenorrhoeic by the end of
I >ear. Hysteroscopy is not required. Failure in retroverted
utenLS is due LO unequal distribution of heat over the endo-
metrium. Cramping felt in tl1e first few hour-s is treated with
SAIDs and antibiotics are ghen. Conu-aindications are
endometrium tl1icker tl1an II mm and others similar LO
TCRE. This technique is eas) Lo learn.
Microwave Endometrial Ablation. It utilizes magnetic
energy and works atLhe frequency of 9.2 GHz. It is an OPD
procedure, clone under local anaesthesia. It LLSes an 8 mm
Endometrial lining
138 SHAW'S TEXTBOOK OF GYNAECOLOGY
app licaLOr witJ1 no need of preoperative endomeu·ial
tl1inning. Temperature ofSO•C is maintained for 3 minutes.
About 50% become oligomenorrhoeic and 40% amenor-
rhoeic. Up to 6 mm endometrium gets ablated. No eanl1ing
is required unlike TCRE. "Iota! operming time is 12 minutes.
Hysteroscop) is also not required. ll1e comraindications
and complications are similar LO otJ1er ablative procedures.
Vesta System. This system uses a single-use multielecu-ode
intraute•·ine balloon to ablate the enclomeu·ium. The
silicon inflatable electrode carrier has a triangular shape,
which unfolds when its insertion sh ea tJ1 is wimclrawn. The
controller unit is connected to a standard electro sm·gical
gener-ator. It regulates energy to each balloon elecu·ode
plate. The temperature is set at 75•c. The balloon is
inflated with air following cervi cal dilatation up tO No 9.
T he procedure takes 5 minutes under local anaesthesia.
About90%-94% a re cured of menorrhagia. T he instrument
is very expensive and suffic ie nt cia ta are no t ava ilable to
assess its o utcome.
acute 30Mt 24 hls
Uterine Tamponade. Go ld rath advocated ute •ine tamponade
in ac ute episodes of bleeding b)' inserting a Foley catheter,
distending witJ1 30 mL fl uid and leaving Lhe catheter for
24 hours.
NovaSure (impedance-conu-ollecl e nclomeu·ial ablation)
is t11e latest and most safe procedure, ta!Ungj LISt 90 seconds.
It t.ases bipolar radiofrequency and vaporizes endomeuium
up to myometrium.
Endometrial laser in trauterine 1J1ermotherapy (EUTT)
is a new laser tl1e1-ap) that desu·oys t11e en tire e ndome u;um
as well as 1-3.5 mm of m)Omeu·ium. It is clone as an OPD
p•-ocedure, and mkes 7 minutes. The mad1ine is known by
tJ1e name 'G>neLase'. Both touch and non-touch technique
can be emplo)ed.
The second-genemtion ablative techniques are simpler
man TCR£; tl1ey are more effective, safe OPD p•-ocedures;
mey are cost-effective and sa'·e h)SterecLOmy in several
women. They do not requi•-e p•-e-opemtive p•·eparations,
easy to learn and pe1·form quickly without tl1e risk of fluid
imbalance.
Bilateral Uterine Artery Embolization. P1imarily used in
uterine flbroids, tJ1is tec hnique is exte nded in intractable
AUB in a yo ung woman to preserve he r reproductive
function. It is also useful in AUB co mp licated by varicose
uterine vessels.
HYSTERECTOMY
Hysterectomy for AUB is req ui•-ed:
• If medical/ MIS fails or menorrhagia rec urs.
• In older women more than 40 years not desiroLIS of
childbearing, and who opt for hyste•-ectOm)' as a primary
u·eaunem or ab latio n fails.
Initial!) perfonned b) abdom ina l route, it was replaced
b)• laparoscopic h)Ste•·ectomy or laparoscopic-assisted
vaginal hyste•-ectomy (LAV H) for its quick recovery, less
pain, less abdominal adhesions and avoidance of abdominal
scar. Lately, many gynaecologists have shifted LO vaginal
hysterectOmy for undesce nded uterus which may even be
enlarged. This trend is adopted because o f lesser morbidity,
and lesser postoperalive complications of adhesions, scar
hernia and pulmonal') complications.
Vaginal h)sterectOm) is co nu-aindicated if:
I. Ute nas is gross I) enlarged.
2. PreviOltS surge•') with possible ad hesio ns, fixity and limi-
tation of uterine mobility.
3. Presence of endometriosis or adnexal mass.
Nullipa•-ous women or women wim a very na n·ow vagina.
In a woman less than 50 )Cars of age, ovaries should be con-
served unl ess tl1 ey a1-e diseased.
Sequelae or Delayed Complications of Hysterec:tomy
Altho ugh hysterecwmy is a o ne-tim e procedure, safe and
cures AUB, delayed complica tions are kn own to occ ur.
T hese are as follows:
• Ovari an atrop hy due tO devasculariza tion; the woman
develops menopa usal S)•mpto •ns and its co mplications.
• Adhesions of the ova ri es to th e vaginal va ult causing
a n ovarian res idua l syndrom e, dyspareunia and chronic
pelvic pain.
• Vault prolapse.
• Sext.tal clysfw1ctio n - dyspareunia cl ue to a short
• Chronic abdominal pain due to postoperative pelvic
adhesions.
• Urinary and bowel S)lnptoms clue to denervation.
• Psychological disturbances.
NEW SYSTEMS
VERSAPO JNTfM bipolar elecu·osurgical S)'Stem works in
normal saline, is cheap, has excellent haemostasis and
causes instantaneous tissue
Advanmges of Mirena l lJCD over ablative techniques :u·e
as follows:
• Low cost
• OPD procedu•·e - no h ospitali zation
• Prese•'\-ation of ferti li ty after its removal
Pregnancy occ urs wi tJ1in a year. The o nl y disadvantage is
occasional systemi c side effects of progeswgen.
SUMMARY
I. Medical treatm ent sho uld be the first li ne of treatment,
unless con traindicated. The drawbacks are the side
effects of hormones a nd Lhe fac t tha t S)•mpwms so me-
times return once the hormone the rapy is stopped. A
prolonged t11 erapy may not be desirab le.
2. If medical t11erapy fails or is co ntra indicated, consider
tvlirena IUCD.
3. If Mirena fails or side effects develop, go for ablative
techniques. The second-genemtio n ablative techniques
are safer. quick to perform and are eq ually effective.
4. When me abo'e methods fail, consider hysterectomy.
IRREGULAR RIPENING
It is an ovulatory bleeding due to deficient co•·pus luteal
function. The breakthrough bleeding occurs before the

actual menstruation in the form of a spo ttin g or brownish
discharge. Progestogen given d urin g the late luteal phase
cures the spotting.
IRREGULAR SHEDDING (HALBAN DISEASE)
It is rare and self-limited. Irregular shedding is due to per-
sistent corpus luteum. The menstruation comes on Lime, is
prolonged but not hea'T· Progeswgen can suppress the
bleeding, but needs to be ta ken on a tapering dose for
20 days to complete the cycle.
ADENOMATOUS ENDOMETRIAL POLYP
This fonn of polyp is really a locali zed area of endometrial
hyperplasia when area or areas of thickened endomeu·ium
project into th e cavity of the endometrium to look li ke
polyp. T he polyp may be single or multiple, small or large
enough to protrude thro ugh the cervical ca nal. Mostly, t11ey
are sessile and small.
Th is type of poi)'P occurs in fo llowing:
• Endometri al h)•perplasia (a novulawq • C)•cles)
• Metropathia haemorrhagica (diffuse pol)•posis)
• A woman on tamoxifen
• Some cases of fibroid
PATHOLOGY
A pol)p is covered b) cubical epitheli um and contains e ndo-
metrial glands that do not respond 10 hormo nes.
CUNICAL FEATURES
These pol) pi cause menorrhagia, metront1agia or post-
menopausal bleeding. The uterus is nonnal in size or
slighlly enlarged un ifonnly. Ultrasound, sonosalpingogra-
phy and h)'Sterosalpingography detect these pol)pi, but may
miss them, if they are very small. Hysteroscopic visualization
and •·esection is the best treatment, and h)Sterecwmy can
be avoided. Histopathology is mandatory to rule out a tna-
lignant change.
Adenomromatous polyp resembles aden omatot.tS polyp,
but it contains muscle tissue in the stroma. The symptoms
and management are similar in both conditio ns.
ENDOMETRIAL HYPERPLASIA
This occurs in following cases:
• Anovu latOt)' C)'Cies with un opposed oesu·ogen acting on
th e endome u·ium
• Metropathia haemorrhagica
• Obese women
• PCOO
• A woman on tamoxifen
• A menopausal woman on hormo ne replacement
Ll1erap) without progestogen
• Feminit.ing ovarian tumours
H)petplasia ma) be simple h)perplasia, glandular or atypical.
Two per cent women with simple h)pe•·plasia are at a risk
of endometrial cancer, and lo/o- 10% women will1 glandular
h) pe•plasia de,elop the cance•: Atypical hyperplasia,
CHAPTER II - ABNORMAL UTERINE BLEEDING {AUBI 139
however, has th e tendency to deve lop into carcino ma in as
much as 60%-70% cases.
While 80% cases of simple h)'perplasia wi thout atypia re-
spond to progestogens, response of atypical hyperplasia is
only 50%. but with the risk of malignancy. For this reaso n,
atypical endometrial h) perplasia should be treated by h)'Sler-
eCLomy and not merel) b) an ablative tedlnique. A small por-
tion of endometrium left behind and undergoing malignancy
may not be easily detected follo\\ing ablative u·eaunenL
Surprningly, Mirena not iff1'clitlt' against e1ulometrial
hyperplalia wused b)' tamoxif('ll.
ABNORMAL UTERINE BLEEDING
IN ADOLESCENTS
The comm onest cause lies in the H- P-0 dysfunction (50%) .
Immatu re develop ment of these orga ns resultS in anovula-
tion in t11e 1-5 years following menarche, unopposed estro-
gen causing endo metria l h)•perplasia. As t11e girl matures,
the normal mens u·ual C)•Cies a re estab lished.
• Blood d)•scrasia- Coagu laLion disorders, thrombocytOpe-
nia pt.u·pura, Von Wi lleb rand disease, leukaemia acco unt
for 20% of cases.
• Hypothyroidism- 4% of cases.
• PCOO - 10%-12% of cases.
• Genital tuberculosis- 4% of cases.
• Liver disorders.
• Feminizing ovarian tumours - granulosa cell a nd t11eca
cell tumours.
• Adrenal h) perplasia.
CUNICAL FEATURES
Menontlagia may be noticed from t11e start of menarche,
but often the initial C)cles may be nonnal. It takes t11e fonn
of heavy regular C)cles, or normal bleeding lasti ng for sev-
eral days, but d)smenorrhoea is invariably absent in a novula-
l.OI')' crcles. Anaemia may supervene. T he pelvic findings by
ulu-asound scanning are normal except in ovati an tumolll:
It is important to rule out other causes of menorrhagia
before instituting hormonal therapy.
INVESTIGATIONS
• Blood profile- li b%, bleeding and clotti ng ti me, coagu-
lation fac to rs; b lood fi lm.
• X-ray chest fo r tube rculosis.
• Thyroid function testS.
• Pe lvic ultrasound to n de ouL PCOO, early fibroid.
• If medical u·eaU11ent fails, O&C sho uld be done to ru le
o ut endometrial tuberc ulosis by PCR tes t
MANAGEMENT
Aim is to:
• Conu·ol menon·hagia.
• Prevent or treat anaemia.
• Prevent recu•·rence.
• Treat the cause.
140 SHAW'S TEXTBOOK OF GYNAECOLOOY
• Anovulatory cycles lonjkgated
p estrogen
• In an acute episode of bleeding, i.v. Premarin 25 mg
6-8 h ourly will control bleeding in 24-48 hours. There-
after, oestrogen for 21 days with progestogen added for
10 da)S for H C) des "ill •·egulari.t:e the C)cles.
• In chro ni c menorrhagia, oral combined pills or cy-
clical progestogen is the first line of treaunenL
About 70%-80% responds well. Medical u·eaunem
is detailed below.
• SA1Ds: Mefenam ic acid 250-500 mg t.i.d during
Naproxen, ibuprofe n.
• Androgens (dana:t.ol) are not recommended, though
effective, because o f androgenic effects in yo t.mg girls.
• Gn RJ-1 the rap)' ta kes 4 weeks to act, so not useft.tl in acute
episode. The drug is expe nsive and a prolonged treat-
mem more than 4-6 months can cause osteoporosis.
• If progestogens cause side effects, Mirena l UCD for a few
momhs ca n co ntrol menorrhagia.
• Ane ria l e mbo li:t.a ti on is requi red in case of varicosity of
ute rin e vessels.
• Whe n th e above u·eaun e nts fail, ute rine tamponade us-
ing Foley cath eter fo r 24 ho urs can con u·ol bleeding in
th e acute episode.
• Anti-TB trea tme nt in endometrial tuberc ul osis.
Blood u-ansfusion may be required to correct anaemia.
Lately, the trend is to give intravenous tranexam ic acid
I g with 25 mg of oesu·ogen , and then continue with oestro-
gen and progesterone as mentioned above. Desmopressin
analogue of a•·ginine vasop•·essin is given intravenously or
by a nasal sp•-ay ( 1.5 mg/ mL- total l 50-300mcg diluted in
30mL saline) in \'lin Willebrand S) ndrome.
Tranexamic acid inhibits tissue plas minogen activator
which is a fibrinol) tic enL) me, whose level increases in AUB.
KEY POINTS
• AUB ma) be due to general systemic causes, local
pelvic patholog) such as fibroid, adenomyosis, endo-
metrial pOI)p, PI D, fe miniL.ing ovalian tumot.u·s and
pelvic e ndo me uiosis.
• T he manageme nt of AUB is based on th e age of the
woman and her parit)', and th e cause.
• Medical the rapy co mprising va ti o us hormo nes and
drugs sho uld be e mp loyed in youn g wo men as the
first line of treatment. Whe n this fai ls, Mire na, conser-
vative minimal surge•)' or hysterectomy should be
co nsidered.
• Medical th erapy is effective and is the first-line
treatment. Some, howeve1; develop side effects with a
prolonged the•-apy; Mirena IUD is the next choice.
• Mirena is a nonslll-gical effective method to comrol
menorrhagia, and may h elp avoid h)Sterectomy in
many women. Abla li\ e therapy was popular in the
pasL H)Sterectomy is the last choice in AUB.
• In perimenopausal women, D&C is mandatory to rule
out malignanc). lfhistOIOg) is benign, either honnonal
the•-ap), t.lirena o•· hrste rectom) wi ll be required.
• HySLerectOm) can be don e b) alxlominal, vagi nal
route or laparoscopic h)Sterectom). f.ndomeuial hy-
perplasia ma) be simple or glandular without atypia
whose malignant potential is low. It can be treated
conservatively with honnones or minimal invasive
procedures.
• At)pical endometrial h)perplasia has 28%-30% 1isk of
malignancy and should be managed by
SElf-ASSESSMENT
l. Enumerate the catL.Ses of AUB.
2. How wo uld you investigate and manage a case of AUB.
Define AUB. How would yo u manage an adolescem witl1
AUB?
3. Desc tibe t11 e alte rnatives of minimally invasive surgery in
the manage me nt of AUB.
4. the med ical manageme nt of AUBin a 35-)•ear-old
woman.
5. Desc ribe puben y menorrh agia and its management.
6. A 38-year-old wom an presents witJ1 polymenorrhagia.
T he uterus is 12 wee ks size. Disc uss tl1 e management.
7. Write shon no tes o n tJ1 e following:
• Me u·opatJ1ia hae morrhagia
• Endomeu·ial hyperplasia
SUGGESTED READING
Aberd een Endome1rial Ablation Trial> Group. A r-mdom.ized trial of
for 1he Jreatmem of
endomelrial ablaJ.ion
dysfunctional uJerine bleeding: ouJcomc of four )<!at'S. Br J Obstet
Cynaecol 1999; I 06:360-66.
Bre.ilkopf Fredric.k.on RA, Sn)dcr RR. er al. Detection of benign
endome1rial ma»e> byendomclri.thtripe measuremem .in premeno-
pausal women. Ob>rer C)'1Ccol2004:104(1):120.
Farquhar Lerh:tb) A, ct al. An c\aluar.ion for risk factors for endo-
metrial in premcnopau>dl women with abnormal ulrine
bleeding. Am J Ob>rcr 1999:181 (S) :585.
Rhrouf Terr.L> R. Dial-,'llO>i> and .\l.tnagcmcnt of Fonnerly Called
"Dysfunctional L'tcrinc Bk-cding· According LO PAL.\1-COEJ!'\ FICO
Classifiettion and 1hc 1\cw Guidclin<-.. J Ob>tct Ctnaccol India.
20 14 ;64 (6) :388-93.
Rouide$ PA , Phatak PO , Burkart P. ct al. Gynecological and obstetrical
morbidity in women with •on Willcbrand di>ea,.,c: Resui LS of
patiem sun·cy. tl cmophilia 2000:6(6) :643.
Laberge P, Leyland N, Mwji A, F'onin C, Martyn P, Vilo> C, ct al. Endo-
mclrial ablation in ehc management of abnonnal u1crinc bleeding.
J ObsiCI Cyn ac<.:ol Can. 2015;37(4):362-79.
Munro MC, CriJ<.:hlcy 1100, F'm;cr IS, FICO Menstrual Disorders
Working Croup. Th e FICO cla.'i$ifica1ion of caUS<.-s of abnormal
ut erine blee ding in I he rcprodu c1ive years. Fcrlil Sr.cril. 20 II;
95(7):2204-8, 2208.c 1-3.
Pinion SB, Parkin DE, Abamrovich OJ, el al. Randomiscd trial ofh)'>ter-
ecwmy, cndonH:Irial laser abl:uion IJ.ii'ISCervkal cndorneuial
resection for u1crine bleeding. Br Med J 1994;309:
SperoffL, Frit1. MA. Gynecologic Endocrinology and ln ferlility.
81h ed. Lippincou Williams & Wilkins, 2011: 591-62.
S1uddj, S"'ing Lin Tan, Fr.1nk A Chcncnak. Progress in Obsletricsand
Cynaecol<>!,•y. 1996;12:309.
S1uddj, Seang Lin Tan, Fr.1nk A Chcncnak. Progress in Obsletricsand
Cynaecol<>!,'}'- In : Ablati\C Procedure> in Abnonnal L'rerine Bleeding
and 2000:14.
S1uddj , Seang Lin Tan, Fr.mk A Chencnak. Progress in Obsreuicsand
C, naecology. 2005;16:!189.
Studdj, Se-'.tng Lin T.m, Frank A Chenenak. Progress in Obsteuicsand
Cynaecolog). lm·"->i•c Surge!') 2006:1i:259.
\ '!los CA, Ture-'mu V, Garcia Abu·Rafea B. The k·\Onorgt:strd inlf".t-
uterine an cfTt-"Cti\C in women v.ith abnonnal
uterine bleeding:md anticoal-,'\tlamther.tp).j Minim lmasin: C)necol.
2009; 16(4):48().4.
 Primary and Secondary
Amenorrho ea
Amenorrhoea 141 Key Points 153
Primary Amenorrhoea 141 Self-Assessment 154
Secondory Amenorrhoea 146
AMENORRHOEA
The initiation of mensu-uation is an imponant milestOne in
the reproductive lives of women.
Ameno•·rhoea denotes the absence of menstruation. It
ma) be ph)'siolbgical or patholbgictll.
Its onset may be pri"wry or seco11dar)'.
Plr;•swlogical tmterUJrr/UJe(l nawrall) prevails before the
onset of puberty, dt.tring pregnancy and lactation and after
menopause.
Pathological tlmeJwrrhtie(l is th e result of gene tic factors,
systemi c diseases, endoc rin opathies, diswrbance of the
h)'PO tha la mic-pituitary-ova rian-t tterine ax is, gynatresia,
nuu·itional factors, drug usage, psychological factOrs and
other •·arer causes.
Primary tmwwrrhoea refers to the failure of the onset of
menstmation be)ond the age of 16 )ears, regardless of de-
,-eJopment of secondary sexual charactet'S.
Seco11tlary amnwrrhow1 refers to the faillU·e of occurrence
of menstruation for 6 momhs or longer in women who have
previously menstruated.
Normally, menarche occurs between 10-16 years of age,
with a mean age of 12.5 years.
PRIMARY AMENORRHOEA
Prima•-y amenorrhoea at the age of 11 years behoves the
clinician to unden.ake investigations for the cause of
of occurrence, and institute a timely therapy. How-
eve•·, 111 the presence of well-<leveloped secondary sexual
characteristics, investigations ma) be dela)ed lllltil the age
of 16 )Cars with the hope Ll1at spontaneous menstruation
will eventually ensue in due course of time. This occurs in
tklayed p ubert)'·
In the vast majority of cases, a detai led evaluation of
growtJ1 charts, height and weight reco rds, chronology of
t of seconda•-y sexual ch arac teristi cs, body
hab ttus, htstory of cychc abdom inal pain, administration of
drugs, histOry of illnesses such as wberculosis, thyroid
d isease, juvenile diabetes, mumps and an)' previous s urgery
may be important in revealing the possible aetiological
cause. Physical examination should include documentation
of tJ1e height-weight ratio, stature, l 'imner evaluation for
maturation staLUs of Ll1e seconda•-y sexual characteristics
and obse r'l'ation of any genetic or endoc•·ine stigmata. The
presence of the uterus and vagina must be established
by ultrasound scanning of Ll1e pelvis. In all patients present-
ing with primary amenorrhoea, estimation of the levels of
serum fo llicle-stimulating hormone (FSl-1 ), oestradiol and
prolactin is important. Serum FSI-I levels he lp to differenti-
ate between the central nervous system (CNS) ae ti ologies
and gonada l failu re. A baseli ne radio logical evaluati on of
bone age and a simple skull film or cr to exclude pitui tary
macroadenoma should precede further investigations.
Genetic ka•-yotyping is slrongl)' indicated in all subjects
revealing serum FSH levels elevated more tl1an 10 miU/
mL. A few selective investigations such as th)•·oid function
profile, •·enal function tests and androgen estimation must
be done when indicated.
ClASSIFICATION
The spccu·wn of diagnosis preseming cli nicall)' as primary
amenorrhoea can be conveniemly class ified accord ing to
the status of her serum FSH levels in to h)' pergonaclotropic
(FSH > 40 mlU/mL), e ugonadou·opic or hypogonado-
tropic (Tahl e 12. 1).
HYPERGONADOTROPIC PRIMARY AMENORRHOEA
• Gonadal dysgenesis: 450X (Tumer S)ndrome) mosaics,
abnormal X.
• 46XX pure gonadal dysgenesis.
• 46XY gonadal dysgenesis - Swyer S)ndrome, testicular
femini:ting S)'lldrome.
• Gonadou·opin-resistant ova•-y syndrome Savage
sy ndrome.
EUGONADOTROPIC PRIMARY AMENORRHOEA
A. Absence of development:
• Androgen insensitivity syndrome (testicular feminization).
141
142 SHAW'S TEXTBOOK OF GYNAECOLOGY

• l-l) pOth alamic hypogonadism (Kallma nn S) ndrome);

Table 12.1 Classification of Primary Amenorrhoea gonadou·opin-releasing hormone (GnRII ) d eficie ncy
Secondary sexual characteristics normal
S) ndrome.
Imperforate hymen • Ps)ch ogeni c causes, weight loss, stress, anore xi a ner-
• Transverse vaginal septum vosa and maln utrition.
• Absent vagina and functioning uterus B. Pituita•)' ca uses:
• Absent vagina and nonfunctioning uterus • t>i tuitarism causes short statw·e, obesity, genital dr->uuph)\
(Mayer- Rokitansky- KUster- Hauser syndrome [MRKH]) menta l reta rdation, pol)•dactyly and retini tis pigmemosa.
• XY female - androgen insensit ivity • Neoplasms - prolac tinomas, cra niopharyngiomas,
• Resistant ovary syndrome ade no mas and empty sella tu rcica.
• Constitutional delay • Hypopituita •)' StateS- Simmond disease, Chiari-Fromme l
Secondary sexual characteristics absent S) ndrome, Forbes-Albright syndrome and pineal gland
Normal stature tumour.
Hypogonadotrophic hypogonadism C. Severe S)'Stemic diseases sud1 as tuberculosis, S) ph ilis.
Congenital D. Other e ndoc•·inal disorders - th)l·oid o r adre na l gland.
Isolated gonadotrophin-releasing hormone defiCiency
Olfacto-genital syndrome
Aoquired AETIOLOGY
Weight loss/anorexia
Excessive exercise
According to the location of cause of ame no rrl1oea aetiol-
Hyperprolactinaemia ogy is as follows:
Hypergonadotrophic hypogonadism
Gonadal agenesis • De layed pubert)'·
Chromosomal aberrations resulting from XX· agenesis • Pregnancy before menarche is exu·emel)' rare, b ut not
Gonadal dysgenesis impossible.
Turner mosaic • Ce re bral co n e x - stress, emo tional disturbances, infec-
Other X deletions or mosaics tion . tra uma, tumo ur.
XY enzymatic failure • H) pothalamus- Kallmann syndro me.' igo rotiS exe rcise ,
Ov a"ian failure
weight loss.
Galactosaemia
Short stature
• Piwitary gla nd - empty sella turcica, Frohlich S) ndrome,
Hypogonadotrophic hypogonadism Laurence-Moon-Biedl syndrome, Cushing disease,
Congenital pineal tum our, prolactinaemia, galactosaemi a.
Hydrocephalus • Oval)' - Turner syndrome, primat)' ova ri an failu re
Acquired (Savage syndrome), polycysti c ovarian disease (PCOD),
Trauma 17-hyd rox)•lase defic iency.
Empty sella syndrome • Gen ital u·act- abse m uterus, (Ma)•ei'-Rokitansky-Kuster-
• Tumours l-la\ISe r [MRKH] syndrome. Testicular fe minizing syn-
Hypergonadotrophic hypogonadism drome), refractOry endometriLtm, obstructio n in the lower
Turner syndrome
ge nital tract, ge nital tuberculosis, Ashe rman syndrome
Other X deletions or mosaics
(uterine adhesion) .
Heterosexual development • Chro moso mal - ime rsex, Turner S) ndro me, testicular
Congenital adrenal hyperplasia femini1.ing S) ndrome, Swyer S) nd•·ome.
Androgen-secreting tumour • Other endoc•ine glands - juvenile di abetes, thyroid,
Sa-reductase deficiency adre nal glands.
Pa'tial androgen receptor deficiency
• Drugs- u-a nquillizer·s, antihypertensives, antidepressantS,
• True hermaphrodite
• Absent M Ollerian inhi bit or
metoclopramide, oesu·ogen.
• Nuuition- overweight, weight loss, tuberculosis, malnuuition.

ANOREXIA NERVOSA
Anorexia nerv0.5<'l is a pS)'C hological somatic self-impo.sed eating
• M Clile rian agenesis- th e abse nce o f ute rus/vagina. disorder mainly affecting adolescents and )'O ung women more
Ro kita nsky-KCISter-Hauser synd ro me. tJ1an men. It is tJ1e failure to maintain bo<l) weight for age and
B. ormal Mf1lle rian development: height. For me n$truation to occur, minimal fat should consU.
• Female o r true intersex. Lute 22% of bod) weight. Loss of weight > 15% catt$es amenor-
• Po l)C)'Sti c ovar y sp 1dro me. •iloea Leptin in tJ1e fat initiates GnRH secretio n. When weight
• Adrenal or thyroid diseases. reduction fa lls below required body fat, GnRH and gonadotrO-
C. C.)'ptomenoni1oea - imperforate hymen, vaginal pin secreti ons faiL Clinically, fasting, excessive exercise \,1111 or
septum, cervica l atresia. witJ1out pu•·ging and self-induced vomiting ca use auu phy or
D. Tube rcular e ndometritis. nondevelo pment of breastS and amenorrhoea ( 12. 1).
£. Constitlllional delay- nuu·ition. Hypoes u·inism tJ11.1s induced following ca uses:
HYPOGONADOTROPIC PRIMARY AMENORRHOEA • Morta li ty tJuough cardiac failure, arrh ytJ1mia ( 15%).
A. Hypothalam ic causes: • Ame no rrhoea, infertili ty, decreased libido.
• De layed menarche and puberty. • Osteopo rosis.
 CHAPTER 12 - PRIMARY AND SECONDARY AMENORRHOEA 143

• Nutritional
• GnRH to 1n1Uate h)• potha la mic-pituitary-ovarian
(H-P- 0 ) axis
• Ho nnona l the rap): To initiate o r co mple te H-P-0 axis

About 70% imprO\e "ith treatme nt.

KAUMANN DISEASE
This disease occurs in I :50,000 girls. Low o r abse m GnRH is
due to either autosomal d ominant or an X-linked autOso-
mal recessive gene. The condition is charaCLet-iLed by anos-
mia and ma ldevelopment of n eurons in the a rcuate nucleus.
Management
• GnRH and pituitat)' h orm ones to induce menstruation,
ovulation.
• OesLrOgen and progestogen cyclically to induce mensu·uation.

CUNICAL APPROACH
T he cli nician is req uired to make an assessmem of the
cause of primary am enorrhoea on th e of history,
clinical exam ination and tests tJ1at are most likely to provide
the answers to the unde rlyin g cause . Such information will
provide ilie basis to offe r a reaso nable prognosis and ini tiate
rational u·eaunenL Table 12.2 offers clinical guide lines for
Rgure 12.1 Anorexia nervosa. (Source: Lawrence A. Schachner, mana gem em of primat)' ame no tThoea.
Ronald C Ha nsen . Pediatric Dermatology. Cutaneous manwestations of Some believe in clinical classifica tion based on tl1e
endocrine, metaboliC, and disorders. Mosby, 20 11 .) presence/abse nce o f seco ndary sex characters, stawre and
heterosexual develo pment.
• H)percortisolism, decreased muscle mass, low lGF-1 , 1mponant features to be no ted are as fo llows:
h) poili) ro idism, anae mia, granulocytOpenia, neuu·openia.
• Ps)chiauic problems. 1. HistOI') of diabetes, TB, mumps.
2. Family histOI')' of PCOD, d ela)ed pubeny, testicular fetni-
Management
niLing S) ndrome.
• Ps) chological 3. Height, weight, breast developmem- cenain stigmas.
• Ps) choilierapy 4. Thyroid enlargemenL

Table 12.2 Clinical Approach t o Primary Amenontloea

Clinical
Features Presumptions Di stinguishing Tests

Breasts Lack of breasts indicates lack of oestrogen production from FSH level identifies cause of oestrogen lack; high
absent; gonads (causes - H-P-0 1allure, lack of ovarian follicles, lack FSH (ovarian failure), low FSH Indicates hypothalamic-
uterus of two active X chromosomes, Tumer syndrome [Fig. 12.2D; pituitary failure; GnRH d istinguishes hypothalam us
present presence of uterus Indicates that the Y chromosome is absent (LH tl from pituitary cause (no LH response)

Breasts Presence of breasts Indicates presence of gonadal Serum testosterone levels high In androgen (Y
present; oestrogen ; absent uterus Indi cates MUllerian agenesis, chromosome), but normal In 46XX with M Ollerlan agenesis;
uterus or presence of Y chromosome or testicular fem inizing karyotyping confirms genetic sex. Gonadectomy advised
absent syndrome for androgen sensitlvly syndrome, MUllerian syndrome.

Breasts Absent breast suggests lack of oestrogen; because of Karyotyping - 46XY, high FSH and testosterone -
absent; gonadal agenesis, the absence of gonads, gonadal en - normal female range suggests gonadal agenesis/
uterus zyme defects; absent uterus Indicates the presence of Y absence; gonadal biopsy to detect enzyme
p resent chromosome with testes that suppresses MOIIerian devel· deficiency
opment ; the presence of normal female external genitals
Indicates the absence of testes, hence no testosterone
present when external genitals were developing

Breasts The presence of breasts Indicate oestrogen present; uterus Investigations Include following: progesterone challenge
present; present Indicates Y chromosome is absent test, S. prolactin and thyroid profile, tests to exclude
uterus genital TB; urine test for the presence of and
present UPT and USG to be done to rule out pregnancy
144 SHAW'S TEXTBOOK OF GYNAECOLOGY
Short stature
·------Characteristic
facial features
Low hairline - - - -
+-+---Poor breast
development
Rudimentary
ovaries
Small
finger nails Gonadal streak
(underdeveloped
gonadal
structures)
Brown spoiS (nevi) ---+
No menstruation
Figure 12.2 Clinical features of Turner syndrome.
5. Abdominal mass.
6. Uluasound for presence of uterus, haemawmeu-a,
presence of oval'ies.
7. Chromosomal study
MANAGEMENT
HYPERGONADOTROPIC PRIMARY AMENORRHOEA
Hyj>ergonOllotropic jJrinwry ammorrh()('a patim!S have gonadal
failtt1'11. Various fonllS of gonadal dysgenesis account for
t11ese cases. These women h ave streak ovati es with the ab-
sence of ovarian follicles, there is no oestrogen production
and they have eleva ted levels of FSH (>40 m iU/mL) and
low oesu·ad io l levels (< 25 pg/ mL ). T he sexual develop-
me nt is prep ube rtal with no endometrial proliferation;
lumce, the fJroge:.teroue clwllfnf,re II'St is 11egative. Chromosome
studies reveal 45XO chro mosomes (Turner sy ndrome) .
Some pa ti e nts wi tJ1 mosaicism or minor su·ucLUral abnor-
ma li ties of the X chrom oso me ma)' have a few functional
fo llicles capable of inducing menstn.tation, stray ov ulation
and pregnancy. Cluvmruome is rPlruant.
Gonadectomy is indicated in patientS with testicular
femini.ling syndrome, as these male go nads are prone to
malignancy. Intersex is discussed in Chapter 9.
Women with streak ovaries are infertile, but tl1ey can bear
children with OOC) te donation. All women in tl1is group must
be treated with C)clic oesu·ogen and progestogen to promote
feminialtion and secondat) sexual characterisLics and pre-
vent osteoporosis. Women with resistant ov:uian srndrome
have nonnal ov:uies on histology, tlley show the presence
of pt·imordial follicles, but there is probably a deficiency of
receptors for FSH. They are not amenable to u·eaunenL
Savage syndrome is due to a receptor defect of gonado-
tropic hormones in ovaries, and resembles autoimm une
disease and resistant ovary S) ndrome. The height is normal,
ovaries com:Lin follicles but serum FSH is raised.
EUGONADOTROPIC PRIMARY AMENORRHOEA
l ftlle FSH levels are within a normal range, t11e women have
nonnal breast development; but due to abnonnal Mullet;:m
development, tlle ULentS may be ntdimemat)' or absem
because of insetlSiti,'ity to androge tlS.
ln women witll testicular syndrome, the
phenotype is a female with a kat)Otype of 46XY chromo-
somes. The gonads are testes often present in the inguinal
canal and produce testosterone and Mullerian-inhibiting
factor, but because of androgen insensitivity at tat·get ot·gans
(due to deficiem andt·ogen receptors or lack of enzymes
to convert testostero ne to th e mo re active dihydrotesLOster-
o ne) tl1ese patients present witJ1 lack of axillary h air and
pubic hair, absent ute ms and upper vagina. T hey h ave a
blind pouch of the lower vagina. Breast develop ment
appears normal because of peripheral co nve rsion of a ndro-
ge n to oestrogen. T hese gonads a re prone to maligna ncy;
therefore, as soon as full sex ual deve lopmen t is ac hieved b)'
the age of 18-20 years, a prop hylactic gonadec tomy sho uld
be advised, followed by oesu·ogen tJ1 erapy to maintain
feminization. A vaginoplasty may be contemp lated at an
appropriate Lime in the future.
On t11e contrruy, women witJ1 simple MCtllerian agenesis
and a kaf)'Otype of 46XX present witJ1 normal secondary
sexual cl1aracters and functional O\-aries (RokitaJlSky syn-
drome). Tl'le) reveal a normal hormone profile. l11issp1drome
is associated with renal and skeletal abnonnal ity in 30% of tlle
cases. l11ese women do ovulate, and appropriate managemem
requires a-eation of a functional vagina for coital putposes. If
tlley plan to have children, it may be through sw-rogacy.
ln women with Ct)ptomenot·rhoea presenting as pt·imaJ)'
;unenorrhoea, tlle common cattSe is an intact hymen or vagi-
na l septum. A histOt)' of cyclic abdominal colicky pain, reten-
tion of urine, tl1e presence of a palpable abdominal lump
a11d t11e of a tense bluish bulging membrane on
separation of tl1e labia enables the diagnosis. Ultrasotmd
scan ofthe pelvis confirms it. A simple cntciate incision ofthe
hymen permits free drainage of t11e collected mensm.tal
blood and leads to a normal reproductive functi on.
Septate vagina or a u·esia vagina req uires excisio n and
vaginoplas ty.
T he vagina l septum is recognized from the im perforate
hymen by a pinkish concave cove ring in co mrast to the
b lu is h convex bulge in the Iauer. The vaginal sep u.un , i.e.
atres ia, requires more ex tensive dissection and vaginop lasty.
T he atresia in tl1 e upper vagina and cervix often restenosis
after surgery a11d eventually requ ires hyste rectOmy.
• Polycystic disease is desctibecl in the chapter on Ovarian
Ttunours.
• 17-hydroxrlase deficienC) cattSes deficiem cortisol secre-
Lion and raised levels of adrenocorticotropic honnone.
This cattSes h) pertellSion, h) pernatraemia, hypokalaemia
and ;unenot·rhoea.
• Endomeu·ial nonresponsiveness and amenorrhoea are
due to absent hormonal t·eceptors. Honnonal profile
remains normal.
• Tubercular endometritis requires anti-T B treaunenL
 CHAPTER 12 - PRIMARY AND SECONDARY AMENORRHOEA 145

HYPOGONADOTROPtC PRIMARY AMENORRHOEA NUTRITION

l11ese women have FSH level less than 40 mlU/ mL Hypogo-
nadotropinaemia leading LO h}p ogonadism is usually t11e result
of h)-pothalamic d) function, pitui tary failure o r systemic
illnesses. Administration of GnRH helps to differentiate hypo-
tllalamic dysftulction from pi LUi tal) failu re. In t11e latte•·, GnRH
stimulation will not raise LuteiniLing Honno ne (LH ) level.
Empty sella turcica is characte JiLed by he.-njalion of
subarachnoid membrane into t11e pituita•) ' sella wrcica and
may exist with pineal gland tumour as prolactin adenoma.
The absence of pituitary gland causes absence or low level of
FSH and LH. Gonadotro pin honnone t11erapy is required.
OTHER HORMONAL DYSFUNCTIONS
Both hypot11y•u idism (c•-etinism) and hype•·tl1y•u idism can
cause amenon·hoea. Congeni ta l ach-enal hype•·plasia an d
tumour are also respo nsible fo r pri mary ame norrhoea, so
also j uven ile diabe tes.
Prematw-e ovari an fa ilure seen in I% of the cases is clue to
poor germ cell migrati on fro m t11 e yolk sac dUJing fetal
development or d ue to an acce lerated rate of depletion
(apop tosis) of unkn own reaso n. In t11i s co nditio n, FSH leve l
is more t11an tiO miU/ mL, and E2 level is below 20 pg/ mL
KaryoL)'ping is req ui red. T he woman prese ntS me nopausal
S)'mp toms. She needs hormo ne r-e placemem tll erapy (HRT) .
Excessive we ight, anorexia ne rvosa a nd maln utrition with
loss of we ight are also respo nsible fo r ame no n·hoea in
yo ung gi rls.
The most common ca use o f h) po thalamic dysfunclion is
re lated to ps) choge nic effects, a nore xia ne rvosa, we iglu loss
and inapprop riate secretio n of neurotransmine rs leading LO
Jack o fCnRH S) nthesis (Kallmann S) ndro me) . Wo men with
Kalbnann S) ndrome manifest isolated d eficiency of CnRH
associated witll olfactory dysfunction and a nosmia .
Pituita ry fa ilure generally follows hypopituitarism,
neoplasms or empty sella turcica. Skull radiogra phy or pref-
erabl y MRI, estima ti on of prolactin levels and ophtl1almic
evaluation of the fields of vision help to arrive at a diagnosis.
Fn:ihlich syndrome consists of short stature, Jet11argy, obe-
sity, genital dystroph y a nd amenoni1oea. In La urence-
Moon-Biedl syndro me, polydactyly, retinitis pigmen tosa
and mental defici e ncy are the additi o nal featur-es.
In all such wo men , C)'Ciic ad ministra ti o n of oestrogen
and p rogestogen to mainta in fe mininity and preve nt osteo-
porosis is essenti al. In case tlle woman desires LO conceive,
induCLio n of ovul ati o n with gonadotropins is warranted.
In wome n with neoplas ms, app rop ria te ne urological
consul ta tion fo llowed by treaun e nt with b romoc rip tine for
prolacti nomas or surge r)' sho uld be pla nned.

( Primary A menorrhoea )
Absence of menses by 14yr with
normal pubertal changes

Examination of girl
height, weight,
breast, pubic &
axillary hair

Normal height Short height

• Tall/Normal height
Normal weight Poor breast
• Features of hirsutism
Normal breast development

Look for presence O varian Dysgenesis Investigate for :

of vagina (Turner's syndrome) • Androgen Insensitivity
45XO/Mosaic syndrome
• Polycystic ova ries

• Absent uterus
Uterus presen 1
• Non canalised
Vaginal patent
vagin a

Mullerian Agenes is Asherman Syndrome

(Normal FSHILH)
Or
Ovarian Dysgenesis
(Raised FSHILH)
146 SHAW'S TEXTBOOK OF GYNAECOLOGY

SUMMARY AETIOLOGY (Fig. 12.3)

MCtllerian agenesis: Absenl/blincl vagina, normal breastS,
normal FSH/ U I.
Ashennan S) ndrome: ormal uterus, nonnal vagina,
nonnal FSI-I/ Ll-1 but fail to have withdrawal bleeding
wil.h oesu-ogen + progesterone.
Ovarian d)sgenesis: o rmal/s hon heiglu, poor breast
d evelopmem , raised FSI I/ LH, ka•)Otype abnonnality.
Androgen insensith·ity S) ndrome: Tall, nonnal breastS, blind
vagina, absent Ulems, 26XY pattem.
PCOD: Obese, hi rsutism, n ormal FSH/ LH, increased LH.
SECONDARY AMENORRHOEA
Secondary ameno rrhoea is clefinecl as amenorrhoea of
6 months or more in a woman with previous normal men-
strual paue rns in the absence of p regna ncy a nd lactation
(2%-3% women).
However, in cli nical practice, pa ti e nts seek advice earlier
and it is prudent to begin with s im pler investigations and
reassurance and awa it the outcome.
Many causes are similar to those of p•imary amenorrhoea.
However. the emphasis is so mewhat different. Dysfunction
of the h)pothalamic-pilllital") - Ova ria n-uterine axis ac-
cotuus for the majorit) of cases of pathological secondary
a me no n"hoea.
The catLSes can be classified as follows:
• Physiological
I. Pregnancy
2. Lactation
• Pathological
I. Genital u-act
• Acquired obsu·ucti on (gynatresia) of cervical canal
causing severe stenosis or atresia follows elecu·ocau-
terization, che mi cal burns, ce rvi cal amputation in a
Fothergi ll repair opc•·atio n, co ni zation for cervical
dysplasia or ce rvi cal inu·aep ith elial neoplasia (CIN)
and genitalwbercul osis.
• Vaginal au-esia due to scam ng following a u-aum atic
delivery.

( Causes of amenorrhoea )

i Critical and external stimulus

( Chromosome Hypothalamus (GnRH deficiency)

Portal vessls

Anterior pituitary gland

Adrenal • Environmental
Endocrine factions
diabetes
gland • Nutrition
thyroid

Ovary
• Turner's syndrome
• Swyer syndrome
• PCOD
• Primary CNarian failure

Normal uterus Obstruct

Absent uterus
(Refractory • Imperforate hymen
• Mayer-Rokitansky-Kuster
endometrium • Absent vagina
syndrome
tuberculosis) • Atresia cervix
Figure 12.3 causes of amenorrhoea.
 CHAPTER i 2 - PRIMARY AND SECONDARY AMENORRHOEA 147

• Ashe rman sy ndrome followin g excessive curettage,

uterine infec tion o r endomeu·ial tuberc ulosis,
transcervical resectio n o f endo metri tun for abnor-
mal ute line bleeding (see Ch apter 21 ) and uterine
packing in postpa rtum hae mo rrhage.
• Vesicovaginal flswla - ca1l.Se unknown.
2. Ova rian causes
• Surgical extirpation.
• Radi othem py.
• Autoimmune d isease (th) roid, diabetes).
• Inducti on of mul tiple ovulation in infertility -
leading to premawre menopause.
• PCOD.
• Resistant ovalian syndrome - due to absent FSH
receptors.
• Infecti o ns- mumps, wberculosis, and in rare cases,
pyogeni c infections.
• Masc uli nizing ovarian w mour'S.
• Pre ma ture menopa use p rematu re ovarian
fa ilure . Figure 12.6 X-ray of pitui tary fossa showing extreme bone expan-
3. NutriLi onal ca uses sion due to pituitary tum our.
• Ano rexia ne rvosa, bulimia (Fig. 12. 1) .
• Ex u·eme obesity.
• Excessive weiglll loss in athletes and ballet
dan cers.
4. Pituitary causes (Figs 12. 1- 12. 9)
• Insuffi cie ncy as in Simmo nd disease, Shee han
sy ndrome .

Rgure 12.4 Acromegaly. Note the broad enlargement of t he nose

and coarse facies. (Source: Wlklmedla commons.)

Rgure 12.5 Gigantism. Child aged 1 yeac, measuring more than

3 feet in height. Figure 12.7 FrOhlich syndrome.
148 SHAW'S TEXTBOOK OF GYNAECOLOGY

Figure 12.9 Cushing syndrome. Note hirsutism of face, obesity and

striae.

• Re na l disease - d ue LO red uced exc re ti on of LH

Figure 12.8 Pituitary infantilism, patient aged 17 years. Note and prolac ti n.
obesity, aplasia of breasts, absence of pubic hair and short stature. • Severe anaem ia, maln utrilion.
• ldiopatl1ic, genetic.
RESISTANT OVARIAN SYNDROME
• 1-l)perprolaclinaemia. In resistant O\'<lJ'ian syndrome and autoimmune disease,
• Tumours such as prolactinomas and chromophobe O\'<lries fail to respond LO gonaclou·opin honnones and
adenomas and Cushing disease. cause amenorrhoea. The O\'<lJ;es show plasma cells and
• Empty sella syndrome. lymphOC)le infiltration. Biopsy, however, is not necessary for
• Drugs - tranquillizers, oral co ntraceptive (OC) the diagnosis. FSH level is high. It may be prudemto study
pills, metoclopramide, dopamine blockers, antihy- antithyroid, rhewnatoid factors and antinuclear amibodies
pe nensives, antidepres.\>ants, cimelidine and p heno- to establish autoimm une d isease. Pregnancy wi tJ1 a donor
thi azine. egg in in viu·o fe 11.ilization (IVF) is possible.
5. Hypothalamus.
• Gn RH deficiency. SIMMOND DISEASE
• Vigorous exercise -stress, obesity. Simmond disease related to pregnancy and Sheehan
• Pseudocresis. syndrome follo,,ing severe postpanum haemoni1age cause
• Brain tumours. pituitary necrosis by thrombosis of iLS vessels, a nd panhypo-
• Ano•·exia nerYosa. pituita•·ism. The woman tails LO lactate following delive•)',
6. u prare nal causes remains letJ1a 1-gic and shows signs of h)pOtll)roidism and
• Addison disease. cortisol deficienC). She requires appropliate honnonal sup-
• Adrenogenital syndrome. pen. A )Oung woman may require ovulation induction
• Suprarenal tumour. drugs to achieve conception.
7. Thyroid In the management of seconda•)' ameno•,·hoea, tl1e clini-
• 1-1 )'pothyroidism, chest wa ll lesions. cian must auempt to answer tl1e fo llowing six questions
• Graves d isease. seq uentiall )' to an·ive at a diagnosis quickly and econom ically.
8. O ther ca uses
• Diabetes. • Is t11e patie nt pregnant?
• Tuberculosis- li ver disease. • Is her semm prolactin level elevated?
 CHAPTER 12- PRIMARY AND SECONDARY AMENORRHOEA 149

• PCOD
• Adrenal
tumour
• Ovarian
tumour

Hormone
assays
• Premature • Gonadal • Turner's Absent Testicular
• FSH
ovarian agenesis syndrome uterus and feminizing
• LH
failure • Testicular vagina (XY-female)
• PRL
• Resistant feminizing • Rokitansk y- syndrome
ovarian syndrome Kuste r-
syndrome • Enzymatic Hauser
• Gonadal failure syndrome
dysgenesis

Delayed PCOD • Turner's • Pituitary f ailure • Hyper-

menarche syndrome • Hypothalamic prolactinaemia
• Resistant failure • Prolactinoma
ovary
• Premature
menopause

Figure 12.10 Investigations in amenorrhoea

Clinica l exam ination, urine pregnancy test and sonographic

• Is th ere cl inical evidence of oesu·ogen deficiency?
• Does she have a positive response to the progesterone
challenge Lest?
• Is it premawre menopause?
• What are the levels of her serum FSH and LH?
The import.·mce of each of the above questions is
analysed in detail below. Detailed history is importanL
INVESTIGATIONS (Fig. 12.10)
PREGNANCY
This is the most common cause of secondary amenorrhoea.
Hence, its exclusion must precede all further investigations.
scan of the pelvis s hould help to establish the diagnosis
be)•ond doubt.
ELEVATED LEVELS OF SERUM PROLACTIN
Prolactin secreted by the anterior piwimry gland is
normally under the inh ibiLOry effect of hypothalamus by
the prolacLin-inhibiLOI") factor dopamine. It is stim ulated by
oesu·ogen and suckling. It is also present in the decidua
and amniotic fluid. Prolactin levels flucwate pe,;odically;
therefore. several measurementS may be necessary LO
confirm h) pe•·p•-olactinaemia which is defined as persistent
high level of prolactin in a nonpregnant and nonlacmting
woman.
150 SHAW'S TEXTBOOK OF GYNAECOLOGY
Causes
Apart from the physio logical condition of pregnancy and
lactation, it occurs in the following cases:
• During sleep, stress, nipple stimulation and chest wal l
inju l)' such as herpes zoster.
• £ mp t)' sella turcica.
• ll)•po tha la mic tum our, p itui tal)' tum o ur and head inj ury
(acro megal)', Cushin g disease, Addiso n d isease) .
• Twenty pe r cent cases of PCOD and in some cases of
endometriosis.
• H)'POthyroidism because of the stimulati ng effect of
raised thyroid-stimulating hormone (TSH).
• Uver and chronic renal disease because of ahered
metabolism and delay in excretion.
• Drugs such as neuroleptics, narcotics, antidepressantS,
phenothiaLine, antihypertensives, calcium channel block-
ers, prolonged use of OCs, oesu·ogen (i n high doses),
cocaine, amphetamine, cimetidine, haloperi dol, mew-
clopra mi de. Seroto nin and opia tes red uce the level of
dopamine and cause hype rprolac Linaemia.
T he woman p rese nts with o ligo rnenorrhoea culminating
in amenorrhoea d ue to suppression of FSH and LH.
About 50% of the cases develop galactorrhoea. Infertility
and abortion through corpus luteal phase defect are other
features. Headache and visual disturbances occur when the
tumotu· presses upon the optic nerve. In males, it causes loss
of libido, impotency and infertility. The normal level
of prolactin is 25 ng/ mL. Levels up to 100 ng/ m l suggest
hyperprolacti naemi a and more than 100 ng/ m l occurs in
the presen ce of a tumour. CT, MRI and visual ch eck-up are
neceSStl l)' in the diagnosis a nd follow-up. Th yroid functions
need to be chec ked.
Treatment
• Treat the cause.
• Drug-ind uced h)'Perprolactinaernia requires stoppage of
drug or alternative therapy.
• Bromocriptine and long-acting del'ivatives are effective in
most cases. Menstrual C)cles are restored in 3-momh
time. About 90% ovulate and ?Oo/o-80% conceive.
• Quinagolide 25-150 mg daily in divided doses with a
ma intenance dose of75 mg dai ly.
• T he d n1gs are disc ussed in detail in th e chapter on
llorm o nal T he rapy.
• Mac roadeno ma (mo re than 10 mm ) and microade no ma
not respo nd ing tO drugs req uire tra nssp heno idal ade nec-
tOm)' o r rad iothe rapy 4500 cGY for 25 clays.
30% rec urrence rate is reported with in 6 years, and
prolonged follow- up is necessary.
EVIDENCE OF OESTROGEN DEFICIENCY
Hot flushes, loss of breast mass, dyspareunia and d 1)'ness of
vagina are suggestive of lack of oestrogen and premature
menopause. It requires oestrogen replacement th erapy.
POSITIVE PROGESTERONE CHALLENGE TEST
T his test depe nds o n the prese nce of oestrogen-primed
endo metriu m in the ute rine cavil)'· T he test is considered
pos1uve, if the patient responds to the adminisu-ation of
01-al tablet medrox) progesterone (Pro,·era / Modus/ Oevil·y)
10 mg dai l)' for 5 days or i1'\iection progesterone in oil
100 mg inu-amuscularly or Primolut-N 5 mg three times a
da)' for 3 days. Withd1-awal bleeding occu1-s withi n 2-7 days.
A positi ve test indicates amenorrhoea seconda1)' tO anovula-
ti on . T he comm on unde rlying causes a re h)•po th alamic
dysfuncti on a nd polycys tic ova ry synd ro me.
A nega ti ve tes t req uires giving oes u·adio l 0.02 mg
or conj ugated oes u·ogen 1.25 mg for 25 days a nd progesto-
gen from 16th to 25th day. A negative test suggestS
endometrial unresponsiveness in the presence of normal
FSl-1.
Pituifltl)'. In Simmond disease due to pan h) popituita-
rism, the woman is lethargic, blo<XI suga1· and th)l·oid
functions are low. When postpartum haemon·hage causes
vascular thrombosis of the pituitary vessels, panhypopituita-
rism is known as Sheehan syn drome. CT and MRJ detect a
tum out: FSH and LH are required.
H)tJotlw lamif tiysfimction is the most freq ue nt ca use of
seconda l)' ame norrhoea. Altho ugh in tJ1 e of
cases no specific cause can be fo und, a careful his w ry may
reveal a prec ipitating factor. Stress and may co nu·i]).
ute to ame nor rh oea. Stress s itLtations are ofte n poorly
recognized by the pa tient (examinations, change of jobs,
economic problems, breaking up of relationships, etc.). A
prolonged use of phenothiazines and triC)clic antidepres-
sant drugs affect dopam inergic systems in the C S and
are associated witJ1 raised levels of p1·olactin hormone.
PollfJill <mlelwrrluJnJ (I%) following tJ1e use of OC pills is
also th e l'esult of hypothalami c dysfunction. The d iagn osis
is made o nly if spo nta neo us menses do not resum e afte r 6
mo ntJ1s of sto pping the pill. In s uch wo me n, cha ngeove r
tO a n OC p ill with a hig he r oes u·ogen co ntent (e tJl inyloes-
tradi o l 0.05 mg da ily fo r 2 1 days C)•clicall)', fo r a few cycles)
he lps to resto re normal cycles. Weight change and mnenor-
rlwea are not uncom mo nly seen in clinical practice. Yo ung
adolescent girls and working women are often the sub-
jects of this disorder. A weight loss exceeding 15% of the
ideal weight may predispose the woman lO menstrual dis-
turbances. hwestigations at tJ1is stage may 1·eveal nonna l
FSH and LII values and the patient will respond positive
to a p1·ogesterone challenge test. H owever, as tJ1e weigh t
loss funher increases (an orexi a n ervosa) to 25% or more,
low levels of ho rm o nes namely gonadot ropins and oesu·o-
gens are obse rved, and th ese are ofte n acco mpa n ied
by tJ1yro id dysfun ctio n. Proper co unsell ing and advice to
rega in we ig ht ofte n suffices. However, th ere is a subgro up
of patients who resist ad vice and may need psyc hia u·ic
u·eaunent. An excessive weigh t gain may a lso be accompa-
nied by mensu·ual irregulal'ities. Obesit) is often a mani-
festation of a stress situation leading to a compulsive
eating disorder. Successful weight reduction often
restores regu lar menstruation. Pol)'C)•Siic ovary• syndrome is
associated with an abn ormal gonadotropin secretion
revealing an increased ratio of LH:FSH exceeding 3: 1,
whi ch differentiates patien ts of PCOD from patien tS
witJ1 hypothalami c d ysfun cti o n. In pa ti ents with PCOO,
ovari a n ste ro idoge nesis is abnorm al, leading lO a n in-
creased prod uctio n of androste ned ione and testoste ro ne,
 CHAPTER 12 - PRIMARY AND SECONDARY AMENORRHOEA
which in turn predisposes the patient to hirsutism, acne
and mensu·ual irreg ularity. The diagnosis is established
on the basis of clinical suspicion, an increased LH:FSH
ratio and sonograph) revealing enlarged ovaries wit11
multiple peripheral qstic follicles. Laparoscopy reveals
bilateral enlarged ovaries wit11 thickened tunica albuginea
and multiple C)Stic follicles.
Ultrasound scanning helps in t11e diagnosis of PCO O,
ov;uian tumour and ute•·ine lesions such as haematometra
and Ashennan S) ndrome.
Specific /real men/ wi II depend on the cause and the
patient's desire for fenility at the time of consultation.
lf she desires fertility, the treatment of choice is induction
of ovulation with clomiphene citrate or gonadotropi ns.
On the conu-a•-y, if the patient does not desire feni li ty,
she may be advised a p•·ogestational agem (medroxyp ro-
gesterone or dydrogcsterone) for 7-10 days every
2 mon ths or so to i nducc pe ri ods. T his t rea tm ent protects
tJ1e patient aga inst tJ1c ill-effectS of e ndome tri al hype rpla-
sia, ad eno mato us hyperp lasia and endo me tri al ca rcinoma
due to prolo nged un opposed oestroge n ac tio n o n th e
endo me trium . T hese patien tS sho ul d be advised to use
so me form of contraceptio n (co ndo ms/diaph ragm)
to safeguard them aga inst an)' u nwa nted preg na ne)' resu lt·
ing from a su·a)' ov ulation or spontaneo us recover)' of
menstrual function. Premature menopa use req ui res HRT
to protect against osteoporosis and avoid menopa usal
symptoms.
A h)'sterosalpingogram or prefe•-ably a diagnostic hyster-
oscop) helps to establish the diagnosis of Asherman
S)'lldrome. first described in 1918. Operative hysteroscopy
to lyse the S) nech iae, followed b) cyclic honnonal the1-apy
with high doses of conjugated oestrogens of2.5-5.0 mg/ day
for 3-6 montJ1s, results in the resto•-ation of menstruation
in about 50% of cases. Some surgeons prefer to insert
an intraute.-ine device in the ute•·ine cavity after lysis of
adhesions to ensure keeping the cavity patent and prevent
recurrence of adhesions. Hypo-oesu·ogenic of
secondary amenOJThoea have senun oestradiol levels
of less than 30 pg/ ml and benefit with oestrogen ;md
progestenme therapy. Ashennan S)'ndrome is caused by
di latation and cureuagc (D&C), medical tenn ination of
pregnancy (MT P), utcline packin g in postpartum haemor-
rhage, uterine infection and wbercular endometri tis. It
ca uses ameno n·hoea, oligome no n·hoea, dysmen orrh oea,
hab itual aborti on a nd inferti li ty depe nd ing upon th e exte nt
of ute line cavity obli tem ti o n.
SUMMARY
Ovarian failu re: Raised FSH/ LH, no witl1d rawal b leeding
witJ1 progestin b ut get witJ1drawal bleeding with Oestt·ogen
+ Progestin
Asherman S)'ndrome: Norma l FSH/ LH, no withdrawal
bleeding with Progestin. No withdrawal bleeding witll
Oestrogen + Progestin combination
1-l)'Perprolact.inaemia: Galactorrhoea, .-aised serum prolac-
tin levels get witJ1drawal bleeding witJ1 Oestrogen +
Progestin
Anorexia nervosa: Low FSH/ Ll-1 , no withd.-awal LO
Progestin
151
PCOD: Normal FSH, raised Ll-1 , feature of hi rs utism,
withdrawal bleeding LO Progestin.
FSH AND LH CONCENTRATIONS
Women with h)po-oestrogenic amenorrhoea have either
ovarian failure or h) pothalamic-pi tu itar)' d)'sfunction.
Serum concentrations of FSH and Ll-1 of more than
40-50 ml U/ ml are d iagnoSLic of ova•·ian failure. Serial
assessments may be necessary because of the pulsatile
nature of pituitary gonadou·opin secretion. Most women
younger than 40 )Cars belonging LO this category
have prematu•-e ova .-ian failure, about I 0%-15% have
gonadotropin-resistant ovaries (Savage syndrome) and
another 10%-15% have autoimmune ovarian failure. The
last two entities have their norma l complement of pri-
mordial follicles, but their granulosa cells do n ot respond
to FSH. T here are no other clues to suggest the gonado-
tropi n-resistant ovarian S)' ndrome. However, evidence of
a n)' o ther auto imm une d isorde r ( myaHhe n ia gravis,
rheum atO id arth ritis, S)'Stc mi c lupus e •-y the ma tosus -
SLE) a re s ugges ti ve of a uto immune ova ri a n fa ilure
wi t11 hypergonado trop ic a me no rrh oea. 1-l )'pO th alamic-
p itui tal")' d)•sfunc ti o n or fa ilure may occ ur witJ1 a we ight
disord er ( < 85% o r > 125% of ideal bod)' we ig ht), a
tu mo u r of the h)•pothalam us o r pitui tary gla nd, after
head inj ur)', fo llowing in fi l u·ating lesions, after surge•-y or
irradiation. Most often the cause is not known. ACT scan
or MRl should be asked for if there is evidence suggestive
of a central mass lesion. In women with FSH and LH v-al-
ues less than 5 ml / m L, measurementS of Lh)'roid func-
tion tests (T, . T. and TSH) and serum cortisol concenu·a-
Lions are important LO exclude pan h)'POpituitarism
involving other tropic hormones additionall)'- Such
women will require concurrent th)l·oid and corticoste-
roid replacement thempy as well. HRT for premature
menopause is wa•·.-anted along with supplementary
oral calcium and advice on change of lifestyle. In women
with hypothalamic failure, the.-apy should begin with
preliminary priming with Gn RH administered in pulsa-
tile fashion with a pump or subcutaneously for several
weeks unti l tl1e circulating levels of serum oesu-adiol of
greater than 600 pg/ ml arc achi eved, before ini tiating
gonadotropin th erapy for ind uctio n of ovulation in
wom en desiring pregnane)'.
See Table 12.3 fo r ae tiolog)' of ame no n·hoea according
Lo a natOmi c sites a nd reco mme nded d iagnosti c wo rk-up.
T he ma nage me nt of seconda r)' amenorrh oea is shown in
Fig. 12. 11.
Sequela of secondary a menorrhoea
I. Menopausal symptoms, osteoporosis.
2. Lnferti liL)' in a young woman.
3. Psychological effects, loss of li bido.
Management
• HRT for menopausal S)mptoms and proph)'laxis.
• Induction of ovulation, IVF for infertility.
• Induction of menstrual C) des.
• Treat the cause.
152 SHAW'S TEXTBOOK OF GYNAECOLOGY

Table 12.3 Aetio logy of Amenorrhoea According to Anatomic Sites and Investigations
Anatom ic Gonadotr op in
Level Anatom ic Site Pat ho logy Leve l Diagnostic Methods

1. Hypothalamus Tumours, Kallmann syndrome, weight Low Clinical evaluation MRVCT

loss, exercise scan

2. Anterior pituitary Panhypopituitarism, Sheehan syndrome Low History, examination,

GnRH stimulation test

3. Ovary Gonadal dysgenesis, Turner syndrome, ovar- High History, karyotyping,

ian falure (premature, radiation, mumps, gonadal biopsy
surgical excision, chemotherapy), ste-
roiclogenic defect (adrenal hyperplasia)

4. Anovulation PCOD, hyperprolactinaemia, weight Normal Hi.s tory, progesterone

loss, stress, exercise, drugs, chest wall challenge test, USG/MRV
stimulation CT scan

5. Uterus or MUll erian agenesis, RKH syndrome, Decreased FSH , History, examination,
endometrium Asherman syndrome, t uberculosis, Increased LH, karyotyplng, USG,
radiotherapy, androgen insensitivity increased prolactin laparoscopy, hysteroscopy

6. Outflow tract Imperforate hymen, vag inal agenesis, Normal History and pelvic
cervical atresia examlnatlon/USG

Secondary ameno rrhoea

(Absence of menses br
duration of 6 mths in
the absence of
pregnancy/lactation)

!
Rule out pregnancy by urine
pregnancy test & UIS

Estimate FSH; LH ;
Prolactin; TSH

Low FSH/LH/normal
Raised FSH Normal FSH/LH
FSH

• Ovarian failure/
Asherman Syndrome/
premature menopause Hypothalamic/
Removal of uterus/
• Polycystic ovarian pituitary cause
Cervical stenosis
disease

• Pituitary causes/
Anorexia nervosa

Figure 12.11 Management of secondary amenorrhoea.

 CHAPTER 12 - PRIMARY AND SECONDARY AMENORRHOEA 153

( Investigat ions )

Rule out pregnancy -Perform pregnancy test

Negative
• Nonresponsive
endometrium
• TB endometrium
• Asherman syndrome
• Progestrogen therapy
• PCOD
• An ovulation

( Management)

Not Interested In pregnancy

or menstruation
[ Interested In menstruation
• Hormone therapy E, P
J Infertility
• Induction of ovulation
• No treatment •lUI
• Hormon e therapy E, P • IVF
• Donor eggs

Figure 12.11, cont'd

KEY POINTS • Failure Lo achie'e pubert) b) the age of 13-14 years

• onnal menstnJation requires Lhe imegralio n of Lhe
H-P-0 axis ''ith a normal functioning uLerus, a paLem
outflow u-acL and a nonnal genetic ka•)Otype of X)(.
• Menarche occurs between the ages of 10 ru1d 16 >eru-s,
with a mean age of 12.5 }ears.
or failure to achie\e menarche b) Lhe age of 15-16
requires imestigations.
• Amenoni10ea ma} be due to a honnonal funclional
disorder or be an earl) S)mpLOm of genital u-acL
abnormalities, hence, the need for Lhorough
im estigation.
154 SHAW'S TEXTBOOK OF GYNAECOLOGY
• Clinical exami nation, honnone assa)S, ulu-asonogl"a-
phy, endoscopic procedures and genetic testing may
be required for t.he diagnosis of amenorrhoea.
• In India, wberculous endomeu·itis and Asherman
syndrome may cause h ypomeno n·hoea or secondary
ame no n·hoea.
• Trca un enL of a menorrhoea depends upo n the ca use.
llo rmonal th erapy o n a lo ng-term basis may be
req uired for proper growth and to maintain men-
strual funct.ions.
SELF-ASSESSMENT
I. Classify t.he causes of primary amenorrhoea.
2. Desc ribe the management of prima ry amenorrhoea.
3. Wh<ll are the ca uses of seconda ry ame no n·hoea. How
would yo u manage s uch cases?
4. I low wo uld yo u diagnose and manage a case of prema-
ture ovarian fail ure?
SUGGESTED READING
Aim.ltl J , Smentek C. Premature o\"arian failure. Obstetrics and Gyne-
cology 198.?;66( I) :9-14.
O,r!;,on I. Alte mari,·es to h)"'tcrcctomy for menorrhagia. N
EngiJ Med 1996;335:198-99.
C'J111ong C.J, Brenne r PF. Management of abnormal ut erine bleeding.
Am .J Obstet Cyne col 1996; 175:787-92.
De Arcc MA. Co.tigan C, GosdenJR, et al. Further '"idcnce consistent
"ith a. an indicator of risk of gonadal bht>toma in Y-bearing
mosaic no mer >p>drome. Clin Genet 1992: 41:28.
Cise Lll. K.1>e Bcrko"itz RL (eds). Contcmpontry 1-..ues in Obstet-
rics and Gynecology. The Premenstmal Vol. 2.
Chu rchill Livin!,>stone; 1988.
Il asin M, Dcnnerstein L, Gotts G. Menstrua l relate d coon plaints:
A cro.,.cttltttml st udy.] Psychosom Obstct Gynecol 1988;9:1!>-42.
Knobil E. T h e n ettrocnd <:>crine control of th<: menstrual 'ycl<::. Recent
Progr I lorm Res
Kra>na Ill. Lee ML, Smilow P, et al. Risk of malignan cy in bilaterdl
>lreak gonads: the role of theY chromtt>Ome. J f'<"<lhdr Surg 1992;
27:1376.
Laitinen EM. Vaar.tlahti K, Tornrni.skaJ, et al. Incidence, phenot}pic
feature• and moleL1.olar genetics of Kallmann >}11Clromc in Finland.
OrphdnetJ Rare Dis 2011; 6:41.
Lukma T. Frp»JP, Rleczkowska A, Van den Bc.yhc II. Role of gonadal
in gonadoblastoma induction in 46. XV indi,iduals. The
Lemen experience in 46, >.'Y pure gonadal and testia•lar
>)1>dromes. Genet Couns 1991; 2:9.
Martin KA, llaii.JE, Adams Cro"·lcy WF Jr. Comparison of exoge-
now. gonadotropins and pulsatile hormon e
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End<:>erinol Metab 1993; 77:125.
Pr.tctice Com mittee of the American Society for Reproductive Medi-
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Warren MP. The effeet of e xercise on pubertal progre>sion and repro-
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Six year follow-up. 1c urosurgery 1983; 12: 180-83.
 Fibroid Uterus
Fibromyomas 155 Key Points 173
Endometria l Polyps 172 Sell-Assessment 173
FIBROMYOMAS
Fibrom)'Omas (leiomyoma, fibroma, fi bro ids) are th e co m-
monest benign neop lasm arising from uterus. T hey are
common!)' seen in women of rep rod uctive age, incidence
varies from 5%-20% of women depend ing upon age group.
They tend to be mul t.ip le in numbers. Size may vary from
peanut size to often as big as size of a head of a newborn.
Small fibroids may be palpable only on vaginal examina-
tion. but once uterus is enlarged, they may become palpable
per abdomen. All fibroids begin in myometrium but some
ma) grow more towards endomeLrial (submucous
type). or others ma) grow tOwards Lhe serosal surface of
uLen.tS (subserotLS t)pe). However, most. Lend 1.0 remain in
m)omet.-iwn (interst.itialt)pe).
Fibrom)omas (leiomyomas, fibroids or simply myomas)
are the commonest benign uterine neoplasms, commonly
encountered in gynaecological pract.ice (5%-20% of women
in the reproductive age group). They are slow-growing
tumours and Lake 3-5 yea•-s 1.0 be clinically palpable unlike
ovarian wmour-s. They tend to be mult.iple in numbers, but
some may grow large in size.
AETIOLOGY
A m) 0 ma is derived fro m smooth muscle cell rests, e ithe r
1 suppl y blood to the fibro id li e in the capsule and se nd radial
from vesse l wa lls or ute rin e musc ulawre.
Al th o ugh oestrogen, progestero ne growLh hormo ne and
hwnan p lacen tal lactogen have bee n im p licated in the
growtJ1 of myomas, the evidence in support of oestrogen a nd
progesterone dependence for their growtJt is impressive:
• Myomas are rarely found before puberty, and they generally
cease to grow after menopause.
• New myomas rarel) appear aft.er menopause.
• The associat.ion of fibroids in women witJt hyperoestro-
genism is evidenced b) endometrial hyperplasia, abnor-
malut.erine bleeding and endometrial carcinoma.
• M)omas are kt10\\1l 1.0 increase in siL.C dw·ing pregnancy
and witJ1 oral conu-acept.ives trsage and shtink aft.er delive ty.
IE To \iew the lecture nole> .can 1he >pnbol or log in to your account on
• Trea un ent witJ1 mi fep ristone to shtink Lhe fib roid proves
that progestero ne, like oestroge n, is respo ns ib le fo r th e
growtJ1 of the fibro id. Gn RII also shrinks Lhe fibro ma.
• Risk fac tors are early menarc he, nu llipara or low pa ri ty.
Un usual fo 11ns of le iomyomas inc lude inu·aveno us
leiomyomatosis, which is characterized by polypoid projec-
tions of smooth muscle wmours into the veins of the para-
metritun and broad ligaments. During surgery these appear
as wonn-like cords of benign fibrous tissue when pulled out
of tJ1e veins. Fragments of tumour emboli can catLSe
obstruct.ion of blood now from tJte atrium and sudden
deatJ1. Similar!). a rare form of disseminat.ed intrape tiLOneal
leiom)omatosis imoh ing large areas of subpe•·it.oneal sur-
faces is seen du.-ing pregnancy and while on oral conu-acep-
tives. The fibroids are often associaLed with adenomyosis,
pelvic endomeuiosis and pelvic inOammaLory disease.
PATHOLOGY
Grossly myoma is a well-circumscribed tumour with a whorled
appeat·ance and a pseudocapsule. It is firm in consistency.
T he cut surface is pinkish white and has a whorled appear-
-
ance. T he capsule consists of connec t.i ve t.issue ,,11ich
surro unds the wm our in the m)'Omeu·ium . T he vessels that
b mnches inLo tJ1e Beca use of tltis arrangeme nt of
b lood supp ly, the cenu·al po rt io n of tJ1e fi broid receives the
least blood suppl)', a nd degeneratio n is no t.iceable early and
most often in tJ1is part of Lhe fibroid. O n t.he other hand,
calcification begins at tlte pe tip hery and spreads inwards
along tlte vessels. T he vessels are best seen over the subserous
myoma whereas in tJ1e case of large in tram ural growth, they
can be seen beneatJl Ule periLOneal covering of the uterus -
tJtis serves to distinguish tlte enlargemem of t.he uterus due
1.0 a myoma from a normal intmuterine pregnancy.
Microscopicall). the tumour consistS of bundles of plain
smooth mtLScle cells, separated b) var) ing amoum of fib roLLS
strands. Areas of embt)Onic mtLSde Lissue may be presem in
a m)Otna.
155
156 SHAW'S TEXTBOOK OF GYNAECOLOGY

The tumour may grow symmeuically, remain ing with in The majority of myom as arise in the uterus b ut t11ey may
t11e myo metrial wall, when it is called 'inu·amural' or 'intersti- also arise from the round ligame nt, the uter<r<>varian and
tial'. Lf the tumour grows outwarcl5 LOwarcls tlle peritoneal uterosacral ligamen LS, the vagina and the vulva. Tumours
surface. it shows itse lf as a bossy growtll and is tenned as 'sub- can t11erefore be classified as uterine and exLrauterine -
serous'. Further extrusion o utwards witll tlle development of the uterine m)omas are further divided in to t110se tllat
a pedicle makes it a ped unculated fibroid. Ln rare cases, sucll a1ise from the bod) and tllOSe that arise fro m the cervix
a mmour gets attached to a vascular organ and is cut off from (Figs 13.2-1:3.7). Subserous and cervical myomas contain
its ute•·ine origin (parasitic fibroid). Ute•;ne conu-actions
may fo rce the m)oma the ca\ity where it is covered
only by a min endometrium, it is then called 'submucous'
m)oma. This myoma may force itself downwards LOwaJds t11e
vagina by a pedicle, and become a 'submucous myomatous
pol yp'. The distribution of m)Oma in me body of tl1e uterus
is broacU y classified as follows (Fig. 13.1A) :
• lmramura l (interstiti al) 75%
• Submucous 15%
• Subserous I 0%

Parasitic fibroid - Figure 13.2 Calcified In tramural fibroid and subserous fibroid on
attached to bowel the right of the picture.

g- pedunculate Ña•ÑtdY
1-
2-
<501

>
501
.
intramural
.
Intramural
/ sabmucosd

Pedunculated -
submucosal fibroid
-1-.a 3- 1001 .
intramural Konta d- e- endometrium
4- Intramural
A
5-
subbasal 17504 Intramural .

6- subserosal ,
<
501 .
Intramural
7-
svbserosal peduncalatd
g- other

Figure 13.3 (A) UHrasound Image o f a uterus (lit) enlarged and

F19ure 13.1 (A) Varieties of submucous fibroid. Va-ious anatomical sites
of fibromyomas. (B) Endometrial polyps. (&lu"ce (A): Hacler ard M::lore's
Essentials of Obstetrics cn:1 4th ed. Saunders,
irregularly distorted by muHiple leiomyomas (arrows). Such studies
are useful to exdude ovarian enlargement. B, bladder; Cx, cervix; V,
vagina. (B) Ultrasound image showing uterus with fibroid. (Source
(A): Hacker NF, Gambone JC, Habel CJ Hacker and Moore's Essentials
of O:lstetrics and Gynecology, 5th ed Philade_,Ha: Else..;er, 201 0.)

Figure 13.4 (A) Interstitial fibroid uterus. (B) Uterus showing multiple fibroids: submucous, Intram ural and subserosa! fibroids.
Figure 13.5 Submucous myoma.
more fibrous tissue and less of musc le as compared to other
varieties of uterine myomas.
The presence of myoma causes hyperplasia of the
myometrial wall. The cavity of the uterus is often distorted
and enlarged. The endometrium tends to be thicker due
to endometrial h)perplasia. The ovaries at times are
enlarged. qstic and h)peraemic with an of
salpingo-oophol'itis in about 15% cases.
Cenical, submucous and broad ligament fibroids are
usually single. Interstitial and subserous fibroids may be
single or multiple, va11ing in siLe from a seedling fibroid to
a huge neoplasm.
CHAPTER 13 - FIBROID UTERUS 157
CERVICAL FIBROID
Cervical fibtuids account for I %--4% of all fibro ids. These
may develop as a central, anterio t; posterior fibroid or grow
laterally in the broad ligament (Fig. 13.8).
PSEUDO-MEIGS SYNDROME
Penduculated fibroid can cause right-sided hydrothorax
and ascites mimicking malignant ovarian tumour. This is
known as pseudo-Meigs S)ndrome and this disappears
spomaneousl) following removal of the tumour.
SYMPTOMS
A cervical fibt·oid exet·ts pressure on the bladder, ureter and
in rare cases on the recwm. A woman may feel a lwnp in the
lower abdomen. During pregnancy, it can cause retention of
urine. Obstructed labour occu•-s if the cervical fibroid lies
below the presenting pan. The other clinical featw·es are
those of uterine fibroids.
Other Sites of Fibroids
Occasionally, fibroids may be found at th e following
uncommon sites.
Broad ligament fibroids: These fibroids are mostly uterine
fibroids wh ich ex tend late ra ll y in t11 e broad ligament
(pseudo broad ligament fibro id). Rare I)' fibroids may
arise d e nova within broad ligament e itl1er from wa ll of
a vesse l or some Other struclllre, a nd then these are
called u·ue broad ligament fibroids. Altho ugh fibroid
from uterus extending into broad ligament displaces
ureters and vessels laterally and downwards, true broad
ligamem fibroids displace ureter and vessels medially
and upwards.
Round ligament fibroid'!: Occasionally, a fibroid may al'ise
from rotuld ligamenL
Ovarian ligament fibroids: Fibroids attached to ovarian
ligamem ma>•al'ise from this stn•eture, but is uncommon.
Parasitic fibroids: When a fibroid is found in a suucwre
such as omentum or surface of intestine, they may arise
from uterus, and subsequently because of blood supply
158 SHAW'S TEXTBOOK OF GYNAECOLOGY

I
.

.
A

Cervical! %
• Anterior
• Posterior
• Central
• Lateral

Interstitial 75%

• Pedunculated
• Parasitic
• Broad ligament fibroid
B
Figure 13.6 (A) Development of different types of uterine myomas. (B) Types of fibrolds.

from these structures, loose their attachment to uterus
and appear to arise from omentum or intestine.
SECONDARY CHANGES IN FIBROIDS (Table 13.1)
Atrophy
As a result of diminished \<aSCula•·ity after menopause, there
is shrinkage in the si.te of the LUmour, which becomes firmer
and more fibrotic. A similar change occurs in myomas after
delivery. when a tumour easil) palpable during pregnancy
may be difficult to define. Temporary shrinkage by 50%
occLu·s following GnRI-Ia therap), but regrows after sLOp-
page of therap).
Hyaline. cystic and fatt) degenerations that occur in the
central areas of fibroids are of no clinical significance and
are caused by diminished vascula•·ity in large fibromyomas
(Figs 13.9 and I:UO).
 CHAPTER 13 - FIBROID UTERUS 159

Rgure 13.7 Submucous fibroid polyp protruding through the cervix.

(Courtesy: Dr Naraya1 M Patel, Ahmedabad.)

Figure 13.9 Fibroid w ith hyaline degeneration: smooth muscle cells

Table 13.1 Secondary Changes and Complications arranged in fascicles wit h marked hyalinization. (Courtesy: Dr Sandeep
in Fibromyomas Mathur, AIIMS.)

• Hyaline change, cystic degeneration and atrophy

• Calcareou s degeneration, osseous degeneration
• Red degeneration
• Sarcomatous change
• Torsion, haemorrhage
• Infection/ulceration , particularly In the dependent part of a
submucous polyp
Inversion of the uterus
Endometrial carcinoma associated with fibromyoma
Endometrial and myohyperplasia
Accompanying adenomyosis
Parasitic fibroid

Figure 13.10 (A) Cystic degeneration In a fibroid. (B) Leiom yoma with
cystic change: Leiomyoma with presence of prominent cystic areas,
oedema and vascular congestion. (Courtesy: Dr Sandeep MathLr, All MS.)

Figure 13.8 Cervical Fibroid .

Calcareous Degeneration
In calcareous degeneratio n, phosphates and carbonates of
lime are deposited in the peliphel') along the course of the
vessels. The best examples of calcareous myomas are those in
old patients with lo ng-standing m)omas. They are like 'womb-
stones· in graveyards. Odcareous tumours are easily idem.i-
fied on a plain X-rayofalxlomen (Figs 13.11 and 13.12) .
Red Degeneration
This complication o f ute rine myo mas develops most
frequently during pregnane), altl1ough it is not rare in cases
of pa.in.ful m>omas in women olde r tl1 an 40 years. The my·
oma becomes tense a nd tender a nd ca uses seve re abdom.i-
nal pa.in with co nstitutional upset and fever. The tumour
itself asSllmes a peculiar purple red colo ur and develops a
fishy odour. lf the wmou•· is carefull)• exa mined , some of
the large veins in the capsul e and the small vessels in tl1e
substance of the tumour will be found thrombosed.
160 SHAW'S TEXTBOOK OF GYNAECOLOGY

Rgure 13.11 Laparotomy finding of uterus with an anterior cervical

fibroid.

T he discolo urati on is possib ly caused by diffusion of

blood p igments from the tJ1rombosed vessels. HisLOiogically,
apart from thrombosis, no specific appearances have
been identified. LiLLie is kn own of the exac t ae tio logy, and
particularly, as of why on ly the myoma is involved and
not tJ1e myomeLrium. AltJ10ugh the patient is febrile wir.h
moderate leucocytosis and raised ESR, the condition is an
aseptic one (Fig. I:U :l). It needs LObe differentiated from
appendicitis, twisted ovarian cyst, pyelitis and accidental
haemoni1age. ILrasound is ttSeful in the diagnosis.
Pseudomeig Syndrome
A pedunculated fibroids ma> cattSe liglu side hydrot.horax
and ascitic mimicking malignam wmour. Removal causes
automatic •·egression of tJ1ese fluids.
Sarcomatous Change
Sarcomatous change in a myoma is ext.remely rare, and t.he
incidence is not mor·e tJ1an 0.5% of all m>omas. Lmramural
and submucottS wmou•-s have a high er pc)lemial for sarco-
matous ch ange than subserous tumours. ILis rare for malig-
nam change to develop in a woma n younger than 40 years.
lL is more co mmonly seen in a postmenopausal woman Figure 13.12 (A) Radiograph showing large calcified myoma
when it is observed that tJ1 e wmour grows s uddenly, ca using (B) Ultrasound showing fibroid uterus. (C) MRI showing degenerative
pain and posune nopausa l b leeding. To the naked eye, a fibroid. (Courtesy: Dr Parveen Gulatl, New Deihl.)
sarcomatous myoma is )'ellowish grey in colour and hae mor-
rhagic. T he consiste ncy is soft a nd ftiab le and not firm like
a simple m)'Oma (Fig. 13. 1tl ). Ano tJ1 er impo n a m sign is the so-called 'wande rin g fibroid' o r pa rastuc fibroid. Axia l
nonencapsulatio n of tJ1e lllmour. Sarcomas are highl)' tOrsion of a subserous myo ma is a mre phenomenon.
malignant and sp read via tJ1e bloodstream. Axial rotation of the who le uterus with myo ma itself is a
very rare occurrence. In such cases, a large subserot.LS
myoma is usually auached near the fundus; the utentS itself
OTHER COMPUCATIONS OF MYOMAS
being only slightJy en larged, and tJ1e site of rotation is in the
Torsion neighbourhood of the intemal os, at abo ut ilie level of
A subserous pedunculated myoma may undergo rotation at Mackenrodt's ligaments; the S)lnptoms are comparable with
ilie site of its attachment to the uterus. As a result, ilie veins those developing with torsion of a subserous myoma.
are occluded and the tumour becomes engorged wiili
blood. Vet") severe abdominal pain is experienced. In very Inversion
rare cases, the rotated tumour ma)' adhere to an acljacem Inversion of the uterus cattSed by a submucottS fundal
viscera, obtain a fresh blood supply from iliese adhesions m>oma has been desclibecl in Lhe chapleron Displacements
and finally gets detached complet.ely from tl1e uterus- t.he of t.he Uterus.
 CHAPTER 13 - FIBROID UTERUS 161

Figure 13.15 Myomas with concomitant carcinoma of endometrium.

Rgure 13.13 Red degeneration of a myoma. Note that the encap - (Source: Nirmala Duhan, Daya Srohiwal. European Journal of O:>stetrics
sulated tumour shows uniform dark dlscolouratlon. and Gynecology. Uterine myomas revisited. Elsevier, 2010 .)

Table 13.2 Clinical Symptomatology and

Complic ations Associated with
Uterine Fibromyom as

Menstrual disturbances - menorrhagia, polymenorrhagia,

Intermenstrual bleeding, continuous bleeding, postmeno-
pausal bleeding
Infertility
Pain - spasmodic dysmenorrhoea, backache, abdominal
pain
• Lump In the abdomen or mass protruding at the Introitus
• Pressure symptoms on adjacent viscera - bladder, ureters
and rectum
Rgure 13.14 Sarcomatous change In a uterine myoma. The dark o Pregnancy losses, postpartum haemorrhage, uterine inversion
Irregular areas in the substance of the myoma, which lie in the middle o Vag inal d ischarge
of the specimen, represent areas of sarcomatous change.

Capsular Haemorrhage o Pain

If one of the large veins on 1he surface of a subserous o PressureS) mptoms
m)Oma ruptures, profuse inLrnperitoneal haemonnage can o Abdominal lump
cause acute haemorrhagic shock. o Vaginal discharge

Infection Not a ll fibroids cat.LSe

Infec tion is common in s ubm ucous and m)'Omato t.LS polyps
if Ll1e)' project imo Ll1e ce rvica l canal or the vagina.
An infected polyp can ca tL5e blood-sta ined p u rulent
discharge. Infec ti on is more like!)' in the postpartum and
postabonal state. lf the tumour causes delayed postpartum
haemon·hage (PPH ) or sepsis, it m ay have to be removed.
Associated Endometrial Carcinoma
Endometrial carcinoma is associated with fibromyoma in
women o lder than 40 years in 3% cases. H) peroesu"Ogenism
expla ins the coexistence of th ese two cond itions (Fig. L3.l5
a nd Table l3.1 ) .
SYMPTOMS (Table 13.2)
o Me norrhagia, pol)1m e norrh oea, me trorrhagia, con ti n uo us
o r postmenopausal bleed ing
o Inferti lity, recurrent abortio ns
11W11)' tl.l 50% women (Ire m)•mpwmatic. These fibroids
are d e tec ted during gynaeco logica l c heck- up or ulu·aso u nd
done for u nrela ted sym ptoms. T he woman may have a
va li ety of sy mptoms depending upon Ll1e number, size and
location of the fibroids. Fibroids are seen in women of
chi ldbeal'ing age, and rarely may be seen in younger women.
Wom an ma>' be nullipai'Ous or of low parity (only 20%-30%
women are multiparous). Oela)e<l men opause is observed
in a woman wiLl1 fibroids. Occasionall)'• woman complains of
posunenopalLSal bleeding.
MENSTRUAL DISTURBANCES
Progre:;sive menorrlwgia seen in intramura l a nd submuco t.LS
myom a is due to increased vasc ularity, e ndom e trial h)•per-
plas ia and en larged uterine cavity. Fu rL11e r away from L11e
caviL)', lesse r is Ll1e possib ili ty of me norrhagia. For this
reaso n, s ubserous and pedunculated nbroids do not
cause menorrhagia.
① interference @ noemal contraction uterus
of
② pelvic
congestion
4 dilation endometrial venous plexuses
③ congestion of

162 SHAW'S TEXTBOOK OF GYNAECOLOGY
Figure 13.16 Fibroid with endometriosis.
metrorrhagia → ulceration
torn vessels
endometrial Ca
Polyme,wrrlwea occ urs whe n cys ti c ova ries and pelvic inflam-
matOt')' disease (PlD ) coexist with fibrom)'Omas.
Metrorrhagia is com mon with subm uco us fibroids. An
infected pol)'P will also cause purule m d ischarge. Metror-
rhagia in a woman older than 40 years requires dilation
and curetLage ( D&C) to ru le o ut endome u·ial
which may be associated with fibroids in 3% cases.
INFERTILITY
Fibroids can be responsible for infenility (Fig. 13.16). Infer-
tility is either due to associated PID, endomeLriosis or anovu-
latot·y C) des or due to distonion oflhe uterine cavity causing
obsLruction to spenn ascent, poor nidation or comual LUbal
block. A fibroid bigger than I em in siLe can cause infenility.
salpingitis Submucous m)omas are more likely to be responsible for
infet·tility and recurrent pregnancy loss in up to 20% cases.
PAIN AND DYSMENORRHOEA
Most women complain of heaviness in the lower abdomen.
Congestive and spasmodic dysmenon·hoea is often symptOms
of fibroids or associated pelvic diseases. A subm ucous
fibroid often causes spasmodic dysmenorrhoea.
Acute pain is seen whe n a fibroid is complicated by
torsion, haemorrhage and red degeneration. Pain in a rap-
idly growing fibroid in an e lderly woman may be due to
sarcomato us ch ange.
PRESSURE SYMPTOMS
Amerior and posterior fibroids in the lower segment or
✓
cervix can cause increase in the freq uency and retention of
wine, more often premensu·ually because premenstrual
congestion resu lts in en largement of the fibroids. Broad
ligament fibroids can cause hydroureter and hydronephro-
sis, changes whid1 are reversible following surgery.
Constipation and intestinal obsU1tCtion are rare, but if it
occurs. itma) be due to a loop ofimesaine acU1eremto fibroid
ABDOMINALLUMIP
A large fibroid ma) be pt·esem as an abdom ina l wmour
which has been gro"ing slowly over a long pet·iod. A rapid
1) distorted /
elongated contractiondefective
uterine -
ascent
uterine →
2) defective transport
preventing rhythmic
-
dilation
3) congestion 4 of venous plexus
defective
implantation
-
nidation
4) a ulceration
defective
-
④ endometrial
⑤ imbalance btw
hyperplasia
TXA 9 Phiz
<
⑥ TSA
growtl1 only occurs during pregnancy clue tO oral contracep-
tive hormones and malignancy. A pedunculated fibroid
feels separate from the uterus and gives tl1e impression of
an ovarian tumour.
Other S) mptoms are due to anaemia such as dyspnoea
and palpitalion. A rare condition of pseudo-Meigs sp1-
drome has been descl'ibed witl1 a pedunculated fibroid
causing ascites and right h)drothorax. Haemot-rhagic shock
due to inuapet·itoneal haemot-rhage is tare.
VAGINAL DISCHARGE
Excessive vaginal discharge is a symptom associated witl1
pedunculated submucous fibroid.
Acute emergency co1ulition: Acute clinical conclitions associ-
ated with utet·ine fibroids are as follows:
• Acute retention of urine and acute abdom inal pain witl1
red degenerative fibroids during p regnancy.
• Reten ti on of urine, torsion of a pedunculated fibroid,
hae morrhage infec ti on and sa rco matous cha nge cause
severe abdo min al pa in.
• Rare case of thromboembolism.
PHYSICAL SIGNS
Anaemia ma)' be no ted. An abdom ina l lum p may be felt
arising from th e pelvis with we ll-defined margins, firm in
consistency and smooth or bossy surface. The tumo ur is
mobile from side to side unless fixed by itS own large size
or adhesions, or by broad ligament fibroid. Ascites is
rare.
Bimanual examination will reveal an enlarged uterus,
regular or boss). depending upon the number and size of
fibroids. The cen ix mo,es witl1 the movemem of mass
whid1 is not felt separate from the uterus unless it is pedun-
culated. ln a cenical fibroid, the nonnal utetus is perched
on LOp of me fibroid. A broad ligament fibroid displaces the
uterus to the opposite side.
ln a m)omatous polyp, the cervical os is open and itS
lower pole is felt. T he uter-ine fundus cannot be palpated if
inversion is associated with fundal submucous fibroid polyp.
The utetus is uniformly enlarged in submucous fibroids.
lnLravascular and disseminated peripheral fibroids rarely
exist but are often diagnosed onl y at laparotomy.
DIFFERENTIAL DIAGNOSIS (Table 13.3)
PREGNANCY
A cystic dege ne rated fibro id ca using a soft e nlarged
uterus can be mistaken for pregnane)'· T he breast sign,
.
soft cervix, u rine pregnanC)' test and ultraso und resolve
the do ubt.
HAEMATOMETRA
HaematomeLra, caused by cervical stenosis, causes enlarged
uterus and secondat') amenorrhoea. ILraso und and ur-ine
pregnancy test are useful.
ADENOMYOSIS
Adenom)osis shares the same clinical features as utetine
fibroma. The uterus of mot·e than 12 weeks siLe or an
 CH APTER 13 - FIBROID UTERUS 163

CHRONIC INVERSION OF UTERUS

Table 13.3 Differential Diagnosis in a Patient with
Suspected Uterine Abromyoma s Chronic inversion of uterus is often associated witJl fibroid
polyp. The sounding of uterine cavity and laparoscopy are
Haematometra!pyometra Full bladder mandatory before surgical excision if utel"in e perforation is
Pregnancy • Bilateral tubo· ovarian to be avoided.
• Adenomyosis masses
• Bicornuate uterus • Pelvic endometriosis
• Endometriosis • Endometrial carcinoma Pelvic Kidney
• Ectopic pregnancy • Uterine sarcoma Rare!)', a pelvic kid ney may be mistaken as a fibro id. T he
• Chroni c PID • Ovarian neoplasms
history is un like uterine fibroids. The wmour is fixed, be-
• Ovarian tumour • Paraovarlan cysts
hind a normal-size uterus. Uitrasow1d wi ll reveal absence of
Chronic Inversion Pelvic kidney
tl1e abdominal kidney, and fVP will locate tJ1e pelvic kidner

irregularly enlarged uterus favours the diagnosis of fibroma.
Besides, adenomyomawus uterus is often tender. Ulu-a-
sound co nfirms the diagnosis. Doppler ulu·asound sh ows
perip heral vessels in a fibromyoma, b ut fo r adenomyosis,
tl1e vessels a re d iffused inside.
BICORNUATE UTERUS
Bico rnuate ULems can be diagnosed by hysterogram, hyster-
oscopy and ultrasound
ENDOMETRIOSIS, CHOCOLATE CYST
The clinical features are similar, but tl1e uterus is nonnal in
and ad herem to tl1e pelvic mass.
ECTOPIC PREGNANCY
Chronic ectOpic pregnancy witl1 pelvic haemawcoele
can give t11e clinical impression of a fibroid. the
histOr)' is d iffere nt- ul traso und will clea r t11e doubt.
CHRONIC PID
The hisLOry and clinical findings may be idemical, but
innammawry masses are slightly tender and the uterus is of
normal si2e and fixed.
BENIGN OVARIAN TUMOUR
A subserous or pedunculated fibroid may resemble an
ov;uian wmour. Menorrhagia may not be presem in all
cases offibroids. Ultrasotmd wi ll show tl1e nature ofwmour,
but at times the true nature of the tumour is revealed only
by lapa ro tomy.
MALIGNANT OVARIAN TUMOUR
One of t11e serio us errors is LO mistake a malignant ovarian
LUmour for a uterine fibroid. LaparoLOmy should be
performed in case of doubt.
ENDOMETRIAL CANCER
Endomeu·ial cancer and m)oma coexist in elderly women.
Abnormal bleeding requires cut·euage of endometrium to
rule out malignancy.
MYOMATOUS POLYP
Myomatous polyp protrud ing tl1rough the os may be
for p roducts of concepti on and cervical cancer.
T he histOI)' and tissue biopS)' establish tJ1e d iagnosis.
INVESTIGATIONS
Ln a majority of cases, the clinical features a re clear-cut, and
detailed investigations are not required. The following
investigations may be cat-ried out.:
• Haemoglobin and blood group are required for management
• Ultraso und (see Fig. 13.3). A fib roma s hows specific
features of a well-defined ro unded tu mour, h)•poec hoic
witl1 cystic spaces if degeneration has occurred. Ulu·a-
sound can also identify adenomyosis as a d iffuse growth
with intramural cystic spaces. ovarian wmour, ectOpic
and ad nexal mass. Preoperative ultrasound checks the
munber, location and si2.e of me fi broids, and helps LO
reduce overlooking small fibroids du.-ing surgery, which
might lead to persistence or recun·ence of symptOms.
Ultrasound is useful in the follow up of fibroids after
menopause and wh ile following Gn RH therapy. However,
it does not recognize sarcomatous change in a fibroid-
MRI docs. T hree-d imensio nal ultraso und is very useful in
deciding tJ1e ma nage me nt. Dopple r ultrasoun d shows
vasc ularity of tl1e uterus and fibro ids. Besides, it can dif-
ferentiate between fibro ids and localized adenomyosis.
The blood flow surrounds t1 fibroid but diffuses through Ctd£n(}-
myruis. The 3D ultrasound is precise in locating t11e site
and t) pe of fibroids.
• 1-l)Sterosalpingogt-aphy and sonosalpingogmph)' identity
a submucous m)oma and check the paterlC)' of fallopian
wbes in the presence of infertility (Fig. I :u 7) .
• Hysteroscopy not only identifies a submucous polyp but
also allows iLS excision under direct vision.
• D&C is req ui red LO rule o ut endometrial ca ncer. It is
necessary in a wo man complaini ng of menstrual d iso rder
and posune nopa usal bleeding. l-listopa tJ1 ology of th e
endometriu m gives clue to iLS ae ti o logy and rules o ut
endomeu·ial cancet:
• Laparoscopy is req uired in rare situations such as inver-
sion of uterus while excising a myomato us polyp and LO
detect associated PlD and endomeu·iosis.
• Radiogr-aphy has been superseded b) ulu-aso und. Calcifi-
cation seen as a peripheral calcified area is also seen in
cet·tain O\'llt·ianwmours, TB mass, calcined mucocoele of
appendix and bony tumour. MRI is very useful in virgins
and old women when pelvic examination clinicall y is not
desirable in tJ1 e former and hysteroscop)' may be difficult
d ue to narrow ce rvix.
• CT scan is not ve t)' useful, b ut MRl is accu rate in ide ntify-
ing adenom)•Osis and sarcoma (Fig. I :3. l!lA and B).
164 SHAW'S TEXTBOOK OF GYNAECOLOGY
Rgur e 13.17 Hysterosalpingogram showing uterine cavity is
enlarged in size with a diverticulum in the uterocervical junction in
the right wall. Cavity was enlarged due to large interstitial fibroid.
(Courtesy: Dr K .K. Saxena, New Delhi.)
Rgure 13.18 (A) MRI shows mult iple uterine fibroids. (B) MRI
showing submucous fibroid. (Courtesy: Dr Parveen Gulati, New Delti.)
• lnu-avenous p)elography may be required for broad
ligament fibroids to check the anaLOm) and course of
ure ter and to identify a pelvic kidn e).
• With the developmem of minimal invasive surgery, it is
very im pot1.am to know the exact location of a fibroid.
The 30 so nograph)' is impon am in this connectio n,
a ltho ugh MR provides more va luab le info rma ti o n than
30 to inte rventional md iologist.
TREATMENT
Small and a5ymptomatic uterine fibroi<l5 <lo 1101 require re-
moval or medical treatment. They crm bl' observed every
6 months. It is needless to emphasiLe that malignant le-
sio n should be ruled out, and diagnosis of fibromyoma
should be certain. A yo tmg woman sho uld be infonned
about the presence of this tumour so that she Ltnder-
sta nds the possibility of growth a nd red degeneration
d urin g pregnanC)'· Similarly, a perim e nopausa l wo ma n
s ho uld rea lize th e importance of regu la r fo llow- up. Also,
it slwu.ld be noted that tumour can grow if tl menofJa'l.tSal
womlm on 1-1 RT.
Duling pregnancy, surgery is contraindicated, except in
the case of a peduncul ated fibroid if it undergoes torsion.
Acute retention of urine is treated by continuous ca theter-
iLation for 48-72 hours, when the growing utems rises
above the pehic b•·im. Red degeneration me.-its consen'3·
Live treaunen L
Similar!), m)omectomy is not advisable during caesarean
section because of the uncontrolled bleeding tl1at may
ensue, excep t for a pedunculated fibroid.
Indications for treaunent in an mum fibroid are
as fo llows:
• Infe rti lity caused by a cornual fibro id bloc king tl1e tube,
a nd h abitual abortions due to a submucous fibroid.
Other causes ofinfeni lity and abortions should be ruled
out m)omectomy is w1dertaken.
• A fibroid of more than 12 weeks siLe and a pedunculated
fibroid which can cause tot-sion.
• An as)lnptomatic fibroid catLSing pressure o n the ureter,
that is, broad ligament fibroid and pressure on the blad-
der, leaving resid ttal ttrine and causing urinary infection.
• Rap id !)' growing fibrom)'oma in a menopatLSal woma n,
implying impossible malignanC)'·
• Whe n the nature of tumour ca nnot be ascertained
cli nicall y (lapa rotom)' is needed in tJ1is situation).
• All S)'mptomaLic fibroids.
Faced with a woma n having S)'mptoms, 1t 1s tmportant
LO determine whether the fibroids are really responsible
for these spnptoms, or are tl1ey mere ' innocent bystanders'.
If so, they can be followed up and the cause of S)lnptoms
managed appropriately. Perfonning surge•') for fibroids in
such a woman ma)' not relieve her srmptoms.
Treatment may be as follows (see ·!a ble l:l. 1):
• Expecta nt- wait and obsen•e (6 montJ1s for growth)
• Medical
• No nsurgical - uterine arter)' (UA£) and
MR I
• Minimal invasive sw·gery
• Surgery
 for 3m
mifepristone 10
-25mg daily torts -6m
damaged -800mg daily
400
CHAPTER 13 - FIBROID UTERUS 165
25
gestrinone 31week
• The purpose of medical lherapy is to conu·o l menorrha-
Table 13.4 Advantages and Disadvantages of gia and improve haemoglobin be fo re surgery, or to
Medica l and Surgical Treatment
shrink the fib ro id befo re surgery.
Advantages Disadvantages • Ln o lde r wo men, successful medical thera py will allow
wo men to reach me no pause whe n 1J1e fibro id will shrink
Med ical Side effects of the drugs
and cease to be a proble m.
Avoids anaesthesia and do not allow treatment
surgical risks over indefinite period
Cures menorrhagia and (see GnRH therapy) RU486 (mifepristone) 10-25 mg daily fo r 3 monlhs
controls anaemia, cures Failure of treatment causes amenont10ea and sl11inkage o f LUmo ur by 50%
pressure symptoms Recurrence of symptoms (recently, 5 mg daily is found effective). DanaLo l400-800 mg
Reduces the sizs of and regrowth after daily for montlu reduces the siLe of LUmour by
tumour and blood supply; stoppage of treatment 60%. However, development of hi rsutism a nd other side
therefore, less operative Surgery may still be effects, as well as the cost, preclude its routine use.
bleeding and allows required Regrowth of fib•·oid is reported following stoppage of
Pfannenstiel incision
the d•·ug.
• Allows laparoscopic
Low-dose ora l contraceptives, such as gesu·inone 2.5 mg
myomectomy by reducin g
vascularity and size
thrice a week, are also effective. A5oprisnil , selective proges-
terone receptor modulator, is be tte r than mifepristone.
Surgery • Risks of anaesthesia and sur- Recen tl y, ulip rista l, a selec tive progeste rone receptor mod u-
• Removes fibrolds and gery (bleeding and trauma) latOr, has been used.
cures symptoms In one • Risk of postoperative
sitting adhesions GnRH THERAPY
• Improves fertility In • Recurrence of fibroids
40% cases GnRH analogues used fo r 6 months reduce the s ize of
due to growth of seedli ng
• Risk of malignancy fibrolds (5%- 10%) tumo ur b)' 50%-80%. T h is trea un e nt in premenopausal
eliminated • Persistence of menorrhagia women and )'Oung wo men wilh infertility may e liminate the
In 5%- 10% due to need for surge ry. IL is also usefu l in red ucing vasc ularity
congestion, enlarged besides size preoperatively, a nd by caus in g amenorrhoea or
uterine cavity reducing me norrhagia resto res the hae moglobin level.
Shrinkage o f fibro id allows Pfanne nstie l incision in abdomi-
nal ope ratio n, minima l invas ive surgery or a vaginal hyster-
ecto my i1u tead of an abdo minal hysterectomy, and also
Table 13.5 Management of Uterine Fibromyoma reduces bleedin g. Mo nth!) depot irtiection of 3.6 mg should
no t be extended bC)ond 6 mo nt11s to avo id me nopausal
Asymptomatic Symptomatic Cervical 1 o/o
symptOms and osteopo rosis. Ont remember tlwt the
Observation with Medical Vaginal tumour can after of the d ntg.
regular follow-up Hormones to polypectomy or l1utead of montltly injecti on, 3-monthly leuprolide
Size < 12 shrink the myomectomy acetate, 11.23 mg, may be convenient to a dminister.
weeks fibroid - surgery Myomectomy
Pure a nti oestrogen (Faslodex) may be effective for the same
U noo mpl icated Uterine artery Laprascopic
pregnancy embolization myomectomy
purpose. T hese hormones, however, do not relieve dysmen-
with fibroid Myomectomy • MAl-guided orrhoea. Otlter anti-£ 2s, such as raloxifene and aromatase
• Surgery • Lap myomectomy myolysis inhibito•· fadrowle, are under tri al.
• Size > 12 • L ap myolysls • Vaginal The disadvantages of GnRH thera py preoperatively are
weeks • MAl- gui ded hysterectomy that tl1e fibroid caps ule may thin o ut, making enucleation
• Cornual fibroid ablation • Total rather clifficulL Small fibroids become invisible at surgery,
causing • Total/subtotal abdom inal but rec ur later. Mirel/it !UCD mn be used to tontrolmenorrhagia
infertility abdominal hysterectomy mul dys11umorrhoea duii to Gn RH analogues are expe n-
• Pedunculated h ysterectomy sive and need to be injec ted subcutaneously.
cornual fibroid • Vaginal
Add-back tl1e rap)' wi th o ra l combined pills, tibo lo ne or
• Pregnancy hysterectomy
with torsion of • Totall aparosooplc
progesterone wi tl1 GnRH, can red uce the side effects and
pedunculated h ysterectomy allow longer use ofGnRI-1. Gn RH an Lagonists are be uerthan
fibroid • Lap hysterectomy agonists, as they avoid inilial ·nare-up' effect and act faster.
• Laparosoopic- Lsoprisinol (selective proges te ro ne receptor modulator)
asslsted vaginal is Lmder trial. HRT n ot be offtrnl to (I mnwp(msttl worrum
hysterectomy with
Aro matase inhibitors, such as le u·ozo le, have been
e mployed. The) inhibit conversio n o f androgen s to oestro-
ge n in tl1 e ovaries a nd in periphe ral fat, and shrink tl1e
MEDICAL TREATMENT (Tobie 13.5) fibro id b) 50%.
• Iron th erap) for anaemia. Blood is rarely used preoperatively.
• The dmgs used to conu·ol menon·hagia have been d e- SURGERY
sc•ibed in Chapter II. Mire na conu·ols menorrhagia, The techniques used are conventi onal m>omectomy and
provided the uterus is not enlarged be)ond 12 weeks. h) sterectomy by laparotomy or laparoscopically.
166 SHAW'S TEXTBOOK OF GYNAECOLOGY

Myomectomy • The capsule should be incised and the fibro id en ucle-

M)·omectomy refers to the removal of fibroids, leaving the ated. This will minirni:t.e bleed ing and avoid u·auma to the
ute rus behind. It is ind icated in an infertile wo man o r a bladder and ure te r. M>o mec to my sc rews help during
woman desiro us of childbearing and wishin g to retain the e nuclea tio n (Figs U.20-l :3.22).
ute rus. It is do ne b) o pen surgery, la parosco pically, vaginal • Fo llowing enucleation, the hae mostasis is sec ured and the
or through h)ste roscopic route. cavityoblite mted witl1 se-.eral catgutsuwres. This will avo id
scar rupture during subsequen t pregnancy and labour.
Preoperative Req uisites • The clamp should be released and haemostasis confinned.
• Hae moglobin should be resLOred . • The raw visceml area should be well pe•·ito niLed to
• Autou a nsfusion arranged a few da) s before surgery preve m postoperative adhesions. H) droflotation also
is prefe1Ted to d on or u-ansfusion at surgery to avoid
transmission risk of HIV, malaria and hepatitis B.
• ln infertilit)\ other causes ofinfen.ili ty should be excluded.
• Sign ature for hyste•·ectomy is required in diffi cult unfore-
seen circumstan ces.
• Myomectom y sh ould be perfonn ed in preovul atory
menstrual cycle to red uce blood loss du ring surgery.
• £ndomeu·ial ca ncer to be ruled o ut by D&C.
• Bowel preparati on avoids bowel

Te chnique o f myomectomy (Fig. 13. 19)

• O peni ng th e abdomina l cavity by Pfa nn ens tie l incisio n is
possib le if tl1e uterus is less than 16-20 weeks size, and is
mob ile . If d iffi culty is anticipa ted as witlt a large uterus,
fixed uterus witlt ad hesio ns, associated PID and endome-
u·iosis, a ve rtical paramedian incis ion is safer.
• Care should be ta ke n no t to iqj ure the bladder wh ile
incising tl1 e parietal pe ritoneum, as the bladder may be
elevated in cervical and low-lying a nterior wall fibroids. Figure 13.20 Bonney's myomectomy clamp.
• The pelvic o rgans should be ca re fully inspected and the
feasibilit) of m>omectOm) co nfirmed.
• An incision ove r tJ1e anterio r uterine wall is prefe1Ted
whenever possible and as man> fibroids removed through
minimal tw1nelling incisions.
• Haemonilage should be conu·o lled with the myomec-
tomy clamp. The cla mp should be applied fro m the pubic
end of the abdominal wound and tl1e round ligamentS
whi ch will include the ute•ine vessels should be g•·ipped.
The ovari an vessels may be tempora•·ily occluded wim a
sponge fo•·ceps. If the myomectomy clamp cannot be
applied as in ce1v ical fibroids, a rubber tourniquet wi ll
serve the pL11pose. Local of dil ute vasopressin
also h elps to reduce blood loss.

Figure 13.21 Multiple fibroid removed by open myomectomy.

Flgure 13.19 Myomectomy operation. Figure 13.22 Myoma screw.

 CHAPTER 13 - FIBROID UTERUS 167

reduces adhesions. The uterus remains bulky foll owing

myomectomy and r·equir·es to be anteverted by plicating
the round ligam e nts with nonabsorbable sutures.

Results. Pregnancy rate of 40%--50% has been reported

following m)omectomy, and pregnancy loss reduced.
However, IOo/o- 15% continue to suffer from menorThagia.
Recur-ren ce offlbr-oids in 5o/o-l 0% cases is due to overlooking
seedling flbmicls at the time of surgery.

Complications. The complications that may result fmm

myomectomy are as follows:

• Primary, reactionary and secondary haemorrhage

• Tra u ma to the bladder, u reter and bowe l dLUing su rgery
• lnfeCLio n
• Ad hesio ns and intestinal obstruc tion
• Rec ur re nce of flbro ids and persis tence of me norrhagia

Vflginrtl ln)'OIIIfttomy (Fig. 13.23): lt is indicated in s ubmu-

cous flb ro id po l)'ps. Vagina l myomec to my is possible in
cervica l fibro ids a nd ped unc ula ted fibro id polypus and if
mo re tha n 50% submucous fib r-oids projec t in to the cavity.
H ystemscojJic III)'OIIUittom.;( Hysteroscopic m yomectom y has
become possible for submucous fibroids not rem ovable
easil y by the vaginal route. T he fibroid is excised eitl1e1· by
cautery, laser or resectoscope. It is best done under laparo-
scopic guidance to avoid uterine perforation. Complica-
tions of h)Steroscopi c m>om ectomy are as follows:

• Cervical trauma, ute.-ine perforation

• Thennal injury
• Bleeding- Fo ley cathe te r can be used as tamponade to
stop bleeding Figure 13.24 (A) Subserous fibroid seen on laparoscopy. (B) Central
• Infection cervical fibroid (lantern on the dome of St. Paul's CathedraO seen on
lap..-otomy. (Ccu'tesy (A): Dr \Iivek Mawah, New Deihl)
• Failure
• Uterine adhesions
• Complications of distending media : Water overload or
pulmonary oedema

Laparoscopic myomectomy: Laparoscopic view of vario us

fibm ids is shown in Figs 1:3.2 1 and 1:3.25.
Laparoscopic myornectOm)' (Fig. 1:3.26A-1) is feasible in:

• A pedun c ula ted flbro id

Figure 13.25 uterine fibroids. (Courtesy. Dr Vivek Marwah,

New Delhi.)

• Subsemus fib•-oid not exceeding 10 em in sit.e and noun ore

RgLre 13.23 Hysteroscopy reveals multiple endometrial polyps.
(Source: From FIQUre 2A Chumda Cheng, Tirg Zhao, Mil Xue, et al In:
Use of suction ctrettage in operative hysteroscopy. Journal of Mirimaly
Invasive Gyneoology. VC>lJrne 16{6): 739-742, 2009.)
than foLU· in number. Multipl e flbroids ofanysit.e should be
approached b)' lapa•-otomy. t.Jnipol;u·, bipolar cautery and
laser have been e mpiO)ed to re move Lhe fibroma and obtain
haemostasis. Th e flb•-o ma is reuieved through posterior
colpotomy, minilapa•-otOm) or b) morcellation. Mrolysis, a
168 SHAW'S TEXTBOOK OF GYNAECOLOGY

Rgure 13.26 Laparosoopic myomectomy- steps of operation. (A) Rbromyoma uterus. (B)Incision taken on the fibromyoma. (C) Fibromyoma
exposed. (D) Myoma screw Inserted to steady the myoma (E) Myoma dissected from its bed. (F) Edges of myoma bed approximated with
interrupted Vicryl sutures. Removed myoma seen in POD. (G) Myoma being morcellated. (H) Tunnel in myoma after removal of cylincrical mass.
(I) Laparoscopic myomectomy. (Courlesy: Dr VP.Iek Marwah, New Deln.)

technique of desu·uction ofm)Qma tissue b)' laser or cautel)\
is a sophisticated ted1nology practised by endoscopistS.
• Laparoscopic-assisted vaginal hysterectOmy (LAVH)
enables vaginal hysterectomy to be completed from
below in the prese nce of pelvic pa thology.
wow1d. 111)'011/eclom)• nury tilrrifow not be safo in an
infertile wonum, except for small fibroids. The recw-rence rate
is reponed higher than that in laparotomy.
Newer minimal invasive procedures successfully intro-
d uced in recen L years are:

Laparoscopic m)•O mectO m)' is made easier and faster by • UA£

newer insuum e ntS, morcellator, newe r e ne rgy sources
and newer suture mate rials. T he b leeding is controlled by
infi lu·ation of ITI)'Oma witJ1 vasoconstricto rs and b ilateral
uterine artery ligation before mromec tomy.
Disadvantages of Laparoscopic Myomectomy
Although a minimal invasive surge ry, and without an abdom-
inal scar, laparoscopic mro mectomy can cause more bleeding
because of no napplicabilit) of a haemostatic clamp, and
being an adhesiogenic procedu re, it lakes longer to perfonn.
Postoperative acU1esions can increase tJ1e infertility rate. Scar
11.1pture is also rep01ted in late pregnancy and dLIIing labour.
Some use imercede (oxidit.ed regenerated cellulose) to
prevem or reduce adhesio ns. The major complication is
•upture of me Ill) omectomy scar dLIIing pregnancy or labour
due to imperfect or inadequate suturing ofthe m)omecwmy
• MRI-gui ded laser ab la ti on
• Laparoscop ic m)•OI)'sis
Uterine Artery Emboli:z:ation
In 199 1, J acques Ravina, a Fre nch gynaecologist, first
perfonned UA£ preope rative !)' to reduce vascularit)' and
the size of fibroid. Improveme nt in symptoms cancelled
definitive surgery is some cases. Me norrhagia was relieved in
80%-90%. pressw·e S)'lnptoms in 40%-70%; the volume
decreased by 50% at tJ1e e nd of 3 months, by 60% at
6 montJ1s and b) 75% at the e nd of I year. Thus, mis
technique is now emplo)ed successfull) in selective cases.
Contraindications
• Subserous Mul jlmtou:uwted fibroid:.. ecrosis and fall of the
LUmour imo me pel'iloneal cavily ca n OCClll: Big fibroids
are not sui led for UA£.
 CHAPTER 13 - FIBROID UTERUS 169

\l
Catheter
I I
Femoral \
artery /
\
\
I y \\ \
A Uterine artery
Rgure 13.27 (A) Trans femoral catheteri zation of uterine arteries. (B) Injection of polyvinyl aloohol particles. (Sovce: Rao, K. A Textbook of
Gynaeoology, India: Bsevler, 2008.)

• Submucous Fibroid is not cured. • Placenta accreta tO red uce bleeding before placental
• Inferti li ty rate m<'l)' increase fo llowing this techn iq ue removal, or caesarea n deli ve t) '
because of postemboli:£ation pelvic ad hesio ns .
• CalciFied Fibroid ca nnot shrink with this tec hnique. Laparoscopic locali zed ute tine an e t)' occl usion using
• Associated inflammatory disease may also preclude the clips or electrodessication is being tried. T his avo ids ovarian
employment of this techn iq ue. devascularization.
UA£ is the most suited proced ure for menorrhagia in a
Technique. Under local sedation, bilateral UAE isapproad1ed mLLILiparous woman.
tJuough percutaneous femoral catheterization. lt is done The following are the advan tages of UAE:
LLSing polyvin)l alcoho l (PVA), gel foam particles or metal
coils. Embolilation reduces vascularity and the size of fibroid • No major surget)
in 3-4 months (Fig. I :t27) ( 40% at 6 weeks and 75% at • o inu-aoperative bleeding
l year). PregnanC) should be postponed foratleast6 montlls. • Short hospital Sta)
The S)mptoms are relieved in 70%-80% women. The • Less abdominal adhesions
following are the postoperative complications: • 75%-80% women are satisfied

• Fever and infection MRl-guided percutaneous laser ablation using high-

• Vaginal discharge and bleeding (5%) intensity focused ulu-asound (HI FU) has been recently
• lschaemic pain suggests successful therapy but can be attempted wit11 success. This genet-ates heat, ss•c, at t11e
unbearable and requires ana lgesia focused point on t11e fibroid for few seconds. It ablates t11e
• Pulmonar-y embolism vessels as well as the tumour. The woman is able to retut·n to
• Ovarian fuilur·e following accidental ovat·ian vessel blockage work in 2 da)'S Lime. This technique may also find a place in
and premature menopause (up to 30%) the treaunent of adenomyosis.
• Fertility rate is reduced due to adhesions
• Failure due to inadequa te emboli zation ca used by arterial MRI-Guided Focused Ultrasound
spasm or tonuosi t)' of the vessels T his is a noninvasive tec hnique and uses hi gh-ime nsi ty focused
• Expulsion of a fibro id in to th e petiwneal cavity (10%) ultrasotmd beam tllaL heats and desu·oys fibrous tissues.
• Allergic reac ti on and co ntrast induced rena l failu re MRl guides in targeting tl1e beam pat11 towards t11e fibroid.
• Radiation exposure A large fibt'Om)•oma ca n be treated in two sessions, or t11 e
• Haematoma at the femora l site fibroid is reduced in size with montJ1 ly Gn RH injec tions for
• Extmsion of a subsero us Fibroid into th e peritoneal cavity 3-4 momhs before u·eau·n e nL
which requ ires retrieval. Side effects are as fo llows:
• lnuaperitoneal ad hesions
• Skin bum
Proper selection of patients is key to clinical success • Pain
and avoiding complications. A follow-up with ulu-asoLmd • Nerve damage (rare)
6 months later is also necessary to observe tlle shrinkage Advantages
of t11e fibroid. and to register success or failure of tllis
u·eatmen t. l. on invasive technique
Other indicalions for UA£ besides fibroids are as follows: 2. Local anaestl1esia- takes 1-2 hours to do
3. o hospitalit.ation
• Anerio,enous aneu t)'Sm or increased utet·ine vascularity 4. oscar
causing menorrhagia 5. Quick reco\et)'
• Postpartum haemorrhage 6. Fertility preservation technique
170 SHAW'S TEXTBOOK OF GYNAECOLOGY

• Extended and Wertheim h)Sterecwmy in cancer of the

Table 13.6 Indications for Hysterectomy cervix and utet·ine cancer
Abdominal Vaginal
Most perfonn a total hysterectomy, as it prevents chronic
Benign Prolapse cervicitis and cancer occ t.min g at a later stage. However,
Menorrhagia Carcinoma In situ occasionall)', subtotal h)•Stereetomy ma)' have to be resoned.
Uterine fibromyoma Cancer cervix -+- lymphadenectomy
Advan tages of subtotal hysterectomy arc as follows:
Adenomyosis Menorrhagia
Tubo-ovarian mass Uterine fibroid
carcinoma in situ Genital prolapse • Cervix retained for sexual function. T he normal cervical
atypical endometrial clischa Pge is beneficial.
hyperplasia • Vault prolapse is less common. Less bleeding and less tisk
Endometriosis of bladder and ureter trauma.
Malignant • In a difficult surgery, total hysterecLOm)' may increase the
Carcinoma of the cervix surgical mOt·bidity due to trauma tO the bladder and de-
Carcinoma of the nervation, causing difficult micturition and incontinence.
endometrium
Carcinoma of the ovary
Uterine sarcoma-mixed
Pap smear before St.trgery ensures that the cetvi.x is normal.
mesodermal tumour
What about the ovaries?
Choriocarcinoma (rare) In benign conditions, the ovaries sho uld be retained to
Obstetric avoid menopa usal symptoms in a premenopausal woman,
Rupture uterus p rovided they look normal.
PPH , molar pregnancy Disadvantage of conserving the ovaries:
Carcinoma of the cervix
• Benign or malignant O\>at·ian tumour may develop in
1% cases.
• Residual ovarian syndrome is known to occur in some
Contraindications
cases and cause d)sparewlia.
I. C'..alcified fibroid • Au·oph) of the ov;uies has been repotted due to kinking
2. Degenermed fibroid of the ovarian vessels within 3-4 years of hysterectomy;
• Interstitial laser ablation is done laparoscopically by they become nonft.mct.ional and cause earl) menopause.
insening laser fibres into the myoma.
Total Abdominal Hysterectomy
l.aparoscopic Myolysis Hyste rectOm)' is straightforward in most cases of fibro ids.
This is an op ti onal surget)' using Nd:YAG lase t; CryoProbe However, in case of a cetv ical, low a melior walJ and a posterior
or d ia thermy to coagula te a subserous fibroid. It is used in fibroid, and one encroaching imo the broad li gamem where
a multiparous woman. The conu-ainclications and complica- bladder, ureter and rectum are displaced from their normal
tions are similar to those of UA£. anatomical position, they :u·e at risk ofi tjury. In a cervical and
large antetior wall fibroid which is close to the bladder, it is
Hysterectomy (Tobie 13.6) prudent to perfonn m> omectomy first. This allows a clear view
Hysterectom>'• the removal of the uterus, is indicated in a of,<aginal \'l!Ultandsafeguards against bladder Thereaf..
woman older than 40 years, a multiparous woman or when ter, hysterectOm) can be perfonned. Similar!), in a low poste-
associated with malignancy. Uncontrolled haemorrhage rior fibroid, the upper portion of the broad ligament may not
and unforeseen SLtrgical difficulties during myomectomy be accessible until the fibroid is first enucleated.
may also necessitate hysterectOmy. Hysterectomy guarantees In a central cervical fibroid, and a huge posterior fibroid,
removal of a ll fibroids and relieffrom symp toms. Norma lly, hem isection of the uterus and en ucleation of Ule fibroid
the aim is total hysterectomy. However, subtotal hysterec- wilJ alJow safe hysterectomy.
LOm)' may be performed in the presence of PLD, endome-
Vaginal Hysterectomy
u·iosis and any technical problem when the cervix is left
behind. Prior cervical cytology is desirable. Vaginal hysterectomy is possible ifu1e uterus is mobi le, uter-
ine sit.e is less Ulan 14 weeks wiu1 no previous surgery or
Types of Hysterectomy there is no other pelvic pathology; in all ou1er cases,
• Abdominal hysterectomy abdominal h)sterectomy is perfonned. The ovaties may be
• Vaginal hysterectomy consenecl in a womru1 younge•· than 50 )Cars, prO\·ided u1ey
• L..aparoscopic hysterectomy are health). Vaginal hysterectomy is not a good approach in
nulliparous women with narrow vagina.
Abdominal Hysterectomy Late!)', '>aginal hysterectomy is being done for uterine
Abdominal h)•Sterecto my incl udes: s ize more Ulan 12 weeks, provided the uterus is not fixed b)'
adhesions, adnexa l inflammatOt)' mass or endometriosis
• Total hysterectomy by perform ing:
• Subtotal hysterectomy when th e cervix is retained
• Pan hysterectomy (TAl-l with B/L Salpingo Oopherec- • Previous laparoscopy to confirm the absence of pelvic ad-
tomy) when ovaries are also removed h esions, si:t.e ofu1e utems and rule out pelvic pau10logy

• Bisection of uterus, and removing eadl half separately
• Myomectomy and enucleation of fibroid first
• Morcellation
Laparosoopic-Assisted Vaginal Hysterectomy (LAVH) . This
avoids an alxlominal scar, minimiLes pain and shon.ens the
recover) period and hospital Sta).
Co11trailltlications to LAV H are as follows:
• Ute.-us more than 11-16 weeks in siLC.
• The fibroid is located in the broad ligament,
fibroids and extensive pelvic adhesions, endomeu·iosis.
Complications o f Hysterectomy
• Primary, reactiona l)' and secondary h aemoni1age
• Trauma to the bladder, ureter and bowel 11tay occur
in cervical and broad ligament fibroma; associated
PLO and endometriosis expose th e urete r LO i1'!ju ry
• Sepsis
• Anaesthe ti c co mplicmions
• Paralyti c ileus, intestina l obs tructi o n due to postopera tive
adhesions
• T hro mbosis, p ulmonary e mbolism, chest infec tio n
• Btu·s t abdomen, hernia
• Postoperative infection such as wo und infec ti on,
periton itis, pelvic infectio n and embolism - chro nic
pelvic pain
• Alxlominal adhesions cause dHonic abdomina l pain
• Dyspareunia
• Vault prolapse
• Residual ovarian S)ndrome and atrophy of the ovaries
due to decreased vascularit), causing premature meno-
pall.Se in 2-3 )ears
• Ovarian cancer in I% if ovaries are left behind during
hysterectomy
• Urinary d) sfunction due to denen•ation of bladder
• Granulation tissue at the \'llult prolapse of the fallopian
tubes
Management of uterine fibromyoma is summarized in
·ra ble 1:3.5.
Coutraception. A young woman with ute1·ine fibroids may
seek contraceptive advice. O ral h o rm onal conu·aceptives
Flgure 13.28 (A) Subserous fibroid associated with uterine pregnancy. (B) Uterus studded with multiple fibrolds and pregnancy.
CH APTER 13 - FIBROID UTERUS 171
sho uld not be prescribed beca use the fibroid may
grow in size under hormona l influence. Intra u terine
contraceptive device (I UCD) can ca ttse menorrhagia
and dysmenorrhoea and is therefore not suitable in this
woman. She can choose between a barrier method and
centchroman.
CERVICAL FIBROID
Surgery for cenical fib1·oids, either m>omectomy or
hysterectomy, is associated with a greater risk of i1'!jury to
bladder and u1·eters besides increased blood loss during
surgery. To decrease risk of injul)' to bladder or ureters,
it may be desirable to first enucleate fibroid and then
proceed with rest of the surgery.
FIBROIDS COMPUCATING PREGNANCY
Pregna ncy associated with fib roids is associated with th e
increased chances of complica ti ons. Pregna ncy ge ne rally
ca uses an increase in th e si:Ge of fib ro icls (Fig. 13.28);
th e re is a n inc rease in their vasc ula rity a nd a highe r
te nde ncy LO unde rgo clegene ra tive changes s uch as hya-
line c ha nge a nd cysti c dege ne ratio n. Red dege ne ra tio n is
a res ult of soften ing of the sur ro un d ing s upportive con-
nec tive tiss ue. Th e cap illa ries tend to ru pture a nd b lood
effuses ou t into the myoma, ca using a d iffuse reddish
disco lo u ration of the same. Such a pa ti ent complai ns of
severe pain in tlle abdomen and may present as an emer-
gency for acute abdominal pain; examination reveals the
pain to be restricted to the utenl.S around tlle site of tlle
fibroid. and all other parameters remain stable. Such a
patient is treated consen>ativel) with bed rest and analge-
sics, until the pain subsides. On rare occasions, when
laparoLOm)' is carded out, the m>oma is seen to be dusky
in appearance; its cut section has an appearance of
cooked meat and is known to emit a fishy odou1: Fibroids
by their sheer siLe may catl.Se respiratory emban-assment,
retention of urine or obstructed labour. They are some-
times known to adver-sely affect the outcome of preg-
nancy and the1·e is an increased risk of abortion, prete1·m
labour, abnormal presentation, accidental h aemoni1age,
dystocia in labour; PPH , puerperal sepsis an d uterine
in version.
172 SHAW'S TEXTBOOK OF GYNAECOLOGY

ENDOMETRIAL POLYPS
UTERINE POLYPS
Uterine pol)ps are usuall) benign comprising endomeuial,
fibroid. adenom>omatous and placental polyps. Cervical
polyps are mucous and fibroadenomatOtiS poi)'PS aJ;se from
the endocervix.
ENDOMETRIAL POLYPS
Endomeu·ial polyps mostly arise from hyperplasia of the
endomeu·ium, some pan of the endomeu·ial lining
protruding into the uterine cavity as poi)'PS. They may be
single or multiple; they appear as pink swellings, 1-2 em
in diameter, with a pedicle. The polyp is composed of
endometrial glands and su·oma covered with a single layer
of colum nar epitheli um. Seconda ry malignant change may
occ ur in a benign polyp; l11us, it is mandaLOI)' LO study its
histOlogy.
In a ma lignant poi>'P ari sing ab initio, th e e ntire polyp
shows ma lignanC)', inc lud ing its base whe reas secondary
malignanC)' is seen at the apex of th e polyp- th e base or
th e pedicle shows no suc h change. Adenomyomatous
pol)•p has s mooth musc le as well as endometria l
e lements. Tamoxifen can cause endometrial hyperplasia
and polyps.
A fibroid pofyp is a submucous fibroid developing a pedi-
cle and protruding into the uterine cavity or projecting
through the os with a long pedicle. It is pale looking, firm
with infection and necrosis at l11e ba.se if it protrudes
through the cervix. It can be sessile or a pedunculated
cervical fibroid.
PLACENTAL POLYPS
Placental pol)ps are fonned from retained placental tissue,
thus causing secondai)' PPII 0 1· intenniuem vaginal bleed-
ing following an abonion or a nonnal delivery.
CUNICAL FEATURES
Uterine pol)•ps can cause menOIThagia, metroni1agia or
postmenopausal bleeding. If l11ese protrude through l11e os,
may cause postcoital bleeding or continuous bleeding in a
young woman after they arc asymptomatic.
Cli nicall y, the ute rin e polyp may not be evident as the
uten.IS may or may not be enlarged; it is easy to diagnose
when tl1e polyp protrudes l11ro ugh the cervical canal.
Ulu·aso und can detec t uterine polyp, so also sali ne sonosal-
pingogram or hys te rosa lpingogram (H SG).
Hysteroscopy is bo tl1 d iagnostic and l11erape utic.
MANAGEMENT
D&C can scrape the pOl)•p. H)•Steroscopic removal of
multiple pol)•ps may be desirab le to ensure tl1 eir complete
removal.
Endocervical pOI)'PS have been dealt with in tl1e chapter
on inflammation of tl1e uterus and the cervix.

Fibroid Uterus

History
Examination
U/s, AbdomenfTVS

Treat if:
• Size>12wks
• Pressure symptoms • Hemostatic agents
• Infertility • Young patients
-Hormones
- MIRENA
- Uterine artery
embolization
- Myomectomy
• Older women(>45y)
consider surgery (TAH)

Management of Fibroid uterus


KEY POINTS
• Fibrom)omas are benign neoplasms of the uterus
affecting 5%-20% of women in Lhe reproductive age
gt·oup.
• Fibrom>omas ma) be prese m without S) mpwms.
Howe-.er. depe nding o n Lheir siLe and location, the)'
ma) comribute to menstrual in·egularities, dysmenor-
rhoea, infertilit), pain in the abdomen, alxlominal
fullness, pressure symptoms and complications during
pregnancy.
• Ultrasonogra phy, CT/MRI, laparoscopy and hysteros-
copy help in establishing the diagnosis of uteri ne
fibrom)om as. They are also useful tO determine the
number, location and si.Ge of tumours. This h elps in
planning the u·eau11 cnt.
• Asymptomatic tumours ofLen do not req ui re treat-
menL b ul follow-up is reco mmended.
• Symptoma ti c fibro icls req uire u·ea une m. Myomec-
to my is inclica tccl in )'Ounger wo me n desiro us of
retaining the chil dbea rin g func1.io n whereas in elde r I)'
wo men, h)'Sterec to my is the proced ure of cho ice.
• Medical u·eatmc m he lps LO re lieve me norrhagia.
Gn RH a and SI::RM arc LO surge ry when a
huge fibro id or mul tiple fibro ids are enco umered.
They shrink Lhe fibroids and red uce Lhe b lood loss
during surgery.
• Endoscopic procedures e nable the removal of
moderate-site m)Omas.
• H)SLerectom> is ad' ised in elderly and multiparous
women.
• Laparoscop), hysteroscop) and ane•·ial embolitat.ion
pro' ide minimal in\'asi'e surger) and have reduced
the number of a bdominal h)sterectom>• in women
with utel"ine fii)J'()ids. high-frequency
ulu-asound is now possible.
• UA£ is not recommended in women with infertility
because of pelvic adhesions and risk of scar rupture
dlll·ing pregnan C)' or in labour.
• Location, site and number of fibroids decide the
route of ope•-alion.
SELF-ASSESSMENT
1. Disc uss the cli nical fea w res of uteri ne fibro ids.
2. How wi ll )'O u manage a case of uteri ne fibro ids in a
32-)•ear-old, para I woman?
CHAPTER 13 - FIBROID UTERUS 173
3. Disc uss the manage me nt o f uterine myo ma in a n ullipa-
rous woman.
4. A woman, 38-year-old, presents with me norrhagia. She
shows three fib ro ids on ui Lraso und. How will yo u manage
the case?
SUGGESTED READING
S. Acute complication> of fibromyoma. Clin Obstet
Gynaecol 2009:5:23.
Baird DO. Gam!tt TA. uughlin K, et al. Shun-term change in growt.h
of uterine ldom)oma: tumor j.,'TOWth spuns. Fertil Steril 2011;
95:242.
Baird DO, Ilannon QE, L:p;.on K, et al. A Prospective, Uhrasound-
Bas<.--<1 Study to E'-aluatc Ri;,k Factors for Vterine Fibroid Incidence
and Growth: Met hods and Re>U Its of Recruitment. J Wo mens lle-ahh
(urch nu ) 2015:24:907.
Bor.th BJ, uughlin-Tomma>o SK, ER, et al. Assodation Between
an d Procedure Among Patie ntS
With Lciomyomas. Obstct Gyn<' OOI 2{)16;127:67.
Brucker llncbner M, Wallwicn cr M, ct al. Clinical characreristics
indicating adcnomyo.si.s coexisting with leion1 yotnas: a retrospective,
qut.-stionnairc·bascd stud y. Fcrtil Srcril2014; 101:237.
Cardozo ER, Clark AD, Banks NK, ct al. 11>e estimat ed annual cost. of
uterine leiom yomata in tl1e Unilcd States. Am .J Obst ct Gyncco12012;
206:211.el.
Cornrnittc-c on Practice Bullelins-Cyncc'Oioj.,')'. Practice bulletin no.
128: diagno>i> of abnormal ut erine bk-eding in rcpmducth·c-agcd
women. Obstct Gync-col2012;120:197. Reaffirmed 2016.
Donnczj , Donnc1. 0, Malltlc 0, ct al. L.ong,..cnn medical
of uterine fibroid> 1\iLh uliprisLal acct>dC. Fcrtil Srcril2016;105:160.
Shulman LP (Eel>). of Obstetrics and Gt11aecology
20 10;379.
Re}C> C, Mur.tli R, Park Jg. s.,,'OndarJ lm ohernent of the Adnexa and
Uterine CorptL> by Carcinoma> of the Uterine Cen·ix: A Detailed
Morphologic De.cription. lntj Gjnccol P>lihol2015;!l4:501.
Sengupta. Chattopadh)<t). Vanna. Textbook of Gjnaecology for Post·
graduatcS and Pr-.tctitioncr;,. Ebc•ier, 2007.
Shiota M. Kotani L:mcmoto et >tl. DeeP" ein thrombosis is associ-
ated "it11 large uterine fibroid>. TohokuJ Exp 2011 ;224:87.
Stel\an EA. Clinical pr.tcticc. L:terine fibroid$. Eng! J 2015;
372:1646.
Studd J (Ed). Em bolit.tt ion of fibroid. Progr Ol>stet Gynaecol
2006:17:333.
Studd J (Ed). PTOj.,•n.-;., in ObMet.riC> and Gp1aecology 2005; 16:277.
Sturdee, et al. (Eds). Yearbook ofOb>tetrics and Gynaecol(>j.,')' 2009;9.
Velez Edwards DR,IIarunann KE, Wellons M, et al. E''.tluating the role
of and me--dication in protection of uterine fibroids by type 2
diabetes e xpo>urc. BMC \\'om ens llealth 2017;17:28.
Wise LA, uughlin-Tornrna>o SK. Epide mioloj.,')' of Uterine Fibroids:
From to Menopause. Clin Ol:>$tet Gynecol 2016;59:2.
 Endometriosis and
Adenomyosis
Endometriosis 174 Key Points 187
Adenomyosis 185 Self-Assessment 187
ENDOMETRIOSIS
Endometriosis is the prese nce of endo metrium a t a site out-
side endo me u·ial lining. This co nd itio n was first desc ribed
b)' Carl Von Roki nst.'\S)' in 1860. Since its original desc rip-
tion, th is condition is being increasingly recognized in
women with infertili ty, chro nic pelvic pain (CPP) and men-
strual irregularity. These islands of endomeu·iosis are com-
posed of endomeu·ial glands surrounded by endometrial
stroma. and are capable of responding to a varying degree
to cyclical honnonal sumulauon. The disease alt.hough a
benign proliferau'e growth process yet having some of the
featttres of cancer like the propensity to invade the nonnal
sttrrounding tissues, causing extreme pain and tendency for
reclll·rences. Whereas cancer can kill the women, endome-
u·iosis cripples her life.
The reponed incidence is about 10%, but inc idence is
increasing on account of greater use of diagn ostic lapa-
roscop)'· Amongst infertile women, incidence is 20%, an d
it is 15% in women with CPP. Th e incidence is very high
amongst j apanese women.
Charactelistics of endometl'iosis
• T he ectopic endometrial tissue responds to ova ri an
ho rm o nes.
• Although prolifem uve e ndorn e u·ium is always seen,
sec re to ry endome u·iurn depe nds upon the presence of
p rogesterone recepto rs in th e tissues.
• Blood oozing d uri ng menstruation in ec topic endome-
trium ca uses local ad hesions in t11e pelvis.
• Malignancy is extreme!)' rare, though e ndome tl"ial tissue
is highl)' proliferative.
AETIOLOGY
Endomeu·iosis is a proliferative hormone-dependent
disease of the childbearing period. It is extremely rare
before menarche and disappears after menopattSe. Its
incidence appears to be on the increase panly due LO
improvement in diagnostic techniques and panly clue LO
changing social patterns such as late ma r-riage and limita-
tion of family si.t:e. It tends to occur more amongst t11e
174
afflue nt c lass, a nd is freq ue nLI )' assoc ia ted with infe rtili ty.
Ge ne tic suscepLibiliL)' a nd fa mi lial te nde ncy a re see n in
15% cases.
Several theories have bee n propo unded to explain
e ndo me uiosis; chief among t11ese are t11e fo llowing.
IMPLANTATION THEORY
Sampson's pioneering work in 1922 attrib uted endometrio-
sis to reflux of menstrual endomeu·i um Ll1rough the
fallopian tubes and its subsequent implantation and growth
on the pelvic per-itonewn and the surrounding structures.
Sampson observed that in cases of uncompl icated endome-
triosis, the fallopian LUbes were ttSually patent Several
workers then questioned the ,-iabilit) of desquamated
endometrium and its capacity to implant and grow.
Convincing support to ampson 's theory of reu·ograde
menstruation, implantat.ion and spread has been provided
by the experimental work of Scolt, Te Linde and Whanon.
The occurrence of scar endomeuiosis following classical
caesarean sect.ion, hyster-otomy, myomectomy and episiot-
omy further suppons this view.
Lately, it h as been suggested that h ypowni a of th e utero-
tubal j unct.io n influences th e qua ntity of retrograde spill
a nd occ urrence of pelvic e ndo metliosis. T he occw-rence of
e ndo me ui osis in youn g girls with crypwme no rrhoea, and
re u·ograde collec ti o n of me nstrual fluid, is also a p roof of
Sampso n's implantation theOI')'·
COELOMIC METAPLASIA THEORY
Me)•er and Ivanoff ( 19 19) propoun ded that endometriosis
a rises as a resul t of me tap lastic changes in embryonic
cell rests of embryonic mesothe liu m, which are capable of
respond ing to hormonal stimulation. Embryologically,
MCtllerian ducts arise from these same ussues; hence, such
a tranSfonnaLion in later life seems plausible.
METASTATIC THEORY
Although the above tl1eories can explain t11e occtm·ence of
endomeu·iosis at the usual sites, the) found it difficult to ex-
plain its occurrence at less accessible sites such as t11e umbili-
cus, pel\'ic l)lnph nodes, ureter, recto"aginal septum, bowel
wall, and remote sites such as the lung, pleura, endocardium
 CHAPTER 14 - ENDOMETRIOSIS AND ADENOMYOSIS 175

and th e ex u·em iLies. Hence, it was suggested by Halban et al.

(1924) that ernboli.t.ation of mensu·ual fragmentS occ urs Table 14.1 Sites of Endo metriosis
tJwough vascular or l)mphatic channels, and t11is leads to t11e
launching of endometriosis at distal siteS. Endometrial tissue Pelvic endometriosis
Pelvic peritoneum, pouch of Douglas, uterosacral ligament
has been retrieved in pelvic l)mphatics in 20% women witJ1
Rectovaginal endometriosis
endometriosis.
Ovarian endometriosis
Chocolate cyst of ovary
HORMONAL INFLUENCE
Other sites - appendix., pelvic lymph nodes; metastatic -
Whatever be the initial genesis of endomeu·iosis, iLS further lungs, umbilicus and scar endometriosis
developmemdepends on the presence ofhonnones, mainly
oesu·ogen. Pregnancy causes au·ophy of endomeu·iosis
chiefly through high progesterone levels. Regression also
follows oophorectomy and irradiation. Endometriosis is
rarely seen before puberty and it regresses after menopause.
Hormones witJ1 antioestrogenic activity also suppress
endometdosis and arc used t11erapeutically.
Cyclical hormo nes sti mulate its growth, but continuous
hormone secreti on or the rapy suppresses iL Smoking re-
duces oestrogen level, the reby t11 e incidence of endometrio-
sis prolifera ti o n.
IMMUNOLOGICAL FAOOR
The perito neal flu id in endo metriosis comains macro-
phages C)'tokines and natura l kille r (NK) cells wh ich clear
blood spilled into t11 e peritoneal cavity. Impaired T cell and
NK cell ac tivity and altered immunology in a woman may
ina·ease t11 e susceptibility to proliferation and growrll.

OTHER FAOORS
Other faCLors implicated in t11e occurrence of endometriosis
are genet.ic, multifactorial, vaginal or cervical atresia encour-
aging retrograde spill. The more frequem the cycles, and tlle A
more the bleeding, greater is t11e risk of endometriosis. Pros-
taglandins secreted by endometriotic tissue may exacerbate
chronic pain and clysmenon·hoea.
Risk factors are polpnenorrhagia, retroverted uterus,
which increases t11e risk of retrograde spill. A woman who
has undergone wbectomy rarely develops endom etriosis.
History of familial tendency is reponed in 15% cases.
Genetic basis accountS for 10% of enclomeu·iosis; and
incidence in first-degree relative is sevenfold. It may be t11at
several factot'S are involved in t11e aetiology of endometriosis
at different sites and none of t11 e above t11 eo ries fitS into the
develop men t of e nclome u·iosis in a particular category.
The incidence is lowe r in multi paras and t11 ose on oral
contraceptives.

SITES OF ENDOMETRIOSIS (Table 14. 1)

Endomeu·iosis is found widely dispersed throughout the lower
pelvis, and below t11e level of umbilicus. The common sites are
t11e ovaries, t11e pouch of Douglas, including rl1e uterosaa·al
ligaments, pelitoneum overlying t11e sigmoid colon,
back oftJ1e uterus, ovatian fossa, imestinal coils and appendix.
Endometriosis is seen in the umbilicus following an operation, Fig ure 14.1 (A) Common sites of endometriosis in decreasing order
of frequency: (1) ovary, (2) cul-<1&-sac, (3) uterosacral ligaments,
in laparoLOm) scars, in wbal stumps following Sterili..ation
(4) broad ligaments, (5) fallopian tubes, (6) uterovesical fold , (7) round
operation. in t11e amputated stump of t11e cervix and in t11e
ligaments, (8) vem1iform appendix, (9) vagina, (1 0) rectovaginal septum,
scars oftJ1e ntlva and perineum (Fig. II. I). Scarendomeuiosis (11) rectosigmoid colon, (12) cecum, (13) ileum, (14) inguinal canals,
following lower segmenL caesarean section is seen in only (15) abdominal scars, (16) U'eters, (17) U'inary bladder, (18) IJTibilicus,
0.2%, buL is high following classical caesarean section. (19) vulva Md (20) peripheral sites. (B) Scar endometriosis.
RectO\'<lginal septal endomeu·iosis has a differem origin (A): Hacker NF, Gambone JC, Hobel CJ Hacker ald Moore's Essentials
and is desct·ibed laLer in this chaptet: of Olstetrics and Gynecology, 5th ed Phlade'*'ia: BSEl'Jier, 2010.)
176 SHAW'S TEXTBOOK OF GYNAECOLOOY

PATHOLOGY
There are three common t)'pes of endometriosis.

• Pelvic endomeu·iosis may be locali.t:ed or diffused and

scauered o'er the pelvic petitoneum, pouch of Douglas
and ULerosacral ligaments.
• Ova•·ian endomeuiosis or chocolate C)SL
• RectOvaginal endomeu·iosis.

Each categO•) has a different mode of development.

PELVIC ENDOMETRIOSIS
Early lesions appear and red vesicles are filled with
haemorrh agic nuid wil.h surrounding flame-like lesions.
With age, these vesicles c ha nge colour and erulometriotic (lrt(IS
appear as dark red, b lu ish or black C)•stic areas adherent to
Figure 14.3 Lining of the primary squamous cell carcinoma of the
the siLe whe re they a re lodged. Scarring aro und the endo-
ovary showing endometriosis at the top (< ) and carcinoma at the
meu·iosis gives it a puc ke red look. Latel)•, atyp ical lesions bottom (<<) (magnification X 4) . (Source: From Figure 1. lntemational
s uc h as nonpigm e nted areas o r >•e llowish-white thick p laq ues Journal of Gynecology and Obstetrics.in: Primary squamous cell carci-
have been noti ced, wh ic h a re healed lesions. PeritOneal cav- noma of the ovary associated vvlth endometriosis. Pages 16-20, 2009.)
ity co ntain s yell owis h-b rown fluid in the cul -de-sac, and this
contains prostagland in respo nsible for pain. Powder-burnt
areas are in active and old lesions are seen scaLLered over the
pelvic peritOneum.
Sometimes, hea led areas of endometriosis appear as
small peritoneal defects (windows) or white patches.

CHOCOLATE CYSTS OF OVARY

Chocolate cysts of the ovaries represent the most imponam
manifestation of endomeu·iosis. To the naked eye, t.he
chocolate C)St shows obviotLS thickening of the tunica albu-
ginea, and vascular •·ed adhesions are well marked on t.he
undersurface of the O\'lll"). The inner surface of the cyst wall
is \'liSCular and contains areas of clark brown tissue. The
chocolate cyst lies between the ov<U") and tJ1e lateral pelvic
wall (Figs I 1.2-1 1.1) .
HistOiog) fails to reveal endomeuial tissue in most dloco-
late cysts. The lining epitJ1elium is usttally colwnnar with a
tendency to form papillae. BeneatJ1 tJ1e epitJ1eliwn, a zone of
tissue containing large ce lls witJ1 brown cytoplasm, polyhedral
Figure 14.4 Focus of ovarian endometriosis adjacent to carcinoma
(magnification x 10). (Source: From Figure 1. International Joumal of
Gynecology and Obstetrics. In: Primary squ<rnous cell carcinoma of the
ovary associated vvlth endometriosis. Pages 16-20, 2009.)

in s hape a nd resembling lutein cells is nearly always seen.

T hese pseudoxantJ1oma cells are probably large macrophages
or scavenger cells, and their brown colouration is due to
ingested blood pigments such as hae mosiderin. The choco-
late cyst develops as a n invagination into tJ1e ovarian cortex.
Circular peritOneal defecLS over the broad ligament and
uterosacralligamenLS reveal endomeuiotic tissue b)' biopsy in
50% cases, and they are healed areas of endomeuiosis. The
levels of tumour necrosis factor and mau·ix metallo-proteinase
inhibitors are raised in pelvic endometriosis.

Rgure 14.2 Typical endometriotic cyst lining containing end0111etrial
glands (right) or a more attenuated lining with sparse str0111a Oeft).
(Source: Fr0111 22-48 Christopher P Crum, Marisa R Nucci
Md Kemeth R Lee: Diagnos!JC GynecologC and Cllstetric Pathobgy.
B5EMer: Saunders, 2011 .)
STAGING OF ENDOMETRIOSIS
The CLu-rent classification ( fa hle 11.2) is based on the
appearance, siLe and deptJ1 of peritoneal and ovarian
implants, presence and extent of adnexal adhesions and
 CHAPTER 14 - ENDOMETRIOSIS AND ADENOMYOSIS 177

Table 14.2 American Society for Reproductive Medicine Revised Classification of Endometriosis (1996)

Patient 's Name Age/ Date

Stage 1 (Mini maO Score 1-5 Laparoscopy/laparotomy/photography

Stage 11 Score 6-15

- - - Score 16-40
(Mild) Recommended treatment

Stage Ill (Moderate)

Stage IV (Severe) Score > 40
Total Prognosis

Peritoneal endometriosis < 1cm 1-3cm > 3cm

Superlicial 2 4
Deep 2 4 6
Ovarian endometriosis < 1cm 1-3cm > 3cm
Right side- superficial 2 4
Deep 4
- - - - 16 20
Left side - superficial 2 4
Deep 4 16 20
Posterior cul·de-sac obliteration Partial Com plate

4 40
Ovarian adhesions < 1/3 Enclosure 1/3-2/3 Enclosure > 2/3 Enclosure

Right side- flimsy 2 4

Dense 4 8 16

Left side - flimsy 2 4

Dense 4 8 16

Tubal adhesions• < 1/3 Enclosure 1/3-2/3 Enclosure > 213 Enclosure

Right side- fUmsy

---------------------
2 4

Dense 4 8 16
Left side- flimsy 2 4
Dense 4 8 16

•11the fmbriated end of the r.-lopian tube is completely dosed, ch<r1ge the assignment to 16.
Note adcition.- endometriosis. Note presence of any associated pathology. (Sourt::e: Reproduoed from FertiKty and Steriity 1985; 43: 351-52.)

t11e degree of obliteration of the pouc h of Do uglas. It does not
take into account comp la in ts s uch as infertili ty o r pain; how-
ever; it forms the acceptab le basis for co mpa riso n of therape u·
tic o utcomes in re lieving symptoms and improving fe n:ility.
Avail abili t)' of lapa roscop ic proced ures has made it possible
to diag nose wi tJ1 confide nce sma ll and early lesions, which are
often as)'mptomaLic, assess the ex te nt and severity of the dis-
ease and allow an acc urate classification prior to initiating of
t11erapy. The classification described by t11e American Fertility
Society ( 1985) is based on the size and location of t11e endo-
meuiotic lesion and is classified as minimal, mild, moderate
and severe (Fig. I 1.5). This classification is correlated witl1
fertilit) outcome ratJ1er than pain sympLOms.
1\linimal. Small spots of endometriosis seen at laparoscopy,
but no clinical S)mptoms.
Mild. ScaLLered fresh super·ficial lesions. o scarr-ing or
reu-action. o adnexal adhesions.
Moderate. Ovalies a re involved, witJ1 some scarring a nd
reu·acti on. T hey co ntain no t mo re t11 an
2 e m in s ize. T he re a re minim a l petituba l a nd periovaria n
ad hes ions. Endome u·iotic lesions in the a nterio r a nd
posterior peritonea l pouc h wi Ll1 some scarring and re trac-
tion ma)' be seen.
Severe. Ovaries are invo lved, wiL11 the size of t11e endome-
triomas exceeding 2 em. De nse peritubal and pe riovar-
ian adhesions severely resu·ict mobili ty. The u terosacral
ligaments are thickened and involved, and lastly, there
may be evidence of involvement of the bowel and urinary
u-act.
Laparosc opic findings \'llf) with the duration of t11e lesion,
sue and location. 'Powder-burn' - puckered black spots,
red \'ltscular. bluish, blackish C)'Sts, choco late cysiS and
dense adhesions in the peh is as well as peri-
tOneal fluid are tl1e findings. Biopsy of tlle lesion may be
necessary to con finn the diagnosis in doubtful cases. Early
178 SHAW'S TEXTBOOK OF GYNAECOLOGY

Peritoneum Peritoneum Peritoneum

Superficial endo - 1-3cm 2 Deependo - >3cm 6 Deependo - >3cm 6
A. ovary A. 01ary Cul-de-sac
Superficial endo - <1 em Superficial endo - <1 em Partial obliteration - < 1 em 4
Filmy adhesions - < 113 Filmy adhesions - < 1/3 L. ovary
L. ovary Deep endo - < 1-3cm 16
Superficial endo - < 1 em 1
Total points 4 Total points 9 Total points 26

Stage Ill (Moderate) Stage IV (Severe)

Peritoneum Peritoneum Peritoneum

Superficial endo - >3 em 3 Superficial endo - > 3cm 3 Deependo - > 3cm 6
A. tube L. ovary Cul-de-sac
Filmy adhesions - <113 Deependo II <1-3cm 32- Complete obliteration 40
A. ovary Dense adhesions - <1/3 a- R. ovary
Filmy adhesions - < 113 L. tube Deependo - <1-3cm 16
L. tube Dense adhesions - < 113 a- Dense adhesions - <113 4
Dense adhesions - <113 t 6• L. tube
L. ovary Total points 51 Dense adhesions ->213 16
Deep endo - <1 em 4 L.ovary
Dense adhesions - <113 4 Deependo - 1-3 em 16
•Point assignment changed to 16
Dense adhesions ->213 16
- Point assignment doubled
Total points 29 Total points 114
Figure 14.5 American Society for Reproductive Medicine Revised Classification of Endometriosis (endo, endometriosis).

and fresh lesio ns appear red flame-like raised areas, SYMPTOMS

whereas older and healed lesio ns present yellow brown
patches and white plaques over th e peritOneum a nd peri-
toneal windows. The lesio ns are mo re marked o n the left
side because the sigmoid colo n fo 1ms a co nduit for the
tiss ue to grow. It is not s urprising for lapa roscopy to reveal
pelvic endome u·iosis in an asy mptomati c woman.
Poor correlation betwee n the naked eye appearance
and histology is we ll doc um e nted. Th erefore, biopsy
of the suspicio us areas becomes necessary to prove the
presence of endo metriosis.
CLINICAL FEATURES
Endomeu-iosis affects women in 1J1e reproductive age,
i.e. around 30 >ears of age. It ma> occur in a n adolescent
if obstruCLion in the lower genital tract cattses crypwmen-
orrhoea and reu·ograde spill of menstrual fluid. A rare
case of endometriosis has been reponed in a posuneno-
pausal woman on honnone replacemem therapy (HRT).
T he symptoms vary according to th e site, depth of lesion
a nd do not always correla te well with the ex te nt of disease.
T he classic sy mptom comp lex includes dysmenorrhoea,
dyspareuni a, meno rrh agia and inferti li ty. Abo ut 30% of the
patients are asymptomatic. Overlapp ing of sy mptoms is
common. T he fo llowing arc the common symptoms.
DYSMENORRHOEA
T his is tl1e most common symptom. About 70% pain begins
before rJ1e onset of menstruation, up co minuously unti l
ll1e flow begins, and thereafter it declines grad ually. 111e dlarac-
ter of pain can be very variable, from a dull ac he to grinding or
cniShing pain. colick) pain or a bearing-down pain. Backad1e is
a common accompanimenL Sometimes, 1J1ere may be radiating
pain along the sciatic nerve. \\'itl1 passage of lime, ll1e intensity
and duration of pain increases and dysmenoni1oea may persist
for a few days after mensU"\Il\tion. Pain of endomeuiosis is
chiefly related to tl1e location and not the extent of the lesion.
Deeper lesions cause more pain than superficial ones. The

peritoneal fluid comains prostaglandin, whidl is supposed to
cause d}smenorThoea and abdominal pain.
ABDOMINAL PAIN
Lower abdominal pain of varying in tensity may appear at
any time but is usuall) common around mensuuation. It is
a dull ache culminating in d)Smenor-rhoea. Occasionally,
the pain suddenl> becomes ver> severe, presenting as
an acute alxlomen necessitating immediate surgery. At
laparotomy, a nrpLUred chocolate cyst is observed.
DYSPAREUNIA
Endometriotic involvement of the cul-<le-sac and the utero-
sacral ligaments may produce adh esions and fixation ofthe
uterus and nodular thickening ofthe uterosanalligaments.
Movements of the cervix elicit tendemess. Dyspareunia and
backache may be th e result of this pat11ology. These patients
are often relucta nt tO atte mpt intercourse, and this adds to
t11e magniwde of infe ni li t)' (25%-50%) .
INFERTIUTY
Endomeu·iosis affects ferti lity at all stages of t11e disease but in
as>•mptomatic women witJ1 mild disease, infertility is d ifficu lt to
explain. AltJ1ough about one-frfth of all women who are inferti le
tend to suffer from endome uiosis, t11e incidence of infertility
amongst women suffeting from endomeuiosis ranges between
30% and 40%. L::ndomeuiosis possibly interferes with tubal mo-
tility and function. It may inhibitovulation, pick-up by t11e
fimbtia. and because of d)Spareunia there is reduced frequency
of sexual intercourse. Other of infertility are luteinized
LU111.1ptLu·ed follicular (LUF) S) ndrome, increased prolactin and
corpus luteal phase defect, nonovulation and tubal blockage as
well as poor OOC) te qua lit). PrOStaglandin affects t11e tubal motil-
ity and also causes corpus luteOiysis. The activated macrophages
in the peritoneal Attid engulf the spenns or immobilize t11em.
MENSTRUAL SYMPTOMS
Menoni1agia (20%) is common witJ1 adenom)OSis, and
bleeding may occur \\ith cerYical and vaginal lesions.
Polymenord1oea is noted \\ith involvement ( I 0%-30%).
CHRONIC PELVIC PAIN
Endometriosis is one of t11 e importa nt causes of CPP.
Brownish·>•ellow peritoneal flu id co nta ining prostaglandin
£.2 is responsib le for th is pa in. Ne rve en u·apment in
endometriosis tissue ma>' also be respons ible for pain.
OTHER SYMPTOMS
Urological S)'mpto ms such as increase in frequency, dysuria
and, in rare cases, haematutia during mensu·uation may result
from bladder or ureteral involvemenL Obstmction of me
ureter directly or as a resu lt of kinking by ad hesions leads to
hydronephrosis and renal infection. Bowel symptornsareoften
t11e result of direct involvement of t11e sigmoid colon and
rectum causing painful defecation, diarrhoea and melaena
arOLLI1d menstruation. Occasionally, pehic endomeuiotic
adnexal masses can Qmse obsu·uctive spnpLOms of constipa·
lion and present with a painful abdominal mass or as an acute
abdomen simulating peritonitis, appendicitis or an ectopic
pregnanq\ Scar endomeu·iosis causes qclical pain and en·
largement, and pulmonary lesion causes qcl ica.J llaemoptysis.
CHAPTER 14 - ENDOMETRIOSIS AND ADENOMYOSIS 179
PHYSICAL FINDINGS
Abdontinal examination rna) reveal a cystic swelling which
simulates an ovarian tumour in a chocolate cyst of the ovary.
1l1e swelling is often fixed and may be sligh tJy tender.
Speculum examination ma> reveal bluish or blackish puck-
ered spots in the poster·ior fornix, and t11ese spots may be
tender to touch. The presence of t11ese puckered spots is
pathognomonic of endomeu·iosis. Vaginal examination
reveals a tender fixed reu·ovened uterus. A fixed tender
cystic mass or bilateral masses may be felt in the pelvis. If t11e
uterosacral ligaments and the pouch of Douglas feel tllick-
ened and shotty with multiple small nodules palpable
through t11e postetior fomix, the diagnosis becomes reason-
ably cenain. These at·e described as cobblestone feel of
uterosacral ligaments. During vaginal examination, tender-
ness in the latera l fornices indicates the possible existence
of endomeu·iosis eve n in the absence of any adnexal mass.
ENDOCRINOLOGICAL ABNORMAUTIES
Endomeuiosis is often assoc iated with anovu lation, abnormal
fo ll ic ular development, luteal insufficie ncy and premenstrual
spotting. Luteinizatio n of t11e unrupwred fo llicle is known to
occur, and h)•perprolac tinaern ia with assoc iated galacton·hoea
are noted findings. However, no definite con·elation between
t11ese endocrine events and the degree of endometriosis has
been established. Cortisol and prolactin may be slightly raised.
DIFFERENTIAL DIAGNOSIS
BecaLLSe of varied clinical feaw res, e ndo me uiosis poses a
diagnostic challenge aL times.
• Chronic peh·ic inAammatory disease (PID) closely mimics
endomeu·iosis in its spnptorns and signs. Both t11e condi-
tions produce pelvic pain, congestive dysmenorri1oea,
menorrhagia and sterility. L::ndometriosis may, if there is
leakage of blood contents, produce leucoq•tosis, raised
erytJ1rocyte sedimentation rate (ESR) and moderate
fever. BotJ1 also have similar physical signs. Laparoscopic
visuali zation of t11e pelvis \\i ll revea l t11e tnJe patl1ology.
• Uterine myomas, unless degenerate, are painless and t11e
uterus is not fixed. Ulu·asou nd a nd laparoscopic visuali za-
tion wi ll differenti ate o ne co nditi o n from t11e o tJ1er.
• Ovarian malignant wmour with metastatic depos its in the
po uch of Douglas ca n be mista ke n for endometriosis.
History, pain, age of the patient and other symptoms
suggestive of e ndo me tri osis are against t11e diagnosis of
cancer, but t11 e physical signs, apart from tenderness, are
very similar to tl1ose of an ovarian neop lasm.
• Rec tosigmoid invo lvement wi ll cause rectal symptOms
which resemble t11e symptoms of rectal carcino ma. It may
be impossible to make an acc urate diagnosis until
sigmoidoscopy and biopS) are performed.
• If t11e chocolate C)St ruptures, all possibilities of an acute
abdominal catastrophe must be considered, including a
rupLLLred tubal gestation, t11ough the most frequent e rTor
is to operate for acute appendicitis.
• Chronic peh·ic congestion S)ndrome due to other· causes
must be excluded by ulu-asound, Cr, magnetic resonance
imaging (MRI ) and laparoscopy.
180 SHAW'S TEXTBOOK OF GYNAECOLOGY
Table 14.3 Investigations
Laparoscopy - diagnostic and therapeutic. Gold standard.
CA 125 > 35 UlmL
Ultrasound - mass, echogenic areas
MRI:
Colour Doppler - increased blood flow
Cystoscopy - Urinary cause
Sigmoidoscopy -rectal cause
Antiendometrial antibodies
INVESTIGATIONS (Table 14.3)
LAPAROSCOPIC FINDINGS
These have already been described earlier. Laparoscopy
sho uld be emplo)•ect not merely for diagnosti c p urposes; the
endoscopist s hotJd be able to proceed with minimal inva-
sive surgery (see be low) in th e presence of this pa thology.
Laparoscopy is the gold standard in the d iagnosis of e ndo-
me u·iosis. T he d iagnosis sho uld be va lidated by pe ri to neal
and tissue b iopsy (Fig. l tl.()) beca use corp us luteal hae ma-
toma can resemble a chocolate cyst.
Role of laparoscopy
• To detect and diagnose pelvic endome u·iosis.
• Locate the site of e ndo me u·iosis and staging.
• To take biopsy.
• To surgical I) treat endo metriosis by ablation and removaL
CA-125. gi)COprotein a nd cell surface antigen, is raised
LO more than 35 U/ mL in 80% cases of endomelriosis
and the level is directly proportional to the extem of the
disease. The Je,el is not specific, because it is also raised
in abdominal lll berculosis, PI D, malignant epithelial
ovarian tumour, chronic liver disease and in 2% normal
women, especiall)• during menstruation. Although CA-
125 estimation may n ot be h elpful in the initial diagnosis,
once the diagnosis is established, raised level of CA-125
indicates either pet-sistence or recu t-renee of the disease
in the follow-up.
ULTRASOUND AND MRI
Tra nsvagina l ultmsound reveals an ec ho-free cyst, low-level
ec hoes or clum ps of hi gh-density level echoes represe nting
clots. T he cyst wa ll is tl1ick and irregul at; and multiple
cysts in different phases of evolution ma)' be observed.
Ultrasound is 83% sensitive and 98% specific, as small
nod t.Jes may not be picked up by ulu·asound.
CT and MRl give identica l picture as in ul u·aso und,
and are not more useful in the diagnosis of endomeu·iosis
(Figs 1 I. 7 and I 1.8).
• Colour Doppler flow shows increased vascularity but does
not confi1m the diagnosis - vascularity is diffuse; in a
fibroid. blood ' essels are seen in the periphery.
• Cystoscop) will idemif) involve mem of the bladder.
• Sigmoidoscop) is •·equired if t11e woman develops
bowel S)lnptoms. A biopS)' is req uired if malignancy is
suspected.
• Antiendomeuial antibodies are identified in tl1e serum,
peritoneal fluid and endometriotic fluid as we ll as in
nom1al endometrial tissue. However, as yet, these are not
measmed to be of screening value and tl.Sed as a tissue
marker. ll1ese ma> also not be sensitive and specific.
• Tlllnour necrosis factor is raised propo rtionately to the
severity of the disease.
• MRl reveals thickening of ligaments and nodules.
PROPHYLAXIS
• Low-dose oral contraceptive pills reduce t11e menstrual
flow and pt·otect against endometriosis. Three montl1ly
ot-al pills are convenient to take and are effective.
• Tubal patenC)' tests should be avoided in the immediate
premenstrual phase to avoid spill.
• Operations on the genital tra ct should be scheduled in
the postmensu·ual period.
• Classical caesarean section and hystero tomy operatio n
which cause scar endometriosis are now rarely perfo rmed.
MANAGEMENT
Mi n imal as)•mp to rn atic cases s ho uld be obse rved over
months. Inferti li ty should be investigated and treated
as necessary (Fig. 1 1.5 ).
Al l symptomatic women need treatment. T he treatment
(Fig. 11.9) depends upon t11e age of the patient, need for
preserving reproductive functions, severity of the symp-
toms, extent of the disease, response to medical treaunem,
relief obtained with an> previOtl.S conse rvative surgery and
the attitude of the patient towards her problem. The oqjec-
t.ive of the treatment should be to e •-adicate the lesion and
avoid recurrence of the dis ease process, alle,·iate S) mptoms,
facilitate childbealing and enable tl1e patient to lead a com-
fortable life. Therefore, t11e u·eaunent should be
ized. The treaunent comptises medical and surgical and a
combination of botl1.
DRUG TREATMENT
Drug treaunent should aim at causing atrophy of tl1e ecto-
pic endometrium witl1 minimal side effects, improving
symptoms, ferti lity rate and avoiding or delaying rec ur-
rence.
Endome u·iosis is oesu·ogen depe nde nt. Horm ones act
o n recep to t-s in the e nclo metrio ti c tissue and cause the ir
a troph y and shrinkage. T he purpose of ad minis u·atio n of
vario us hormones is to act as antioestrogens; the d rugs p ro-
duce a hypo-oes u·ogenic effecL Supe rfic ia l lesio ns respond
better than th e deepe r ones. llowever, one must no te th at
hormonal therap)' suppresses endometriosis for the d ura-
tion of tl1erapy; it does not prevent rec un·ence once the
therapy is stopped. Moreove•; the hormones delay preg-
nancy by tl1eir contraceptive e ffect and cause side effects on
prolonged tl1erapy, besides t11 e drugs being expensive. The
drugs are best suited for multiparous women.
I. Combined oral contraceptives (OCP). It is tl.Sed as a p•i-
mary treatment o r preope•-ativel) to shrink endomeuio-
sis. Administered intermitte ntly or continuously, oral
conuaceptives may aiiC\·iate the disease. However, high
incidence of side effects and risk of thromboembolism
 CHAPTER 14 - ENDOMETRIOSIS AND ADENOMYOSIS 181

Rgure 14.6 (A- D) Appearance of o ld endometriosis w it h 'tattooing' {blue-grey lesions), and red, brown and black raised lesions of active
endometriosis at the t ime of laparoscopy. (E) Pel vic endometriosis showing red lesions on laparoscopy. (F) Complete obliteration of t he pouch
of Doug las (white arrowhead) was noted during diagnostic laparoscopy. (G) Laparoscopic view of bilateral endometriosis. (Source (A-D): Hacker
NF, Gambone JC, Hobel CJ. Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th ed. Phiadelphla: BseiAer, 2010.) (Courtesy
(G): Dr Vivek Marwah, New Delhi.)

li mit tl1eir prolonged use. About 30% p regnancy rate is
reported fo llowing th is treaLmenL OCP de lay pregnanC)'·
Seasonale OCP for 84 days, with 6 days tab let-free, re-
duces the mensu·ua l periods to j ust four cycles in a year
and may be suited in endome u·iosis.
2. Oral progestogens. These drugs exert an antioestrogenic
effect and tl1eir continuous adminisLratio n causes decidu·
alizaLion and endometrial atrophy. The treaunem over a
period of months produces a state of pseuclopreg-
nruK). whicl1 ultimate!) causes regression of the disease.
The drugs in common Ltse are noret11isterone, 5.0-20.0 mg
daily, or d)drogeste•·one 10-30 mg daily. Oydrogester-
one mg daily in the luteal phase relieves spnpwms.
This lwmume tire. 1101 prromt mmlaJion and is suitable for a
wu11um tr)'i1tg to conceive. IL also has less toxic side
effects. Instead of restricted 1\lleal phase adm inistration,
it can be given 10 mgb.d. from clay 5-25 for three cycles.
Tibolone is also Ltseful in e ndome u·iosis. Medroxyproges-
terone acetate may be adm inistered as a long-acting
depot preparation, 50 mg i.m. weekly, 100 mg i.m. every
2 weeks for 3 montllS, followed by 200 mg montl1ly
for 3-6 montl1s or oral 30 mg daily. About 50%-70%
symptomatic relief and pregnanC) rate of 40%-50% have
been reponed. Weight gain and irregular bleeding ru·e
the side effects of progestogens. Other side effects
include reduced libido, mental depression, breast tender-
ness and decreased high-density lipoprotein (HO L).
Moreover, fe•·tility is impaired for 2 )Cars after prolonged
182 SHAW'S TEXTBOOK OF GYNAECOLOGY

Figure 14.7 Ultrasound showing endometrioma. Figure 14.8 MRI showing endometri oma.

Management of endometriosis

Observe for 6-$ months, Minimal invasive Surgery

1
investigate for infertility surgery

Drug treatment +
Laparoscopy Laparotomy
1. OCP I . Destruction I . Incision o f chocolate
2. M irena IUCD by cautery, laser cyst, and removal
3. Progestogens vapourization of lining
4 . Androgens 2. Excision of cyst 2. Salpingo-oophorectomy
5. GnRH analogues 3. Adhesiolysis 3. Hysterectomy and
6. Letrozole 4 . Presacral neurectomy unilateral or bilateral
7. RU-486 5. LUNA (laparoscopic salpingo-oophorectomy
ut erosacral nerve 4. Excision of scar
ablation) endometriosis
Figure 14.9 Management of endometriosis.

hormone Ule rap)'· T he side effectS are dose and duration
re lated. Mimw!UCD red1tces <lynnnwrrlwert mulmenorrlwgia
in It is a o ne-Lime u·eaunent lasting for
5 >•ears with minima l systemic side effectS. Danacrine,
an anabolic drug, does not cause menopausal symptoms,
level does not drop below 50 pg!mL. The progester-
one level rises in 15 minutes, peak5 in a few hours and
stabilizes tl1ereafter. It causes endomeuial gla nd atrophy,
and of stromal cells. I L is ideal LO relieve
pain and menon·hagia in premenopausal women who
have completed tl1eir families.
3. Dydrogesterone mg clail)' in the lllleal phase or
10 mg daily from 5tll-25th cia)' improves S)lnpLOms and
the ferLility rate.
4. Danazol, a S)'ntheLic derivaLive of e tllin)•l testosterone,
inhibitS p ituitary gonadotropins. It is mi ld ly anabolic,
amioesuugenic and an LiprogestaLional. It reduces sex
hormone-binding globuli n SHBG and re leases free
testosterone. It is a very effective, t11ough an expensive
drug, and is administered in closes of200-800 mg daily for
3-6 months starting on t11e first day of menses. It causes
S)'lnptoms simulaLing menopause if lL5ed in higher doses
over 6-8 months. The lesions regress remarkably, but
many paLienLS suffer from side effeCtS such as weiglu gain,
hirsuLism, excesshe sweaLing, mtLScle cramps, depression,
auuphy of breasts and vaginal epithelimn, lowering of
HDL, and liver and renal damage. The resulLing amenor-
rhoea p•umplly con-eelS itself on withdrawal of tl1e dJUg.

The chances of successful pregnancy this ther-
apy range fro m 30% to 50%. It is reported that 80% of
endometrial implants resolve with danazol. Recurrence,
however, is like I) after stoppage of the dn•g (30%) . It is
conu-aindicated in liver dysfunction, and pregnancy
should be avo ided as it is teratogenic. Recently, danazol is
implicated in the development of ovarian cancet·, and
man> ro naecologists are now reluctamto use this drug.
Gestrinone is a 19-nonestosterone det·ivative similar w
da n;uol in action, but it has fewe r side effects and is long-
acting. It reduces the LH surge and SHBG. Dose is
2.5-5 mg twice weekly. About 85%-90% patients experi-
ence amenorrh oea. Anti-inflammatory drugs, such as
mefenami c acid 500 mg three tim es a day dm·ing men-
struation, relieve dysmenon·h oea in 70%-80% patientS.
Other amiprostaglandin and anti-inflamm atOry (not1Ste-
roidal) drugs such as naproxen are also useful.
5. Gonadotropin-releasing hormone (GnRH). This hor-
mone is ad ministe red continuo usly to downregulate and
s uppress pituitary gonadotropins; it ca uses atrophy of the
endometriotic tissue in 90% cases. T he synthetic ana-
logue of GnRII is given in doses of 10-20 mg i.v., twice
da il>'• or 200-tiOO mg in tranasa ll)' dail)' for 6 months.
Monthly depot iqjec tion (Zoladex) of3.6 mg is also avai l-
able. Discontinuation of Gn RH and danazol causes re-
curre nce of e ndome u·iosis within a year in 50% cases.
GnRl-1 is better to lerated than danazol.
prolonged Gn Rl-1 therapy ove r 6 months causes hypo-
oestrogen ism a nd menopausal symptoms such as hot
flushes, dt] vagina, urethral syndro me and osteoporosis.
To avoid this, add-back therapy with progesLOget1S and
l.ibolone or etidro nate is recommended. This also allows
prolonged Lherap) with GnRH for 2 >ears.
Other dt·ugs available are as follows:
Buserelin and leu protide (nonapeptides) .
afarelin and goserelin (decapeptide). The superficial
lesio11S respond beuer than the d eep-seated lesions.
Ceu"'relix (GnRJ I antagonist) -3 mg weekly x 8 weeks.
Goserelin 3.6 mg momhl y subcutaneously.
Leupt"'lide 3.75 mg i.m. monthly or 11.25 mg 3momhJy.
6. Aromatase inhibitors. Aromatase inhibitors available are
letro:wle (2.5 mg), an asu·ozole ( 1-2 mg) and rofecoxib
( 12.5 mg) daily fo r 6 mo nths. These are amioesu"Ogen
and should be give n with vitamin D ( 400 g IU) and cal-
cium (I g) to preve nt osteoporosis. Nausea, vomiting and
di arrhoea are tlte other side effec ts. Anastrozole is less
osteoporotic tl tan others. They b loc k aromatase activity
by preve nting tlt e conversion of androgen to oestrogen.
T he)' may be combined with 2.5 mg nore tJtisterone.
7. RU486 (an tiprogestogen) is also u·ied in a dose of 10-25 mg
dail)' for 3 montJ1S. It red uces pain and delays recun-ence.
T he failure and rec urre nce following medical therapy is
due to tJ1 e following:
The drug cannot penetrate t11 e fibrotic capsule.
Ectopic e ndo metrium respo nds less to hormones as
compared to normal endometrium.
Side effect; - Hormones prevem conception besides
other co t1Sequences.
MINIMAL INVASIVE SURGERY
Honn on es delay pregnancy, so p•·imary surge•·y is preferred
in infet·tile women. Re cent advances in ro naecology have
CHAPTER 14 - ENDOMETRIOSIS AND ADENOMYOSIS 183
imrod ucedlapat"'scopy in tJ1e manage ment of pelvic endo-
metriosis in young women. This o ffe rs the advantages
of conserving the ovaries a nd tJ1 e fallopian tubes, and
improving ferl.iJit).
The method.1 emplu;·ed aTI! a.; folkJws:
• Aspiration of pe.-itoneal fluid in cul-de-sac: It removes
PG£2 and relie,es d)Smenorrhoea, pelvic pain and
improves pregnanC)' rate.
• Destruction of endomeu·iotic impla nts less than 3 em by
diathenny caULel'it.ation, or ' -apo•·it.ation by C0 2 or
Nd:YAG laser. Superficial lesions are easier to d estroy and
yield beuer fertility results than the deep implants. Laser
has the adva ntage of con trolling the deptJt of desu·uction
by adjusting tJ1 e power density. It does not cause adh e-
siot1S and fibrosis. IL can be applied to the bowel and
bladder.
• Larger lesions and chocolate cyst ca n be excised. The
residual lesion ca n be dealt witJ1 by ho nnonal therapy.
Cauterizati on of the C)'SL wa ll is preferred in young
women. It avoids ova ri an destructi o n with peeli ng off
of the cyst wall but rec urrence is slightly high.
• Role of s urgery
• Failed medical tJ1e rapy
• lnfertilit)'
• Rec urrence
• Chocolate cyst o f ovary
• The consensus of opinio n is that cystec to my is more ben-
eficial in extent of pa in relief, longe r recurrence time
and longer pain-free in terva ls. However, tJt e excision of
the cyst wall deprives tll e patiem of potential ova and
t11ereb> reduces her fertilit) potential. In o lder women,
excisio n of the C)SL wall is recommended.
• Laparoscopic lysis of acl hesiot1S in the pelvis relieves
dys menorrhoea and peh·ic pain. It also restores patency
of the fallopian Lubes a nd O\ulation. Presacral neurec-
tomy can be perfonned simultaneously. Bleeding and
haematoma are its complications. Pregnancy rate follow-
ing minimal invasive surgery is at"'tmd 30%-50%.
• Laser ULerine n erve ablation ( LUNA) for midline pain in
endometriosis is eff-ective in some cases.
• Pregnancy rate following conservative surgery is 40%,
50% and 70% in severe, modera te a nd mi ld endometrio-
sis, respectively.
• Prolapse of genital tract a nd bladder dysfunction are
noted witJ1 LUNA. It is advisable LO postpone laparo-
scopic tec hnique for 3 mo nths if hormon e therap)' has
already been given to avo id unde r d iagnosis.
OTHER MODAUTIES OF TREATMENT IN AN INFERTILE
WOMAN ASSOCIATED WITH PELVIC ENDOMETRIOSIS
(Fig. 14.10)
Ultrasonic-guided chocolate cyst asp iration followed by
mifepristo ne for 6 montJ1s is also tried.
• Mild endometriruis. Surgeq followed by superovulation
and IUl/fVF (aspiration of e ndometriosis cyst).
• Advanced endometl'iosis in,olving t11 e fallopian tube.
The choice is between wboplast) a nd IVF. Altematively,
3 montl1S of medical therapy followed by IVF.
• Postopemti,·e medical therapy to deal with the residual
tissue and pt-e\enL recu•·•-e nce.
184 SHAW'S TEXTBOOK OF GYNAECOLOGY
Rgure 14.10 (A) Endom etrlotlc cyst (chocolate cyst). (B) Same as
(A), except that the cyst has burst. (C) Cut section of endometriotic
cyst . (Courtesy (A) and (B): Dr Vlvek Marwah, New Delhi.)
• Oydrogesterone 40 mg in the luteal phase re lieves pain
without compromising inferti li ty, as it does not prevent
• Pre- and postoperative hormonal therapy may alleviate
S)'lnptoms but dela) pregnancy.
SURGERY
Recun·ence following conse•vative surgery may be see n in
10% at the end of I >ea•· and 25% at the end of 3 years.
Adhesions fonn in 10%, more \\ith cauteriLation than laser.
These women may require second surge•·y, which may be
technically difficu iL Therefore, some prefer laparotomy
over laparoscopy when repeat surgery is required. Indica-
tions for open surgery are as follows:
• Advanced stage of disease detected
• Large lesion -can be dealt with
• Medical therap) fails or is intolerable
• Recurrence occurs
• In elderly parous women
LAPAROTOMY
Laparotomy is also required in advanced stages a nd for
larger lesions if medical therapy fails or honnones cannot
be toler-ated and for •·ectm·ence.
• Dissection and excisio n of a chocolate C)'SL
• Salpingo-oophorectomy.
• Abdominal hysterecto my and bilate ral salpingo-
oop horectomy. Surge•)' ca n be d ifficult due tO adh esio ns
in pelvis.
Mirena LUCO is an alte rnative to a repeat surgery.
A premenopausal woman may need HRT afte r the
rad ical surgery; ti bolone is safer than E2 P Lherapy. Scar
endomeuiosis req uires excisio n or danazo l.
HRT following bilateral ovluian remova l in youn g women
may be prescribed under suict monitoring, as the 1isk
of recurrence remruns. Calci um and vitamin 0 are added
w HRT. lt may be better to dela) HRT by l-3 months tO
reduce risk of recun·ence.
As mentioned before, tibolone 2.5 mg daily is better than
E2 and progestogen.
COMBINED THERAPY
Combined therapy is indicated in the folio" ing conditions.
• Preoperative GnRH monthly for 3 months reduces the
sue and extent of the lesions, softens the adhesions and
makes the subsequent surge•)' easier and more complete.
• Postoperative honnonal ther·apy may be required if the
surge•] ' has been incomplete, and some residual lesion is
left behind clue to techni cal difficulty. It also reduces the
rec urrence rate.
ENDOMETRIOSIS OF THE RECTOVAGINAL SEPTUM
Recwvaginal endo me u·iosis oblite •-a tio n ofLhe po uch of
Douglas in volves the uterosacral Iigame ms, posterior
fornix and anterior wall of the rec wm and sigmoid colo n.
T he aetiology of this conclition d iffers from Lhat of pelvic
endomeu·iosis. lt is not caused by deep in filu-ation of pelvic
endomeu·iosis and reu·ograde mensu·uation b ut accord ing tO
Nicolle et al., it is derived from emb•ro logically de•ived
MCtllerian tissue and the theo•]' of Milllerian metaplasia
applies here. Recwvaginal endometriosis contains more fi-
brous tissue than glandular tissue with flame-like appearance.
Laparoscopicall). it is seen as a )ellowish-white appearance
with small haemorrhagic areas and dense fibrotic adhesions.
CUNICAL FEATURES
The woman is often of rep•·oducti\e age. She complains of
dysmenorrhoea, d)spareunia abdominal pain, backache
 CHAPTER 14 - ENDOMETRIOSIS AND ADENOMYOSIS 185

and menorrhagia. If the recLUm is invo lved, rect:a l pain,

constipation and occasional diarrhoea may occu t: Cyclical
rect:al bleeding is also reported. Ureteric compression
with merosacral ligament involvemem causes renal
damage.
Speculum examination is painful. Red spoLS are seen in
the posterior fomix. Bimanual examination reveals Lhicken-
ing of Lhe poste.-ior fornix and uLerosacralligamenLS. Rect:al
examination should be perfonned to assess the rect:al in-
volvement.
DIFFERENTIAL DIAGNOSIS
The clinical featur·es mimic PID, diven.iculitis, colonic
cancer and inflammatory bowel syndrome.
INVESTIGATIONS
Investigations include ultrasound using rectal probe,
CA- 125 ( may be raised), MRI , but are nonspecific and
unrewarding. Proc toscopy and sigmo idoscopy rule out
malignancy. IVP needs to be don e if ureter appears
involved. LaparoscO p)' is both diagnosti c and therape utic,
and biopsy shoul d confirm the d iagnos is.
MANAGEMENT
Poor hormonal response makes lapa roscopic s urgery the
u·eaunem of cho ice. Bowel preparatio n preoperatively is
necessary in case bowel is invo lved and needs resection.
Ablative and excisional techniques are employed depend-
ing upon the degree of involvement. Normally, bowel
mucosa is spared, but in case su·icwre has fonned, resection
of bowel mandates the involvement of anoreCLal SLu·geon.
l\itirena lUCD is \et') effective in relieving S)lnptoms. Fig...-e 14.11 (A) Adenomyosis of the uterus. (B) Adenomyosis of
the uterus showing cystic spaces and myohyperplasia.
PROGNOSIS
Mot·bidity and quality oflife are influenced by CPV, dysmen-
orrhoea, cl)spareunia and renal damage.
Malignam change is rare (1:150) and manifesLS as
endometrioid cancer.

ADENOMYOSIS
Adenom)•osis, also labelled as uterine endometriosis, is a
relatively comm on co nditi o n in which islands of endome-
l!'ium are foun d in the wall of the uterus. It is observed
freque ntl y in e lder!)' women. More tl1an one-third of the
hysterec tomy specime ns from wome n aged 40 yea rs and
above reveal the presence of adenomyosis, irrespective of
tl1e indica ti o ns fo r hysterectomy. T he d isease often coexisLS
with uterine fibromyomas, pelvic endome u·iosis ( 15%) and
endometria l carcinoma.
Grossly, tl1 e uterus appears symme u·ically en larged to not Rgure 14.12 Laparoscoplc view of adenomyosis of the uterus.
more than I <I weeks size. The cut section may show only a (Courtesy: Dr Vivek Mawah, New Delhi.)
localized nodular enlargement. Most of the time, the af-
fected area reveals a peculiar, diffuse, striated and noncap-
sulated involvement of t11e m)Omeu·ium, mostly the poste- fields beyond the endom)Ometrialjunction (Fig. ll.ll),
tior wall. with tin) dark haemorrhagic areas imerspersed in more tl1an 2.5 mm beneath the basal endomell'ium.
between (Fig. II. II ). These women are tLSuall) parotLS, aged around 40 years.
Laparoscop) re,eals a uniformly enlarged uterus Some are as) mpLomatic, others present witll menon·hagia
(Figs I 1.12 and I 1.1 :l). llisLOiogical examination reveals and progressively increasing d) menon·hoea. Peh'ic discom-
islands of endomeu·ial glands su tTounded by stroma in forl, backache and dyspareunia are ilie otherS) mpLOms of
ilie midst of myometrial tissue at least two low-power adenom)osis. Clinical examination reveals a S)lnmeuical
186 SHAW'S TEXTBOOK OF GYNAECOLOGY
Figure 14.13 MRI showing adenomyosis of the uterus. (Courtesy:
Dr Parveen Gulatl, New Delhi.)
Figure 14.14 Adenomyosis uteri. Note t he Island of endometrial
glands with associated stroma deep In t he myometrium (X33).
(Source: Wikimedla commons.)
en la rge ment of tl1e ute rus ifLhe adenomyosis is diffuse and
the uterus is tender. The uterine e nlargeme m rare ly ex-
ceeds that of a 3-month pregnancy and is often mist.aken for
a lll)•oma. lf a patient gives a histOt)' of menorrhagia with
accompan)•ing dysmenorrhoea, o ne sho uld always consider
tl1e possibility of adenomyosis. If t11 e adenomyosis is local-
ized, the enlargement is asymmeuical and the resemblance
to a myoma is closer. A myoma of tl1is size is rarely painful.
Therefore, a painful, symmetrical enlargememof tl1e uterus
should suggest the correct diagnosis. MRL is superior to
uluasound showing h) po- or anecho ic area in the uterine
wall. luasound shows ill-<lefined hypoechoic areas,
heterogeneous echoes in the ll1)0metrium, asymmetrical
utet·ine enlargement and subendomeu·ial halo thickening
(Fig. 1 1.15). It also shows endomeu·ial infilu-ation imo the
myomeu·ium.
44 was , painful imenollhagiat dysmenorrhea
Figure 14.15 Adenomyosis with chocolate cyst.
[ Management of Adenomyoslsl
Young woman Older women
• Medical (NSAIO) D&C br Menorrhagia
• Hormonal (menorrhagia)
• Mirena IUCD
l Normal
• LocaliZed excision
Hysterectomy with or
without bilateral
salpingcroophorectomy
14.16 Management of adenomyosis.
TREATMENT (Fig. 14.16)
A diagnostic hyster·oscopy combined with a curettage is tl1e
initial step in the management of adenomyosis because
of menorrhagia. Most women are elderly and past tl1 e child-
bearing age, total hys te rec tOm)' is the trea une m . In yo unger
wo men, in whom a locali:t.ed adenomyosis is found co nfined
to one part of the ute rus, a locali:t.ed excision is some times
feasible, and tl1is conse tva ti ve resection is reasonable if tl1e
patient is partiCtLiarly anxious to have a child. T he possibil-
it)' of scar rupture should be borne in mind.
Nonsteroidal anti-inflammatory dmgs (NS..<\!Ds) and hor-
monal therapy are empiO)'E:d with some success in women t-e-
luctant to undergo hysterectomy, but the overall results are not
satisfactory. Dntgs used are dana:wl, CnRH and Mirena IUCD
for menorrhagia and pain. TranscetVical resection of endome-
Lriwn (TCR£) is effective for about 2 years. nlike fibroid,
utet·ine artet) embolialtion has no effective ro le in adenomyo-
sis. Mirena has been increasing!) used in adenom)osis.
Unlike endometriosis, adenOm)OSis does not respond
well to honnone tllerap). MRJ-guided ultrasonic-focused
sw·gef)• and reseCLion is under trial, and is desit-able in
young women.

STROMAL ENDOMETRIOSIS
It is a rare type of endometriosis, ,,11en only su·omal tissues
\\1thout glandular elements an? pr-esent in ectopic sites. The
Stromal cells peneu-ate the uterine wall and spread via lymphat-
ics and ' eins into the broad ligaments. The spnpLOms are simi-
lar lO endomeuiosis and the uterus appeat'S enlargec:L H)Sterec-
tOm)' is recommende<l. The 0\aries may be retaine<L Local
t-ect.ul·ence is common and the tt.unot.Lr behaves like a malig-
nancy. In case itt-ecurs, radio the raP> is the u-eaunem of choice.
New under trial:
• Aromatase inhibitors and selective oestrogen receptor
modulator (SE RM)
• Dopamine agonist cabergoline, Pentoxifylline
KEY POINTS
• Endometriosis refers to the presence of ec topic endo-
metria l tissue o utside tl1e cavity of tl1e uterus.
• T heo ries of o ri gin include retrograde me nstru a tion
and im planta ti on of menstrual b lood into tl1e perito-
neal surfaces and organs, coelom ic metaplasia, vasc u-
lar emboli zation and lymp hatic penneation.
• Endomeu·iosis manifests as islands of flame-shaped
chocolate deposits orappeat'S like powder-burn marks.
It can cause extensive adhesions between the oval"ies,
back of t11 e uterus and the pouch of Douglas, oblitet·-
ating the same and causing dense rectal adhesions.
Many appear as a C)Stic ovarian or ovar-
ian endometriomas (chocolate C) st).
• The patient presents witl1 pehic pain, dysmenor-
rhoea, dyspa•·eunia, menstmal disturbances and
infet·tilit). S)lnptoms related to other organs depend
on t11e extent of spread of tl1e disease.
• Laparoscop) is tl1e most t.LSeful tools in establishing
tl1 e diagnosis.
• Medicaltreaunent consiSts of analgesics to control pain.
Hormonal tJ1eraP> and CnRH analogues provide relief
from pain and help regression of disease, but delays
fertility. For women desirous of childbeating, operative
laparoscopy witl1 elecu·ocamelization/laser ablation of
endomeuiosis, evacuation of large endomeuiomas with
cautery, peeli ng out of its li ning and surgery to restore
utbo-ovarian relationship help to improve feni li ty status.
• Medical treaunent is the Fi t'St li ne of trea unent in mild
and moderate endo me uiosis. All hormones are
eq uall y effective. One s hould choose the d rug tl1at is
cost-effective and has less side effects.
• Recen tl)', a long-acting progesterone, Endoreg, has
bee n found to be effective and a t.LSeful alternative in
t11e treatment of endomeu·iosis.
• Dydrogesterone does not prevent ovulation and is
prefet-recl in infertile women.
• Pre- and postoperati'e hormonal therapy relieves
pain and S) mptoms, but do not improYe fertility rate.
• LaparOSCOP>' catLSes less postoperati'e pelvic adhesions
and is prefen·ed O\er laparotomy in )Oung women.
• For adenom)OSis and extensive disease, a hysterec-
tOm) "ith o•· witJ10ut bilateral salpingo-oophorectomy
blings t-elief to middle-aged patients.
• The relationship between mild endometl"iosis and
infenilit) cannot be explained on tl1e basis of ana-
tOmical alterations alone.
CHAPTER 14 - ENDOMETRIOSIS AND ADENOMYOSIS 187
• Both laparoscopy and laparotomy )'ield similar preg-
nancy mte, but lapat·oscopy has less morbidity and
causes less postopera ti' e adhesions.
• Infertility is best u·eated surgically. I\IF has a thempeu-
tic role when other measures fail.
• Recw"aginal endomeu·iosis is a sepamte entity and
requires Stu·ger), but Mirena is also found t.LSeful.
• Malignant change in a long-standing endomeuiosis
has been reported in tl1e fonn of clear cell carcinoma
or endomeu·oid carcinoma of ovat).
• MalignanC) kills a woman; endometriosis cripples her.
SELF· ASSESSMENT
1. t11e clinical features and management of pelvic
endome u·iosis in a young nu lli parot.LS woman.
2. A woman, para I, presents wi tl1 d)•Smenon·hoea, menorrha-
gia and chron ic abclom ina l pain. A tender mass is felt in the
right forn ix. How )'OU investi gate and manage the case?
3. A 35-year-old woman prese nts witl1 menorrhagia,
clysmenord1oea. T he uterus is 14 weeks enlarged. Disc uss
t he d ifferential diagnosis and management.
4. Short notes on:
• Chocolate cyst of ovat-y
• Endometriosis of •-ectovaginal septum
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\'ercellini P, \'ig:mo P, Somigliana E. L Endometriosis: patho-
genesis and tremmcnt. :\at Rc' Endocrinol 2014: 10:261.
Vercellini P, e1 al. Curr Opin Ob>tct Cp><-<:ol 2005:17:359.
Yap C, et al. Cochrane Damba>c Rc, 2004;(3): CD003678.
 Hormonal Therapy
in Gynaecology

Oestrogens 188 Antiandrogens 196

Progesterone 190 Pituitary Hormones 196
Androgens 191 Growth Hormone 197
Antioestrogens 192 Gonadotropin-Releasing Hormone ond its
Aromatose Inhibitors 194 Analogues 197
Selective Oestrogen Receptor Modulotors Key Points 199
Acting os Antioestrogen 194 Self-Assessment 200
Antiprogesterone 195

Hormonal therapy is extensive ly used in gynaecological
practice LOday. A few of these ho nno nes are available in their
natural fonn in adequate quantity, but mos t of them are now
and effective!) and safely used in infertility, con-
u-aception. menopause and menstrual disorders. Lately, hor-
monal merap) has reduced tJ1e number of hyste recLOmies in
abnonnal utetine bleeding. Various honnonal assays and
avai lability of a large range of S) nthetic honno nes have en-
abled the application of con-eeL dosage, optimal ro ute and
me suitable hormone for each individual condition. Differ-
ent routes ha' e been empl O)e<lto cater LO individual nee<ls,
convenience as well as m eir effecth·eness. They are used for
botJ1 di agnostic and therapeutic purposes.
Broad groups of common hormona l preparations are
discussed in this chapter.
OESTROGEN$
Oestrogens are nawrally occurring C-18 s te roidal sex hor-
mones produced b)' tJ1e ova ri es, ad rena l glands and the
p lacenta durin g pregnancy. In th e ova ries, tJ1e lute inizing
honnone (LH ) induces theca cells to prod uce androstene-
dione, which is aromatized to oestroge n by the gra nulosa
cells. Adipose tiss ue in the peripheral areas and liver also
contain aromatase, which cotwe tts androstenedione tO oes-
tro ne. The bio logically ac tive oestroge n is oestradiol. It is
S)'llthesi:t.ed during pregnancy in tJ1 e placenta. It is also syn-
U1esized from cholesterol a nd metabolized in the liver to
conjugates of oesu-adio l, oestrio l and oes tro ne, which are
excreted in tJ1 e Ut·ine. Oesu·iol a nd oestro ne are biologically
weak oestroge ns. After menopause, tJ1e source of oesu·ogen
is adre na l gla nds, and oestro ne is in tl1e body
fut mass peripherally by com·ersion of epi-androsteneclione
secreted by m e O\'l\11' LO oestrone. Ot-al oestrogen is
188
extensively metabolited in the walls o f tJ1e small intestine
and liver and only I 0% reaches tJ1e circulatio n as oesu-adiol
(Table 15.1 ) . The t-est is co nverted to oes trone and oesu-a-
diol glucuronide. nuse are weaker OI'Strogens; tlumfore, t1 large
dose is Tl'quira:l if tilL oral route i.s clw.sm. This iff«t is krwwn tiS
the 'first jXtSl effect' in tiU' lilll'r. Oestroge n increases tJ1e sensi-
tive proteins in the liver, such as sex honnone-binding
globulin (SHBG), conicosteroid, Lh)l·oxine-binding globu-
lin, renin subsu-ate and \<a.-ious coagulation and fib•·inolyt.ic
factors. The risk of hyperteiMiOII and thrombosi5 tlumfore increases
with oral hon11o111:s. However, high-density lipoprotein (H DL)
also increases and ora l route is cardioprotective. Almough
the nonot-al•·oute avoids tJ1e 'first pass effect' and tJ1e above
complications, they do not protect the patient from ca•·dio-
vascul ar risks. SyntJ1eti c ocstrogens are derived from tJ1 e
extracts of soya and Mexica n ya m, are inexpensive, effective
and have found a wide applica ti on in clinical tJ1 erapeutics.
PHYSIOLOGY
Du ring tJ1e reproductive )'Cars of life, natura l oesu·ogens are
prod uced principall)' b)' tJ1e Graafia n fo llicles in response tO
Table 15.1 Advantages and Disadvantages
of Oral Oestrogens
Advantages Disadvantages
1. Easy to take 1. Dally dose
2 . Cheaper 2. First pass effect in the liver
3. Can be withdrawn 3. Causes hypertension and
quickly if side effects thrombosis
develop 4. Lage dose is required
4. Cardioprotective becaJse of the fr.;t pass effect
 CHAPTER 15- HORMONAL THERAPY IN GYNAECOLOGY 189

pituitary gonadotropins. O estroge n i.s responsible for r.he
developme nt o f seco ndary sex d1 aracters, including r.he
b reasts, provides the nega tive feedbac k sign al to the pitu-
ita ry gland and h) po thalamus a nd main tains adequate min-
e raliza tio n of th e bones.
The liver and adipose tissue a lso con tain aro mar.ase,
which converts androstenedione to oestrone. Sixty per cent
of circulating oesu·ogen gets bound r.o SHBG and 38% to
albumin. The rest is left as free honnones circulating in the
blo od. About 60% is excreted in the urine, of whi ch 20% is
oestradiol a nd the rest are its metabolites. About 10% is ex-
creted in th e faeces, and the fate of the rest is nor. known.
Oestrogen binds to the cytoplasmi c recepr.ors and then
translocated to th e nudeus and influences th e tat·ger. tissues.
Oestrogeni c prepa•-ations ("la hl e 15.2) are used singl y or
in combinati on with progestogen in va rious gynaecological
disorders.
COMMONLY USED OESTROGENS
l. Ethinyl (1::1.::2) mul mestrmwl are given orally in
th e form of a skin patch and gel. It has a half-life of
12- 14 hours, reac hing the peak level in 4 hours. 1t is a
common co mponent in o ral combined contraceptive
pills (OCP) and is used in abno tmal ur.etine bleeding
(AUB) to regulate and conu·ol t.he amount of b leeding.
Realizing that the side e ffec ts of breast cancer and
tJuomboe rnbo lism in co ntraceptive pills were due r.o a
high dose o f oestroge n, the dose o f EE2 in OCP is now
reduced to 20-30 meg o f oestroge n in each pill. Syn-
t11 etic oestrogens are most po te nt
£ thin) I oestradiol (E£2) dose is 0.01-0.05 mg. O esu-adiol
valerate and succinate tablet 1-2 mg.
Mes u-anol 0.0 1-0.05 mg.
Mes u-anol is no more used in combined pills because o f
inct·eased risk of tJuombosis.
2. ConjugMed Of1>1rr>grtl is a natural oesu·ogen d erived from
mare's urine. It i!, tl.!>ed inm('lwprmsal women to promote bone
minemliutlion and clmliojJrottKiiiJ(' iffwL It is also effective
in controlling pr·ofuse bleeding of puben y men ot·rhagi a
when given as 25 mg i.v. or as an Ot<tl tablet Premarin
containing 0.625 and 1.25 mg oesu·ogen.
3. cream is no nsteroida l oestroge n (oestriol ) f or
topical l l.)e in vaginitis (vaginal), kraurosis vul:ut1
and urethral sytl(lrome in 11U't10f)(msal w<Jirum. Gel is also
availa ble . Th e crea m is ap plied once or twice da ily for
2- 10 days each mo nth for 3-'1 mo nths. It has no pro tec-
tio n against bo nes.
4. are used as part of a lo ng-term ho nno nal re-
place mem therap) (HRT) in spontaneous o r surgically
induced me nopa usal women . Altl10ugh pro,·idinga good
compliance, its surgical inserti on and re moval, if side e f-
fects d evelop, a•·e the disa<h<antages.
5. jJtddt is a trans derm al patch applied over t11e
outer aspects of t11e buttocks or lower abdomen, but not
over the breasts, in H RT. By avoiding the first pass effect
in the li ver, t11e side effects are minimized; it lowers tri-
glycetides. The skin patch can caiLSe skin irritation. The
gel gets abso rbed in 2 minutes a nd does not cause skin
irritation.
6. Micronized are used o ra ll y.
7. Stil boestro l - syntheti c nonste roid is used in prostatic
cance•:
CONTRAINDICATIONS
Oesu·ogen is co ntraindicated in:
• Suspec ted ma ligna ncy o f t11 e ge ni tal trac t
• Breast ca ncer
• History of tlwo mboembolism
• Liver and gall bladder d isease
• Cardiac. h) pertens ive and d iabe tic wome n
• Lactatio n -reduced milk production
• Sickle cell anaemia because of tJHombosis
• With ,;fampici n, barbiturates, ph en>r.o in and anticoagu-
lan ts, as these ch-ugs imerfere with its metabolism and
reduce its efficacy
INDICATIONS
• Short-tenn use for menopausal sympw ms. Pt·emarin
0.625 mg or Evalon 1-2 mg ora ll y daily for 3-4 momhs is
effecti ve (see Chapte r 7). Oesu·ogen cream is prescribed

Table 15.2 Oestrogen Preparations In Therapeutics

Generic Name Doses In Common Use Indications

1. Oral
• Ethinyl oestradiol O.D1 , 0.02, 0.03, 0.05, 1.0 mg lrreg ular menses, OC pill s
• Conjugated equine oestrogen (Premarln) 0.325, 0.625, 1.25 mg HAT puberty
• Micronized oestrogen (E2) 1- 2 mg Menorrhagia, Irregular menses
• Combined pills Contraceptives

2. Injectable
----------------------------------------- -
Conjugated equine oestrogen 25.0 mg slow i.v. Puberty Menorrhagia

3. Topical vaginal
Dienoestrol cream , Evalon cream 0.01 % in cream base Senile vaginitis, urethral syndrome
4 . Transdermal patches
17 p -oestradiol (3-7 days) 0.03-0.1 mg HAT
Combined E + MPA 0.625 mg- 5.0 mg HAT
Oestrad iol implant 25, 50, 100 mg Long-acting HAT - 6-monthly
190 SHAW'S TEXTBOOK OF GYNAECOLOGY
for local symptoms such as ci t)' vagina and urethral syn-
drome.
• Long-term HRT prevents or delays osteoporosis and is
also cardioprotective (see Chapter 7).
• Oesu·ogen cream is prescribed in vulvovaginiUs in chil-
dren. senile vaginitis and ureth rat S)'Tldrome in meno-
pausal women.
• Oral contraceptives- see chapter on Conu-aception.
• Abnonnal ute.-ine bleeding- see Chapter II.
• Intersex. Patients suffering from Turner S) ndrome and
testicular tumour should receive oestrogen
combined with progestogens cyclically throughout life to
develop secondary sex characters, avoid cardiovascular
accidents and osteoporosis.
• Oestrogen is used in prostatic cancer.
• Supresses lactation.
• Improves mood in postpartum and menopausal depression.
• Premensu·ual tension syndrome.
SIDE EFFECTS
• Nausea and vom iting when given orall y.
• Mastalgia, water re tention and increase in weight.
• Th romboembolism and cerebml th rombosis.
• Endomeu·ial and breast cancer if given for a long pe tiod
witl1out progestogen.
• Hepatic adenoma and ga ll bladder disease.
Tibolone and selective oestrogen receptor modulatOrs
(SERMs) have both oestrogenic and antioestrogenic action.
1l1ey have an tioestrogenic action on t11e breast tissue but
agnostic action on the endometrium and bones. They can
cause endomeuial h) perplasia and cancer.
PROGESTERONE
Progesterone is l11e natural hormone produced by the theca
cells of l11e corpus luteum and t11e placenta. It is metabo-
lized in the liver and excreted in t11e urine as sodium preg-
nanediol glucuronide. Natural progesterone is not active
orall y and is given only by inu-amuscul ar injection in an oil
base. Progesterone acts on target tissues only the lat-
ter are primed with oestrogen, as oesu·ogen prod uces pro-
gesterone receptors.
A la rge numbe r of S)'n t11etic compo unds whi ch can be
take n orally have been ma rketed in rece nt yea rs.
PREPARATIONS
Progestogens are synt11etic compounds belonging to two
main groups - t11e oestrone or 19-norprogestins, wh im
are su·uctura lly similar to testosterone, and pregnane or
17-acetoxy compound stntcwrally similar to progesterone.
The oestrone compounds are mainly incorpot-ated in oral
conll'llceptive pills, and pregnane compounds are used in
pregnane) and AU B.
CLASSIFICATION
• Pure progesterone- Oral and vaginal microni.ted proges-
terone ha'e no acherse effects on lipid profile.
• Pregnane (derived from progesterone molecule), lynes-
trenol (allyloestrenol), medroxyprogesterone, megesu·o l
acetate.
• Estrane (derivati'e of testosterone) - Noretl1isterone,
noretl1andriol (first genemtion).
• Gonane - Levonorgestrel, norgestrel (second gene•-a-
tion). The) reduce t11e level of SHBG, have androgenic
and ami-£ effects.
• 1l1ird-genemtion progesterone (desogesu-el, gestodene
and norgestimate). These a•-e les; androgenic and cause
less metabolic disorders but inc1-ease tlle risk of tllrombosis.
• Hybrid drospinmone (3 mg equivalent to 25-mg spiri-
none) now used in oml pills for acne and PCOS. Yasmin
contains 30 meg of ££.1 (21 days) ,Janya contains 20 meg
E£ 2 for 24 da)'S in a cycle.
• Hybrids (drospil-enone) have amiandrogens, and an-
timineral corticoste•·oid effect; are used in premenstn1al
tension; causes hyperkalaem ia by dec reasing potassium
excretion in l11e urine, less water re tention and weigh t
gain .
T hese have no infl uence on lipid pro fi le and have a very
good con u·ol of mensU1 tal cycles. Micronized p rogesterone-
oml table t (IOO mg) causes vom iling, gidd iness and liver
damage. Micronized vagina l lablet ( 100 mg) is witho ut
these oral side effects but causes vaginal ini tation.
Progestogens are adm inistered:
• Orally- singly or wil11 oestrogen
• Intramuscular ia"\iection monthly, three-monll1ly as con-
U'llceptives
• Implants- orplant (conu-aceptives)lnu-aute•;ne conu-a-
ceptive device (IUCD) impregnated wil11 levonorgesu·el
(Progestasen, Mirena)
• Vaginal tablet and .-ings
• Skin patches
Crinone 8% (90 mg) vaginal gel is a microni£ed proges-
terone in dilute emulsion S)Stem.
THERAPEUTIC APPUCATIONS
• Pu re progesterone as it1jeclion in oil or microni zed
vaginal or oral capsules is used in threaten ed a nd recu r-
re nt abortions, and in corp us luteal-p hase defi cie ncy
(C LPD).
• High closes of injec Li o ns are used in adva nced endo me-
trial cancer.
• Con u·acep ti on - Oral in combinatio n with oestroge n,
mini-pills and i are used as con u·aceptives.
Implants (No rp lant) are effective over 5 years (see chapter
on Conu·aception). IUCDs impregnated with progester-
ones are availab le (M irena). Mirena is effective for
5 years.
• Abnormal merine bleeding (see Chapter II).
• Dysmenorrhoea. premenstrual tension S)'Tldrome.
• Although Dana£ol is the drug of choice, but
owing to cost and hirsutism, progestogens continue to be
employed in endomeu·iosis.
• Endomeu·ial ablation in A B. Before the u-anscenical
resection of endometrium (TCR£), endomeu·ial shrink-
age is achie'ed by progestogens gi,en over weeks.
 CHAPTER 15 - HORMONAL THERAPY IN GYNAECOLOGY 191

• Ame1wrrhoea. Progesterone challen ge test- A single it1jec-

tion of 100 mg progesterone will induce withd rawal Dehydroepiandrosterone I 100%

bleeding if endometrium is p timed by oestrogen (see I sulphate (DHEA-5)

I
Chapter 12). Oral tablets also work. (Primolu t-N 5 mg
t.i.d. X 3 days.)
• Postcoital pill - Levonorgestrel 0.75 mg tablet given 10% .I Dehydroepiandrosterone I 90 %
within 72 ho urs of unp rotected coitus and repeated I -I (DHEA)
r I
12 hours later will prevent pregnancy in 98% cases.
• With oestrogen in H RT (see Chapter 7).
I Ovary I I Adrenal cortex
I
• Postponement of menstruation- 5-mg norethisterone I 50%
J Androstenedione (A) L 5o% I
t.i.d. for 4-5 days or longer will delay the onset of "I I
menstruation (starting 3 days before an ti cipated
period). 50 % 50 %
.I Testosterone (T) I
• All)' I progesterone is used in abortions.
• Progestogens are used as 'add-back' therapy with gonad-
Figure 15.1 Sources of androgens.
otropin-releasing hormone (Gn RH) to prevent osteopo-
rosis and allow prolonged GnRH therapy.

progestogens, which have s imilar biological effects. About

CONTRAINDICATIONS 50% androgen in women is derived from the ovaries and
• Und iagnosed vaginal bleeding 50% comes from the adrenal cortex. About 90% is bound
• Breast cancer, breast tumour to SHBG and some to albumin and remains inactive, and
• T hromboembolism the rest ( I %) circulates in the blood. At the target tissues, it
is converted to dihydrotestosterone, which is biologically
active and causes acne and hirsutism in excess as seen in
SIDE EFFECTS polycystic ovarian syndrome.
• Nausea, vomiting DHEA - 90% from adrenal gland; 10% from the ovary
• Headache, mastalgia, water retention, cramps in the legs, DHEA > 8000 ng/ mL is seen in the adrenal cortex
weight gain tumour. T he compo und is quickly metabolized and
• Hirsutism in androgen-related compo unds cannot be estimated clinically. Its normal level is 40-
• Depression 340 mcg/ dL. Plasma level of more than 700 mcg/ dL
• Increased low-density lipoproteins and cardiovasc ular occ urs in adrenal tumours. Serum 17-hydroxyprogester-
acc idents one level of more than 5 ng/ mL is seen in adrenal hyper-
• Deep venous thrombosis, pulmonary embolism with plasia . Ovarian production of testosterone is 0.2-0.3 mg
desogestrel and gestodene daily and is responsible for 50% of total testosterone,
• Breast tumours, cancer the other 50% is derived from the adrenal gland. Andro-
• Medroxyprogesterone acetate ca uses bone loss stenedione contribution is 50% eac h from ovaries and
• Increase in low-density lipoprotein (LDL) and decrease adrenal gland .
in HDL DHEAS comes exclus ively from the adrenal gland.
LH stimulates production of ovarian testosterone hor-
mone in the ovarian stromal tissue as in PCOS. Insuli n
ANDROGENS (Fig. 15.1 ) resistance is often the cause of LH stimulation to produce
ovarian androgens.
Androgens are 19 carbon steroids derived from choles- It is used orally, i.m. or as a 6-month implant.
terol and formed in the adrenal gland, ovaries and also Androgens cause masculi nizing effect such as
peripherally.
• Mo ustache, beard, hair on the chest
• Frontal baldness
TYPES • Acanthosis nigricans is often assoc iated with insulin resis-
• Testosterone- Potent (T) tance
• Dihydrotestosterone by conversion of ( DHT) testoster-
one by 5a-reductase- Most potent hormone acting at the
target organs, i.e. hair follicles
USES
• Androstenedione- Weak androgen • Endomettiosis- Danazol is effectively used.
• De hydroepiandrosterone (DHEA)- Weak androgen • Male infertili ty- Oligospermia.
• De hydroepiandrosterone sulph ate (DHEAS) - Weak • Decreased libido - 100 mg implant for 6 months is
androgen available for menopausal women to improve libido.
• In mastalgia and fibrocystic disease of the breast.
Testosterone is a natural androgen hormone secreted b)'
the ovarian stroma and the adrenal glands. T he normal
level is 0.2-0.8 ng/ mL. Its use in modern gynaecology is
SIDE EFFECTS
li mited on acco unt of hirsutism and availability of synthetic Virilization and hirsutism
192 SHAW'S TEXTBOOK OF GYNAECOLOGY
DANAZOL
DanaJ:ol is an isoxazole derivative of 17-alpha-et.hinyl
testosterone. It aCLs directly on the endomeu·ium
causing at.rophy by d isplacing oesu·ogen receptors in
the endometrium. ItS indirect supp1·essive action on the
pitui ta !) ' gland also reduces oestrogen a nd p rogesterone
secretio n . By reducing the SH BG, it bo und testOs-
te ro ne in LO circ ula tio n. It has a ndroge n iC a nd anabolic
p roper ties.
• IL is largely used in endometriosis eit.her as a primary
treaunem or followi ng surge1) to eradicate residual tu-
mour and prevem recun·ence. The oral dose \'li lies from
100 to 800 mg daily in divided doses. About 75o/o-90%
improvemem is seen within 6 months.
• Abnonnlll utnine bleeding. DanaJ:ol should not be offered
to young women in view of risk of hirsutism, but in older
women, it is used whe n oestroge n is co mraindicated
and progestogens fa il to cure me no n·hagia. With the
ava ilab ility of seve ral drugs such as no nstero idal ami-
inna mmato rr drugs (NSAIDs) and antifib rinol)•tics, the
role of Danazo l is limited in this d isorder.
• Dana:wl is given in a dose of 200 mg daily for 4-6 weeks
before u-anscervical resection of endometrium in AU B to
produce endomeuialthinning and au·oph).
• DanaJ:ol is effective in cyclical mastalgia: I 00 mg
daily will improve 60% cases.
• Fibrocystic disease of breastS is also treated wit.h
Dana£01.
• Gynaecomastia.
• It im proves li bido in menopausal wo me n.
• It shrinks fib ro id and is used befo re surge ry.
• Im proves spe 1mawge nesis in male infcni lity.
Sute eff«ts . on tl1e endometriu m and cervical mucus, caus1ng shght
Darua.ol should not be given for more tluw 6-91rumths at a tzme
because of cmtioestrogrnic action and virilizing effect.
Other side effectS:
• Weigtn gain, headache, water 1·etention and oedema.
• Acne, hirsut.ism a nd muscle cramp.
• B1·east at.rophy, amenorrl1oea; deepening of voice, whi cl1
is irreversible.
• Li ver da mage, increased LDL, lowers IIDL with iLS associ-
ated ca rdi ovasc ula r co mp licati ons.
• IL is tera togenic in early p regna nC)', causing masc uliniza-
tion of a female fetus.
• Glucose imo lerance.
• Cont.raindicated in liver disease and prostate cancer.
GESTRINONE
Gesuinone is a t.rienic 19-norsteroid derh'l!t.ive of testoster-
one, which has an drogenic, antioesu·ogenic, amipr·ogestO-
genic and anti pitui tary acti on. ItS mode of is_similar
to Danawl, and itS clinical applicati ons are also S1m1lar, but
it is mo re expensive.
O ral dose of 2.5-5 mg twice weeki)' LO be t.a ke n at the
same tim e a nd the same day in t.he week will ind uce amen -
orrhoea in 85% cases of AU B. ILS side effecLS are milder and
are t.herefore preferred LO DanaJ:ol. Vaginal tablet 2.5 mg is
applied weeki)'·
ANTIOESTROGENS
Apart fro m and roge ns, which are a nti oesu·oge ni c (inhibi t
the ova ri an functi o n through tl1 e pituita!)' gla nd and op-
pose the ac tion of oes trogens o n tl1e ta rget o rga ns), the
d rugs which antagonize oestroge ns at tl1 e receptor level are
clomiphene and tamox ife n.
CLOMIPHENE CITRATE
In 1956, G1·eenblatt first inu·oducecl clomiphene in g)nae-
cology for inducing ovulation.
Clomiphene ciu-ate is a nonsteroidal compound related
LO dietl1ylstilbest.rol ( DES). h is a mixture of two isomers, cis
(now known as zuclomi phene) and u-ans (now known as
e nclomi phe ne ciu·ate) . Cis frac ti o n is respo nsible for induc-
ing ovulatio n. Clomiphe ne citrate contains 38% cis and
63% trans iso me rs. It has a half-life of 5 days. It is met.abo-
lized in t11e liver and excreted in b ile and faeces.
MODE OF AOION
Clomiphene is t11e first drug of cl1oice for inducing ovula-
tion. B) competing witl1 C)'lOplasmic oesu·ogen recepLOrs 111
the h) pothalamus, it blocks tl1e negath·e feedback of circu-
lating endogenous oest.rogen. This allows release of Gn RH
into the pituiLai)' por·tal system and stimulates LH and
follicle-stimulat.i ng h or·mon e (FSH) secretion. St.arting on
the 2nd day of t.he cycle and given for 5 days, E2 level st.arLS
increasing 5-6 days after s topping tl1e d rug a nd induces
maturit)' of t.he Graafi an follicle and ovulat.io n witl1 LH
s w·ge. T he best ac tio n is seen if a certain amount of oestro-
gen is present in t11 e body. However, it exerts anti-E ac tion
decrease in t.he fertility r-ate.
INDICATIONS
Clomiphene is indicatecl in:
• AnovulatOI)' infe1·t.ili ty
• Polycystic ovaria n syndrome (PCOD) associated with
infen.ili ty
• In in vit.ro fe rti lizati o n: Gamete intrafallo pia n transfe r
(G Wr) tec hnique and assisted rep rocl uct.ion tl1 erapy
(ART)
• 25 mg orally fo r 25 days eac h month for 3-6 mo mhs tO
stimulate spermatogenesis
CONTRA INDICATIONS
Clomiphene is cont.raindicated in:
• Ovarian cyst- The cyst can increase in si£e.
• Cht·onic liver disease, because it is metabolited in t.he
live1:
• Scotoma.
Lf the wo man suffers fro m a me no rrhoea, clomiphe ne
can be started an)' da)'· In normal C)•cles, t11e d rug is st.an ed
on the 2nd clay of tl1e period in a dose of 50 mg da ily for
 CHAPTER 15 - HORMONAL THERAPY IN GYNAECOLOGY 193

5 days. Monitoring is done by serial ultraso und from the malignancy if tJ1e trea un ent is extended beyond I year and
lOth day onwards unti l the signs of ovulation are observed. (xv) premature O\<arian fail ure, caused by exhaustion of fol-
Normally, the follicle increases in size daily b)' 1-2 mm. licles through multiple ovulation.
When tJ1e domina nt follicular size reaches 20 mm, 11Llman Incidence of unruptured IULe in ized follicle is increased.
dlol·ionic gonadotropin (hCG) 5000 I is injected intra-
muscular!). o, ulation occu•·s about 36-'10 hours after i•1ject- OVARIAN HYPERSTIMULATION SYNDROME
ing hCG - the couple is advised intercourse around tllis Q,<aria n h)perstimulation S) ndrome (OHSS) (Fig. 15 .2 and
time. ot on I) does the hCC injection indicate tlle precise Table 15.:3) is a complicatio n of assisted reproductive tech-
time of ovulati on , it also compensates for CLPO caused by nologies and an iau·oge ni c complication occulTing in tl1e
clomiphene. luteal phase or early pregnancy. It is a potentially life-threat-
On clomiphene administra tion, 80% ovulate and about ening condition, occun·ing in I %-I 0%. It results from in-
50% conceh•e. This low pregnancy rate may be attributed duction of ovulation in infertility cases. It is more common
to the antioesuogenic effect of clomiphene on ce1·vical in FSH / LH therap)' tJ1 an clomiphene and pulsatile CnRH
mucus, CLPO on endomeu·ium. The qcl ical therapy is drugs. Its incidence is higher in PCOS and anovulatOry in-
recommended for 6 months, after wh ich a break is given fertility as compared to inferti lity ca tt5ed by amenord1oea.
for 2-3 months. Further attempt to induce ovulation is Raised LH in PCOS is responsible for hyperstimulation, and
repeated after that. If ovulation fails to occur and follicular hCC should not be included in tJ1e tJ1erapy in tl1 ese cases.
size does not attai n 20 mm, tJ1e dose of clomiphene is Administration of hCC increases tl1e risk, so also the dose
inueased by 50 mg in eacl1 cycle to th e max imum of 150 mg of dnJgs, s ize and number of ova ri an follicles. It is also
da ily. Alterna te ly, the tab lets may have tO be ta ken for 7 days co mm on in a concep ti ona l C)•Cle if multiple ov ula ti on oc-
in eac h cycle. If tl1is too fa ils, the pa ti e nt is offered FSH/ LH curs. It is characterized by ova ria n en largemen t, ple ural and
tl1erapy. peritoneal effusion, o li guria, liver damage and tl\ro mboem-
To red uce tl1e periphera l an tioesuoge nic ac tion and bolism. Severe form ofOHSS occu rs if the woman co nceives
improve the ferti lity rate, clom iphene is late !)' rep laced b)' d uring tl1at C)'Cle.
leu·ozole 2.5 mg dail)' for 5 days. Howeve1; the drug can
ca use drowsiness.
Ln endomeuiosis, 30% co nceive, and in PCOS, although
80% ovulate, 40% beco me pregnant.
Ln PCOS, the high level of OHEAs reduces tl1e preg-
nancy rate. Adding 0.5 mg dexametJ1asone lowers OHEA
levels and improves conce ptio n rate.
SIDE EFFECTS
The side effects are (i) O\'<ll'ian e nlarge ment in 10%, (ii) hot
flushes, sweating du e to oestrogen deficiency, osteoporosis,
(iii) nausea, \ Omiting, (iv) visual disturbances, blurring,
scotOma, (v) headache, di.u.iness, urtica1·ia, (vi) hair loss
3%, (vii ) weight gain, (viii) antioestrogenic effect on ce1vical
mucus and endometrium (ix) CLPO, (x) hyperstimulation
S)•ndrome, (xi) two-to threefold increased 1·isk ofneuralwbe
defect has been re poned by many, altJ1ough not proved,
(xii) multiple ovulation and multiple pregnancy in 10%,
(xiii) abortion rate 25%-'10% due to CLPO, (xiv) ovarian R gure 15.2 Ultrasound showing multiple maturing follicles.

Table 15.3 Varieties of SERMs and Comparison of their Therapeutic Effects

Hot Flashes Genital Endometrial Breast

Therapy Insomnia Atrophy Proliferation Ovulation Osteoporosis Cancer CVD

Oestrogen• i i NA NA i i i
ERT/HRT
Clomifen NA i i i NA NA NSC

Tamoxifen i i i NA i i i
Raloxifene i NSC t NA i t t
Genistein t t NSC NA t NSC t
Centchroman NA NSC NSC NSC t t NSC

'Estrogen abne are used folloiMng hysterectomy.

CVO, cardovascula- diSease indl.dng deep wnous thrombosis; NA, not appicable in the dinical situation, NSC, no significant change.
194 SHAW'S TEXTBOOK OF GYNAECOLOGY
Pathogenesis
The main reason for O HSS is the increased vasc ular perme-
ability leadi ng to Auid shift from intravasc ular LO extrav-ascu-
lar space. This causes decreased blood volume and albttmin
as well as electrOI)te levels. It leads to accumulatio n ofAuid
such as ascites and h)droth orax. The increased vascular
penneabilit) is due to prostaglandin, cytOkines and growth
factors secreted b) multiple growing follicles.
The .-isk factors for OHSS are as follows:
• Young age of the woman.
• PCOS.
• Previous OHSS.
• increased oestradiol level, >3000 pg/ m l.
• 20 or more small foll icles.
• increased renin and angiotensin facwrs.
• Vascular endothelial growth factor (VEGF) causes neovas-
cula rization of granulosa cells and increased E 2 level.
• PCOS, hi gh Lll / FSII ratio, hCG and pregnancy in s timu-
lated cycle.
• FSH/ LI-1 causes hi ghe r incidence of O HSS (30%) than
clo mi p hene ( 10%) a nd Gn RH ( 1%) .
01-ISS can be pred icted by high level (>3000 pg/
mL) , more than 20 follicles on ulu-asound and increased
Doppler b lood flow. The re is increased re lease of ren in and
angiotensin.
Complications
Complications of 01-lSS are as follows:
• Vascular - cereb rovascular accide 111s, thromboembolic
phenomenon, deep venous t.hrombosis
• Coagulopath)
• Liver dysfw1 ction
• Adult respirat.ory disu·ess caused b)' ascites/ h)drouJOrax
• Renal failure due t.o h)po,olaemia
• Gastrointestinal - Relat.ed to E2 level
• Torsion and haemon·hage in the ovar·ian C)St
Prevention
hCG should be wiu1held in a cycle if more u1an 20 follicles are
seen on ulu-asotmd and E2 level rises LO 3000 pg/ m L In
PCOS, it is pn rdentto ,,1u1hold hCG. Albumin 5% infusion in
500 m L lacta ted Ringer's solu tion during and after oocyte re-
uieval prevents O J ISS. Dopa mine ago nist cabergoline 0.5 mg
claily for 8 days sta rti ng on day I of hCG avo ids OHSS.
Ovarian h)•persti rn ulation synd rome occurs \\1 th smaller
umn larger follicul ar size 5-8 days after hCG adm in istration.
Lt. is an iau·ogenic cond ition of increased vascular permeabilit.y
resu lting in exudation of Auids from the inu-avasc ular to the
exu-acellular comparunent. Progesterone support helps.
Treahnent
Ov-arian hype rstimulatio n syndro me requires hospitaliza-
tion. Medicaltherap) includes:
• 111fluid:. for Colloids, plasma expanders or
human albumin infusion 5% in 500 mL Ringer's lactate.
Half-life of albumin is 3- 10 da)S. Fifty grams of albumin
(25% albumin in 50 mL) ra ises blood volume tO 500 mL
Human a lbumin 20% wiu1 2 L of dextrose may be
needed. Gelofusine for hypovolaemia may be requi red-
continuous autotransfusion of ascitic Auid (CATAF) is
performed for 5 hours eac h day.
• Dittret.ics and NSAIDs sho uld be avo ided becatLSe of hy-
povolaemia and poor renal perftLSion e xcept in pulmo-
nary oedema and to correct e lectro lytes.
• High thigh venous support swcking prevents deep
venoLLS thrombosis.
• l nununoglobulins i.v. may p•·o,·e to be effective.
• Glucocorticoids.
• Anticoagulants- heparin.
• Dopamine impro, es renal blood Aow, oliguria and pre-
vents renal failut·e.
• Cot·rection of elecu·olytes.
Investigation and Monitoring
• Investigation and monitoring are done by
• Hb %, WCC, platelet count- TLC 15,000 and haematOcrit.
• Urea, elec u·olyte estimation, se rum p ro tein level.
• Repeat ul u-asormd to mon itor si:te of ovarian cyst and ascites.
• Weight recordin g.
• Renal function tests.
• Liver func ti on tests.
• Coagulation profi Ie.
• Cen u·al veno tLS press ure reco rd ing.
• X-ray chest for p leural effusion.
Surgrtry is required if u1 e ovarian cys t ruptures, undergoes
wrsion or haemorrhages. Aspiration of ovarian cyst, ascites,
pletu-al and pericardia! effusio n may be required.
AROMATASE INHIBITORS
LETROZOLE
Letro.£Oie (nonsteroidal aromatase inhibitor) is used in the
induction of ovulation. It has a half-life of 45 hours and is
eliminated through kidn C)S. It prevents conversion of an-
drostenedione to oestrone. A dose of 2.5 mg daily for 5 days
in a cycle has the following advantages over clomiphene:
I. lL has no antioesu·ogenic action on the endometrium
and u1e cervix- yields beu er pregna ncy rate.
2. lL ind uces monofoll icular stim ul atio n, adeq uate LH
surge and avoids m ulti ple pregna ncy.
3. Be uer im p lanta ti on.
4. No hyperstimul ati on synd rome. I L is suited in cases of
PCOS. Late ly, a s in gle dose of 20 rn g o n day 3 is being
tried . lL is con u·aind icatcd in hepatic dysfunc tio n.
LL can, however, cause drowsiness and liver dysfunc tion.
Anastrozole is useful in endomeu·iosis ( 1 mg a day).
SELECTIVE OESTROGEN RECEPTOR
MODULATORS ACTING AS ANTIOESTROGEN
(Table 15.3)
TAMOXIFEN
(Tamoxifen, qtofen, eldtam, mamofen and oncomox)
Tamoxifen is a nonsteroida l anti oestroge nic ch-ug. It acts
by binding to and reducing u1e a' -ailability of oesu·ogen

receptors. It is mainly used in the palliative treaunent of
advanced breast cancer in postmenopausal women. It has
also been used successful!) in cases of PCO D. Tamoxifen is
effective in plimal') and secondary prevention of breast
cancer; it prevents spread to the other breast, and recur-
rence b) 50% and mortalit) b) 25%. It is also bone and
cardioprotecti,e. Primaq chemoprevention is indicated in
BRCA1 and BRCA.t gene positive women, usually first rela-
tives of breast cancer patients.
Side effects (tw()ofold increase) are hot flushes, vaginal
dryness (anti-£.1 action), endomeu·ial hypet·plasia, polyp,
endometrial carcinoma and sarcoma.
Hypergl)ceddaemia, deep venous thrombosis, ischaemic
heart disease and retinopathy are other complications LO
watch for dur·ing tamoxifen ther·apy.
Progestogens do not protect against tamoxifen-induced
endometrial hyperplasia.
DOSAGE
T he dose is 10-20 mg twice dai ly for not more than 5 years
in breast cancer beca use it becomes ineffective afte r that.
PRECAUTIONS
Tamoxifen en hances iJ1e effects of warfarin. It is known to
ca use endomeu·ial h)•perplasia and cancer. It is mandatory
to monitor endome u·ial growth by setial sonography and
uteline aspiration.
An important second-generation SERM is raloxifene,
whid1 has less beneficial action on tJ1e breast than tamoxi-
fen. It is cardioprotective, maintains bone density and has
no adverse effect on iJ1e endomeui um unlike mmoxifen.
However. it is antioesu·ogen and does not cure menopausal
spnptoms such as hot flushes.
The dose is 60 mg dail). It is mandatory to discontinue
therapy before, during and after surgety, to avoid tl1e lisk of
supel'ficial and deep 'enous thrombosis.
Raloxifene, 60 mg daily used in endometriosis do not
cause endomeu·ial hypet·plasia.
ORMELOXIFENE (CENTCHROMAN)
It is a nonsteroidal anti oestrogen developed fot· its contra-
ceptive potential. Due to its lo ng half-life, it is available in
Indian market as a 'wee kly nonsteroidal pill'. It is free
from adverse effects on the breast, endo metrium, ovat) ',
liver and coagula ti on factors. It does not inh ibit ovulation
and exerts co ntraceptive effec t o n implan tation. It has
antioestrogen ac ti vity on endome u·ium (also see chapter
on b irtJ1 control).
ANTI PROGESTERONE
An antiprogesterone in common use is mifepristOne
(RU486).
MIFEPRISTONE
Mifept·istone- RU486 (M ifegest and Mifept·ine)
Mifeptistone is a 19-norsteroid det·ivative of tl1e splthetic
progestogen norethindt-one. The drug bincls to tl1e recep-
tors in the cell nucleus and blocks progesterone action at tl1e
CHAPTER 15- HORMONAL THERAPY IN GYNAECOLOGY 195
target organs. It also b inds to glucoco rticoid and androgen
receptors. About 85% of iJ1e drug is absorbed after oral
tl1erapy. Peak level is reached in 1-2 hours. The half-life of
tl1e drug is 24 hoLU·s. It is excreted in bile and faeces. Bi()o
availabilit) is 60%.
Adminisuation of the drug (150 mg) during ilie first
3 days of the follicular phase has no effect on tl1e men-
su·ual C)•cle. Drug administration in the late follicular
phase suppresses Lll surge, and ontlation fails to occur.
A single dose of the drug given within 2 days of the LH
surge does not alter menstruation. Late adminisuation
in the luteal phase causes luteolysis and prevents preg-
nancy. Epostane is another progesterone synthesis in-
hibitor.
THERAPEUTIC APPLICATIONS
This drug has been approved for medical termination of
pregnancy (MTP) up to 49 days. Successful abortio n oc-
curs in about 85% of cases. Usuall y, iJ1e abortio n takes
place within 5 days of drug ad ministratio n; however, o ne
has to wa it for 28 days LO j udge s uccess. In 15% cases,
when abortion fails to occ ur or is incomple te, o r the pa-
tient con tinues to b leed, surgical evac uation becomes
necessary. The drug is adm inistered in th e form of three
tab lets (200 mg eac h) , fo llowed b)' two tablets of misopro-
stol 200 meg, each orally or preferably vag ina lly 48 hours
later. JLISt 200 mg m ifeprisLO ne has a lso been proved effec-
tive. Latel y, MTP extended up LO 9 weeks of gestation with
mifepristone and misoprostol has proved successful. By
reducing the le,el of it causes necrosis of the
decidua and death of iJ1e embl')O.
• It is LISeful in ripening of the cervix before prostaglan-
din induction of mid-trimester abot·tion. A dose
of 200-600 mg RU 186 followed b)' prostaglandin
24-18 hours later ( 100 meg) shortens induction-
abortion interval, and reduces the dose and the side
effects of prostaglandin.
• It is effective in missed abortion (same dose as in MTP).
• Ectopic pregnancy - mifepristone injected intO tl1e un-
ruptw·ed ectopic pt·egnancy causes itS resolution (see
Chapter 17 on Ectopic Gestation).
• Cushing syndrome - because of its anti glucocorti coid
therapy.
• Postcoital conu·aception- 10 mg given within 72 ho urs
of unpro tec ted coitus is used as a postcoital co ntracep-
ti on.
• It has some benefic ial influence on th e s hrinkage
of fibroids and e ndometriosis ( 10-25 mg daily for
3 months).
SIDE EFFECTS
• Headache (5%).
• Gastrointestinal symptoms of nausea, vomiting (3.5%) .
Occasional diarrhoea.
• Fainllless. skin rash.
• Adrenal failure if massive dose is employed.
• TelaLogenic. If medical method fails with RU486, preg-
nancy should be tenninated.
• Endomeuial h) perplasia by reducing progesterone
effect.
• Low pomssium le,el, increase in creatinine level.
196 SHAW'S TEXTBOOK OF GYNAECOLOGY
ANTIANDROGENS
CYPROTERONE ACETATE (DIANETIE
AND ANDROCUR)
Cyproterone. chemical!) related to progesterone, is deJ;ved
from 17-alpha-h)drox> progesterone and exens a mild pro-
gestation acth•it). iL is a potent antiandrogen, and competes
dih) drotestosterone for intracellular androgen recep-
tor sites- it inhibits its binding. It has a weak con.icosteroid
effecL Small doses have no effect on the pituitary funct.ion,
but large doses cause amenorrhoea, loss of libido, suppres-
sion of spermatogenesis and gynaecomastia in males. By
lowe ling LH level, it also reduces production of androstene-
dione in the ova1-y.
It is used in the treatment of hirsutism. A dose of 50-
100 mg cyproterone acetate is give n during th e first 10
days of the cycle along with 30 meg of ethi nyl oestradiol
given cyclicall y for 3 weeks eve r-y momh. The effects
begin to be ouly after 3 month5 of thempy. Cyclic adminis-
u·ati on s ho ul d con ti nue fo r 6-12 mo nths, followed b)' a
maintenance dose of 5-l 0 mg of cyp rote ro ne acetate
with ££ for a prolonged period to preve nt rec urrence of
hi rsutism. Combination with EE is necessar)' tO prevent
pregnanC)' and tJ1ereb)' avo id teratogen ic effects; it a lso
reg ulates tJ1e cycles. In cases of PCOS, treatment reg ular-
izes menstruation, increases the levels of seru m sex-bind-
ing globulins which bind the free testosterone, thereby
reducing ha.ir growth, acne and dry skin. On stopping
t11erapy. results of induction of ovulation protOcols
improve. The drug is also useful LO treat acne. The dose
for acne is 2 mg with EE2 to be taken daily for 21 days of
each C) cle (also see Chapter 9).
SPIRONOLACTONE
Spironolactone is an aldosterone antagonist and was used as
a diuretic. Its antiandrogenic properties have been pUL to
use in t11e treatment of hirsutism. Its beneficial effects are
observed after 3-4 months of therapy. The drug blocks the
androgen effect at the receptor level in t11e ha ir follicles.
It also reduces the I ?-alpha-h ydroxylase activity, lowering
t11e plasma levels of testosterone and a ndrostenedione
(see Chapter 9).
DOSAGE
A daily dose of 150 rn g along with the cyclic administration
of££ provides re lief in about 60% of the cases. It is useful
in cases of PCOS. The ma intenance dose of 50 mg is con ti n-
ued after 6--12 months of the rap)'·
SIDE EFFEQS
Transient diuresis; polymenorrhoea is encountered in 10%
of users; breast engorgement; and electrolyte disn.rrbances
(hyperkalaemia) when high doses are used.
FLUTAMIDE
(Cytomid-250. Drogenil, Flutacare, Prostamid and Flutide)
Flutamide is a substituted anilide. It is a nonsteJ"Oidal,
antiandrogenic <h-ug blocking tJ1e action of androgen at the
receptor Je, els.
DOSAGE
A close of 125-250 mg twice daily for 6 mont11s along with
OC pills are useful in the treaunent of hirsutism. In males,
it has been used in the treatment of prostatic hyperplasia
and cancer.
SIDE EFFECTS
Hepatotoxicit), dr) skin, oligomenor-rhoea and decreased
libido.
FINASTERIDE
(Finast, fincar, Fistide and finpecia)
Finasteride is a competiti'e inhibitor ofthe enzyme 5-alpha
reductase, which converts testosterone to dihyclroteSLosterone.
It has no affinity to androgen receptors. It has no effectS on
otller hormones and it does not influence t11e hypotllalam us-
pitui tary-gonadal axis.
It is also used in benign pros tate hyperplasia.
DOSAGE
A close of 5.0 mg/daily for 6 months is recommended.
SIDE EFFECTS
H)'persensitivit)' to the drug; decreased libido; Leratogen ic
effect on t11e fetus during pregnancy.
GLUCOCORTICOIDS
Dexamethasone 0.25-0.5 mg or prednisone given at night
daily for 6 montJlS reduces ACTH secretion and hirsutism.
It is contmindicated in obese women. The drug is also used
in PCOS, with clomiphene in infertilit), and adrenal hyper-
plasia.
PITUITARY HORMONES
GONADOTROPINS
The anter·ior pituitar-y gland secretes FSH, LH and prolactin
(PRL). The physiology of tJ1eir secretion is described in
Chapter4.
FSH is ex u·acted from tJ1e urine of me nopa usal women
and is available in form. One a mpo ul e co ntains 75
I U FSH as a frozen d ri ed powder along witJ1 a solve nt.
Human !>-chorioni c gonadotropin hormone, which sim-
ulaLes LH in ac ti on, is exu·acted in a similar manne r: It is
available in 1000, 2000 and 5000 IU frozen ci t)' powder
with an ampo ule of solvent.
Botll recombinant FSJ-1 and recomb inan t gonadotropin
are now available. They are self-adm inisLered subc utane-
ously, ver-y effective and have lesser risk of hyperstim ulation.
THERAPEUTIC USES
Gemzell first reponed its use in 1958.
Therapeutic uses of gonadotropins are as follows:
• Induction of ovulation in anovulatOI") infer·tility. Those
who fail to respond to clomiphene are treated witJ1 FSH
and LH. Infertility caused by pituitar')' h) pofunction also
needs this tllerap)'· The dose is acljusted according to

ulu·asonic findings of fo llicular growth and L; level. The
treaU11em is started on the second day of the cycle and
cominued until ovulation occurs.
• Induction of multiple ovulation using hyperstimulation
pro LOco Is for infertile women going t11rough ART as in in
viu·o fertilitalion, GHT, L.)gote intrafallopian u-ansfer
(ZI FT) and LCSI.
• H)pogonadou·ophic h)pogonadism in males.
• C.) ptorch ism.
• ln prima•)' and secondat)' amenont10ea caused by piLLL·
itary failure in h)pogonadou·opic hypogonadism.
• hCG is used in CLPD, infertility and early abot·tions.
No teraLOgenicity is reponed.
250 meg recombinant hCG is equal to 5000 IU of hCG
\\1th less local side effects.
SIDE EFFECTS
T he side effects are as follows:
• Hyperslimulalion S)•ndrome.
• Mu lti p le pregnanC)' in I0%.
• Local reaction at th e site fever, arthritis.
Anti-FSH and anti-Ll-1 are in t.he process of being deve l-
oped as con u·aceptives.
GROWTH HORMONE
Growth honnone (G I-l ) is a polypeptide secreted by ilie
ame,;or pituitaf) gland. Its action is to induce and pro-
mote linear growth at puben). The growth of the long
bones are indirect and is mediated ,·ia insulin-like growt11
fuctor I (IGF 1). secreted main I)' b)' the liver in response tO
GH. SubcutaneottS adminisu-ation of GI-l causes rise in t11e
serum IGF I witl1in 4-6 hours, and IGF I in turn has a dit·ect
negative feedback on the pituitary honnones. GH is
secreted in a pulsatile fashion during sleep. At pubeny, its
!eve I rises.
Recombinant GH is ava ilable as a subcuta neous it1iection
and is ttsed in Tu.-ner syndrome and t110se witl1 shon. stat·
ure. In adults, it reduces the body fat mass, decreases pro-
tein catabolism but increases protein synthesis. It ca uses
carbohydrate intolera nce. Side effects include an kle oe-
dema, carpal wnnel S)•ndrom e, arthra lgia, a rthritis and dia-
betes. It, howeve t; im proves osteoporosis.
GONADOTROPIN-RELEASING HORMONE
AND ITS ANALOGUES
GnRH is a decapeptide first isolated by Matsuo et al. and
Scally et al. in 1971. PuiS.'\ tile administration of t11is hor-
mone or its analogues causes a rapid rise in FSH and
LH. The t-ate and intensity of pulsatile release deter-
mines the secretion of pituitary hormones. ContinuottS
administration. howe' er, suppresses t11e pituitary go-
nadotropins. It has a half-life of 15 minutes. Because of
its inactivation in the gut, parentet-al routes (subcutane-
ous and nasal spray) are empiO)•ed. Agonists and antago-
nists are available.
CHAPTER 15 - HORMONAL THERAPY IN GYNAECOLOGY 197
AGONISTS AND ANTAGONIST GNRH: MODE
OF ACTION
ln in vitro ferLiliL.ation, Gn RII agonists cause an initial rise
in FSH and oestrogen called 'flare up' followed by gonado-
tropin suppression (downregulation). Therefore, it takes
longer for induction of ovulation.
Synthetic antagonists (ceu·orelix and gan irelix) compete
with receptors in the anteriot· pituitary gland and direCLiy
suppress gonadou·opin secretion. They, therefore, have Lhe
following admntages:
• Smaller amount of gonadou·opin required for ovulation.
• Shoner stimulation peliod with FSH.
• Reduced incidence of OHSS and multiple pregnancy.
• Comparable success as agonists in IVF.
Cetroreli x 0.25 mg is started 6 days after· FSH therapy
umilthe time of hCG ad minisu·ation, or a single 3 mg dose
given at the end of FSII stimulati o n.
CUNICAL USES
DIAGNOSTIC
GnRH stimulation tes4 50- 100 meg, i.v. causes rise in FSH
and LH in h)•pothalamic fai lu re. In pituitary fai lu re, there
is no secretion of FSH and Ll-1. This differentiates between
hypot11alamic and pituitary gland failure in amenorrhoea.
Synt11etic GnRI I analogues (buserelin, Factrel and gose-
relin) have been used in clinical practice as follows:
• Pttlsalile GnRH analogues 5-10 meg i.v. every90-I20 min-
utes (infttsion pump) and pulsatile 15-20 meg subcuta-
neous!)•Or 200 meg inu-anasall)' eve•) ' 2 hours have been
useful in h)pOthalamic amenot-rhoea to stimulate Lhe
h)pOthalamic-pituitar)'-0\>arian axis and induce cyclical
menstruation in dela)ed puberty.
• Pulsatile GnRl-1, in the above doses, has been used \lith suc-
cess in hypothalamic h)pogonadal infertility or in those who
fail to respond to FSH/ LH. Monitoting of ovulation is done
ultrasonically and by estimation of L; level and the dose is
either reduced or replaced by hCG in the luteal phase fol-
lowing ovul ation; 50-I 00 meg i.v. induces FSH secretion in
30-60 minutes and LH secretion in 15-30 minuLes.
• GnRH analogues are used in down regulati on protOcol to
bring down pilltitary hormones before starting on FSH/
hCG regim e in ind ucing ovulation.
• Gn RH in infenilit)' ca used by PCOS and endometriosis
yields a lower s uccess rate.
• Cf)•pwrchism in males.
Continuous ad m in isu·ation or month ly depot it1iections
(Zoladex 3.6 mg) are usefu l in the fo llowing:
• Precociotts pubert) to suppress pituitary-o,-arian hor-
mones tultil such time that normal puberty is desired.
• Conu-aception. but administration is difficuiL and expen-
sive. Bttserelin 6.6 mg implants suppress E2 for 6 months.
• Abnonnal utetine bleeding if other measures fuil.
• Endomeuiosis.
• To shrink the siL.C of lllet-ine fibroid preoperatively. Depot
it1iection of 3.6 mg i•1iected i.m. eve•) ' 28 days for
198 SHAW'S TEXTBOOK OF GYNAECOLOGY
3 montl1sshrin ks tl1e volume and vasc ula ti r:y by 50%-80%.
The size o f the fibroid starts growing again afte r stoppage
of the drug; the refore, surgery should be undertaken
soon a fter tl1 e therap).
• To slwink tl1 e e ndo metrium befo re tra nsce rvical resec-
tio n of endometriu m in me no rrhagia.
• Breast cancer to suppress oes u·ogen.
• Prostatic cance r. Cl)ptorchid ism.
When gh en inu-a, enously or subcuta neously in a pulsa-
til e manner, a special infusion pum p is used and the site of
infusion changed e' ery 2-3 da)S.
SIDE EFFECTS
The following are tl1e side effectS:
• Hype rs timulati on syndro me is reponed between 0.6%
and 14% (no rmall y I%).
• Multi p le pregnancy is the same as in tl1e gen eral pop ula-
tio n, i.e. I %.
• Abonion rate ma)' be s li ghtly increased.
• ln g)•naecological usc, prolonged adm inismttion for more
tl1an 6 mon tllS causes hypo-oesu·ogenic State and meno-
pausal S)'mpto ms, osteoporosis. Fo r tl1is reason and cotlSid-
ering tl1 e high cos4 GnRH tl1 erapy sho uld not be given
beyo nd 6 montl1s at a time; 'add-bac k therapy' can be t.LSed
ADD-BACK THERAPY
1l1e concept of add-back t11 erap) is to co unteract the hypo-
oestrogenic side effect witho ut affecting tl1e co nditio n fo r
which GnRH tl1 erap) is emplo)ed. This a llows pro lo nged
use of Gn RH tllerap). The ch-ugs t.LSed in add-back therapy
are oestrogen, progestogens, tibolone and bisphosphonates
especially to prevent osteoporosis. Norethistero ne 5-10 mg
daily is better than MDPA, as the Iauer causes osteoporosis.
Tibolon e is also effective.
AgonisLS as well as antagonists are now ava ilable in GnRH
tl1erapy. Antagonists, such as ceu'Orelix and ganirelix, act
faster (3-4 da)'S) against agon ists, "i1id1 may take 3 weeks,
and carry some adva ntage in cer tain siw ations.
Othe r side effects a rc as follows:
• Insomnia, nausea, clcc re;lSe in b reast size, myalgia,
d izziness, decreased li b ido, LDL, HDL a nd increased
cho lestero l.
• Allergic reac ti o n a nd infec ti on at the site of injection or
spra)', bronchos pasm.
• Drugs used are:
• Nafa reli n 400 meg intranasally for 6 mo nths. Ha lf-life is
4.4 ho urs.
• Buserelin 300 meg t.i.d. subcutan eo usly o r intra nasally
for 3-6 mo n ths o r 6.6 mg 3-mo ntllly injectio n (na no -
pep tide) .
• Goserelin (Zoladex) 3.6 mg im plant o r i.m. mo nthly
(nanopeplide).
• Leup rolide 3.75 mg 4 wee ki) fo r 3-6 montllS or 10.8 mg
3-monthl).
• Superfuct 200-500 mg subcuta neot.lSI)' daily.
• Buserelin im plant 6.6 mg suppresses ov:uia n honnones
for 3 months.
• Tripto relin 3-7 mg i.m. 4-wee kly.
An tago nistS of Gn Rh :
• Anta relix
• Ce u·ore lix
• T hese p revent premature LH surge. Advantages o f :m-
tagonists over agon ists are as follows:
• T he)' are cost-effective.
• Sh ort durations of drugs are required compared to pro-
longed the rap)' witl1 agonisLS.
• Smaller doses a•·e •·equired.
Distulua ntoge: \Veekl y subcutaneOLL5 ny ection aga inst
montl1 ly and 3-m on tl1l y il'yections of agon ists.
PROLACTIN
PRL is a polypeptide ho nn onc resembling GH a nd human
placental lactogen. It contains 198 a mino acids and is se-
creted by p iwitary lac to u·ophs in a pulsa tile manne c Extra
pituitary sites for p t'Oiac ti n pmcl uction are e ndomeu·ium,
decid ua, hypothalami c neurons, in testi ne, lungs and certain
tumors li ke renal cance1: Pro lac tin is no nna ll)' unde r the in-
hib ito ry infl uence of prolac tin -inhibiti ng dopam ine,
wh ich actS o n lac to u·ophs. Pt'Oiactin exists in three
forms, little PRL, big PRL and big big PRL Native or li ttle
PRL (50%) which is biologically most active, a big PRL which
is elevated in pregnancy and a big big PRL whid1 is inactive.
fo r pro lac tin:
• Pro longed lactation .
• T hyro id-releasing ho nno ne.
• Oesu·ogen promotes PRL release b) inhibiting dopamine
of h) pothalami c Je,el as we ll as b)' d irectl)' stimulating
lactotrophs.
• Endorphi11S, tricyclic a ntidepressa ntS metllyldopa pheno-
thia.t.ine stress.
• Sleep increases itS secr-etion.
• Empty sella w rcica and pituitary w mours, cra niophar yn-
gioma.
• Some cases of endomeu·iosis.
• Some cases of PCOS.
• Li ver a nd renal diseases red uce itS excreti o n.
Cliniw l of hype rprolac tinaem ia are oligomen or-
rhoea, ame norrhoea, galac torrhoea, infe n.ility and rec utTe nt
abo n.io ns tluo ugh CLPD (see Chapters I 0 and l 2 also) .
Normal prolac ti n level determ ined by rad io-immunoas-
say (RIA) is up to 25 ng/ mL. It is up LO 100 ng/ mL in hy-
perprolac tin aemia, b ut leve l crosses 100 ng/ mL in tl1e pres-
ence of a tumour. Apart fro m CT and MRl LO de tec t a brain
tumour, visua l exam ination is necessary LO detect pressure
o n t11e optic nerve.
Treatment is by anlipro lac tin drugs o r s urgery fo r mac-
roade noma. Antip rolacLin drugs are bro moc riptine and
o tl1 er de riva tives.
Drugs a re used in :
• Hyperp rolactinaemia
• Microadenoma < 10 em
• Macroad e noma (> 10 em ) to slu ink wmo ur before
SLLrge ry

BROMOCRIPTINE
Bromocriptine, a synthetic ergot de•·ivative (lysergic acid
derivative of ergoline) and a powerful dopamine agonist,
was discovered in 1971. It suppresses prolactin while pro-
moting tl1e secretion of gonadou·opins. lt thus ind uces
menstruati on, ovulation and promotes pregnanC)'· It also
suppresses lacta tion .
Bromocriptine is available as pa rlodel, proctinal, caber-
go li ne and serocrip tablets.
Pe•·golide is now also ava ilable as a vaginal tablet and in-
u-amuscular injection by tl1e name of parlodel-LAR (glyco-
lipid microspheres).
CONlRAINDICATIONS
H)pertension and cardiovascular disease
THERAPEUTIC APPUCATIONS
Bromocriptine's therapeutic uses:
• Su ppression of lactation - 2.5-5 mg dail )' orally.
• C)•clical masta lgia.
• Anovu latory infenili ty ca used b)' hyperprolacti naemia.
• Treatment of microadenoma and preoperatively in mac-
•uadenoma to shrink tl1e tumour before surgery.
In infertility due to hype•·prolactinaemia, ?Oo/o -90% ovu-
late and menstruation is established, 70% pregnancy rate is
also encolll-aging. lf pregnanC) follows. the treaunent
should be discontinued, though no teratogenic effect is re-
ported in tl1 e fetus.
In pregnancy, the level of prolactin lises and the follow-
up is main!)' b)' fund us exam ination, which suggests optic
nerve p ressure by tl1 e u.un o uc Bromocrip ti ne can be co ntin -
ued d uring pregnancy if tl1e tum o ur appears to increase in
size as suggested by fund us examination. Cabergoline is safe
during pregnancy.
DOSE
The dose startS witl1 1.25 mg at bedtime and gradually in-
creases to 2.5 mg b.i.cl or more as required. The effeCLlasts
for 12 hours.
In patients who cannottolemte the om! drug, or in resis-
tant cases, tl1e vaginal tablet or cream is to be used daily.
Alternately, the long-acting tab let in the name of cabergo-
li nc (Dosti nex) is ava ilable. Staning with an initia l dose of
0.25 mg twice weekly, tl1 e dose is grad uall )' built up to 1 mg
twice week ly. It acts at a 0 2 receptor site.
Parlodel-LAR monthly inu·amuscular irtiection, used in
the initial dose of 50 mg increasing to I 00 mg if necessary,
causes acute reduction in prolactin level b)' 30%-80%,
reduction in tumour volume by 25% with minimal side
effects.
Quinagolide 25-150 meg daily in di,·ided doses followed
b) a maintenance dose of 75 meg dail).
SIDE EFFECTS
The fo llowing side effects are seen in 10%:
• Na usea, vo mitin g; the patie nt is advised to take the tab let
at night.
• ll ypotension and di zziness d ue to postural hypotension .
• Nasal congestion, headache, constipation.
CHAPTER 15 - HORMONAL THERAPY IN GYNAECOLOGY 199
RESULTS
The drugs normaliLe prolactin level in 86% of idiopathic
hyperprolactinaemia and 77% in microadenoma. The mac-
roadenoma shlinks in 70%. Some require surgery.
HUMAN CHORIONIC GONADOTROPIN
hCG is a glycoprotein co nta ining two linked s ubuni ts alp ha
and beta. Alpha unit con tains 92 am ino ac ids similar to LH,
FSH and thyroid-sti m ul ati ng hormone. 13eta unit contains
145 amino acids, and has a specific biological activity in
pregnancy and ectopic pregnancy.
hCG startS •ising soon after fertiliation and is deteCLed
in the serum 1 week before the due menstrual pe•·iod. The
level doubles every 2-3 days, peaks on the tOOth clay and
then declines g•-adually. The honnone secreted by the S)1l-
cytiotrophoblast is luteotropic, and corpus luteum secretes
progesterone unti l the lOth week when the placenta takes
over the hormonal functions. With progesterone, it p •uvides
endometrial support to the embryo.
Role of hCG
• It supportS early pregnancy.
• In ectopic pregnancy and missed abortion, the level is low
and does not double eve•)' 2-3 da)S. In h)'peremesis and
in h)datidiform mole, the level is high, so also in multiple
and diabetic pregnancy.
• Although the level is high in trisOm) 21 (Down S)11-
drome), it is low in a fetus with trisOm) 18.
• ItS •ule in ovarian stimulation in anovulatOI)' infertility
has already been described.
• hCG is detected b)'
• Ulinc pregnancy test.
• Q uantitati ve Lest in se n1m is useful in monito rin g ec topic
pregnancy and follow-up of molar pregna ncy.
• In management decision-making in ectopic pregnancy.
THERAPEUTIC APPLICATIONS
• In habitual abortion, it provides suppo•t to the embf)O.
• IVF progmmme: hCG given when the follicular size
reaches 20 mm causes follicular rupture 36-38 hours fol-
lowing and provides support in implantation
and endometrial vascularization.
• In CLPO.
KEY POINTS
• Ocsu·ogen preparations in clinical usc include etl1inyl
oestradiol used in conu-aceptive pills, and
oestmgens in HRT in menopausal and u•·ethral sp1-
chume. Implants are mainly emplo)ecl for long-term
use. Vaginal cream is effective in atrophic vaginitis
and urethml S) ndmme.
• Progesterone as injectable in oil or microni.ted prepa-
ration is used in CLPD and early pregnancy supporL
• Pmgestogens are used in ab no rma l uterine b leeding
and as co mbined contracep tive pills and as mini-pills.
ThC)' are required in HRT.
• Androgens (Danazol) are effec ti ve in the trea tm ent of
endometriosis and fibrocystic disease of the breastS.
200 SHAW'S TEXTBOOK OF GYNAECOLOGY
• Clomiphene and tamoxifen are employed in infertili ty.
Tamoxifen is mainly useful in breast cancer.
• MifeprisLOne (a nti-P) is recenll) introduced in t11e
tennination of earl) pregnane>·
• Antiandrogens are used to u·eat hirsutism in PCOS.
• H)pOtllalamic gonadotropin-releasing honnones
(GnRH ) are empiO)ed in va,;ous g)llaecological con-
ditions for not mo•·e than 6 mo nths. However, add-
back thet-ap) allows p•-olonged use of GnRH L11erapy.
• Bromocdpti ne and cabergoline are useful in h)perp-
rolactinaemia and suppression of lactation.
• The side effects of all hormonal preparations should
be known and a' oided in clinical practice.
• hCG hormone is used in the induction of ovulation
and pregnancy support in early gestation.
• Anti prolactin drugs arc employed in hyperprolactinae-
mi a and microadcnoma. They induce mensu·uation
and ovul ati on , and improve pregnancy rate. Macroad-
e noma may require surgery.
• FSH a nd I ICC arc used in the induction of ov ula tion
if clomiphene fa ils, and in IVF LO induce multip le
ovu lati o n.
SELF-ASSESSMENT
I. Describe t11e physiological role of oesLrOgens in t11e body.
£nLUnerate the indications and the commo nly used oes-
trogenic medications in clinical practice.
2. Qassif> progestogens and their clinical applicatio ns.
3. ame the androgenic medications and their clinical
applications.
4. ame the pituitary gonadou·opins and L11eir role in
tllerapeutics.
5. 'vVhat are GnRH ana logues? What is L11eir role in clinical
practice?
6. A woman, 28->ear old, complains of galactot-rhoea. How
will you investigate and manage this case?
7. Discuss the drugs used in anovulatOry infertili ty.
SUGGESTED READING
AGOG Committee on Gynecologic PrdCikc. ACOG Cornrniuee Opin-
ion #322: Comp ounded bioidcnlical hornH)n<:s. Obs1 e1. Gynecol
2005; I 06: I 139.
AGOG Pr.tctice Bulletin No. 141: lll>lllllgemcnl ofmcnopau,;ai>YJnpt<lfn S.
Ob.tetGynccol2014; 123:202.
Arnar A P, Gouldwell WT, ct al. Prt-<1icth c mluc of serum prolactin levels
after tr.tn>phenoidal >ttrgcry. J 1\curusurg 2002;97(2): 307.
Arulkumar.tn S. Clinic. in Ob>tetric and 2009;23:5.
Bergcndal A. Kieler II. Sund>trom A, ct al. Ri,k of venous thromboem-
bolism as:,ociatcd \\ith local and >)1>tcmic 10>e of honnone tht:r.tpy in
peri- and posunenopau>.tl women and in relation 10 type and route
of administr.ttion. Mcnopauoe 20 16; 23:593.
Canonico M. llonnone ther.tp) and thromboembolism amongst post-
menopausal women : Impact of the route of administr.uion of estrogen
and progestogens: TI1c ESTI IER >ludy. Oratl:uion 2007;115(7):
840-&15.
Carr B, Breslau 1". Chen;, C, c1 al. Or.\1 contracepl i\e pill, ago-
nists, or use in combination in the 1.r eumen1 of hin;ul ism. 1Endocrinol
Metab 1995:60(4): 1169-1173.
Cicardli E, Cammani F. Diagt10>i> and drug ther.tpy ofprolacrinomas.
Drugs 1996:51(6):954.
Cr.tndall CJ, llovey KM, Andrews CA, e1 al. Breast cancer, endometrial
canct::r, and cardiov·..beular cvl'nls in participants who used vaginal
in the Women's ll ealt h Initiative Obscrv.tlional Study.
Menopause 20 18; II.
Duncan J & Shulman P. Yearbook of and
Women's l lcalth , 2010;207.
ECAB (Gn Rll ). Clinical Utxlatc in Obstetrics Gynaccok>!.'Y· 2010.
Fdson DT, Zhang Y, l Iannen MT, el al. The eff,"<;l of posunenopausal
L'Strogen ther.tpy on bone de nsity in eld erly women. N Eng! J Med
1993;329:1141-1146.
Fruzzcui F, Bcn;i C, Parrini 0, cc al. Trcauncnt of hirsutism: Compari-
sons between different antiandrogcns with central and peripheral
effect>. Fertil Steril 1999:71:445.
Grodstein F, Man.>on J E, Stampfcr M.J , Rexrode K. Postmenopau,;al
hormone thcr.tpy and >trokc: role of lime since menopause and
age at i•titiation of honnonc therapy. Arch lmem ;-.ted 2008;
168:861.
Kaunitz A\1. Clinical pr.tcticc. I lonnonal contraception in women of
oldcrreproducthe age. l" Eng!J 358: 1262.
Lcgro RS. Barnhart II X. chl.tff\\'D, et al. Clomiphene, metfonnin or
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2007:356(6):551-566.
Luncnfcld B. lnslcr V. !Iuman gomtdotropin>. In Wanach EE, Zacur HA
(eds) Repnxlucti'e and Sufb<el'). St. Louis: - Year
Book 1995:611-638.
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1 Mcd 2003:349(14):1443-1440.
Rosen CJ. Postmenopausal o>K'Oporosis. N Eng! 1 Moo 2005; 353
(6) :595-603.
The NAMS 2017 ll onnone Position Slaletn enl Athisory Panel.
The 201 i honnonc lllerdpy position s1a1em en1 ofThc North American
Menopause Society. 2017; 24:728.
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 COMMON CONDITIONS
IN GYNAECOLOGY

16 Infertility- Male and Female 19 Temporary and Permanent Methods

17 Ectopic Gestation of Contraception
18 Acute and Chronic Pelvic Pain 20 Medical Termination of Pregnancy

201
 Infertility - Male and Female
Physiology of Fertilization 202 Assisted Reproductive Technology:
Infertility 203 An Overview 225
Mole Infertility 203 Key Points 226
Vaginismus 2 12 Self-Assessment 226
Dysporeunio 2 13
Procreati on or desire to have one's own offsp ting is the great·
est desire among human beings. Since inception of civilization,
failtu·e to have one's own 1:>.'\by or infe n.ility has affected count·
less couples both rich and poor alike. Infertility besides being
a health issue is more of a social problem whid1 affectS per·
sonal. social and mental health of affected person. lt is esti-
mated that 1Oo/o-15% of married couples suffer from infen.ility.
Due to changing social S)stem, professional life and academic
ad1ievemem more and more couples face this problem. In
India common I> held notion about infertility is that it is due to
female however, in actual life both pan.ners contribute
equally to infertilit)t Following section discusses physiology of
reproduction, common causes ofinfenility, modes of investiga-
tion and therapeutic approaches for infertility.
PHYSIOLOGY Of FERTIUZATION
Conception results from the ferti li zation of the ovum by a
spermatozoon. Much information is now ava ilable about
the biological process whereby the spermatOzoon enters
the ovum as ferti liza ti o n ca n be swdied in, in vitro fertiliza-
ti on (LVF) progn11nme.
T he mec hanism whereb)' spe nnawzoa pass along the
uterus is not proper!)' explained. A5 ciliary movement of the
cervical and endometrial cpitJ1elia is downwards, the sper-
maLOzoa must migrate against t11e ciliar)' current. ltcan on !)'
be assumed tJ1at spermato:t.oa, which live in an attractive al-
kaline medium of tJ1e sem inal nuid (pH 8), find the ac id
environmem of tJ1e vagina l secretion (pH 4.5) lethal in a
matter of 2-4 hours. The cervix has the same p H as the
seminal nuid and is undoubtedly and demonsu-ably atu-ac-
tive to the spermato£oa. SpermatOzoa are powerful, fast
swimmers. and from tJ1e time of ejaculation to the t.ime of
arrival in the ampulla of the tube, it takes about60 minutes
for the spermato£oa to cover tJ1e intervening 20 em. This
distance compared to the si£e of a spennatoLoon represents
a t-apid and plll·poseful u-avel. The subendothelial layer of
the endometriwn exhibits increased upward peristalsis
202
during th e fo llicular phase near ovulation ti me, and this
ma)' hasten the migration of sperms into tJ1e fallopian tube.
lt is now generally accepted that though a spermatozoon
after may remain moti le for a long period, itS use-
life span is limited to 24 hours, and after tJ1is short inter-
val, it is less capable of performing its biological duty. The
period of survival of a mawre ovum is probably even shorter
than that of aspermato£oon, and the time which elapses after
its escape from a ripe Graafian follicle and its entry imo the
fallopian tube during which it is potentially fertiliLable is esli-
mated atl2 hours and rarely up to 21 hours. The significance
of this statemem is that coiws, to be capable of fet·tiliLat.ion,
must take place in tJ1e 24-hour period around 0\'ulat.ion.
Ovulation most commonly occurs 14 da)S before the onset of
the next period, t110ugh variations are known.
The fimbriae of tJ1e fallopian tube by muscular con u-ac-
tion spread out over the ovary at t11e time of ovulation, a
movemem which simplifies tJ1e u-ansport of the discharged
ovum into the lumen of tJ1e fallopian tube. FurtJ1ennore,
the musc ulawre of th e fallopian wbe undergoes rhythm ical
conu-actions, especially at tJ1 e time of ovulation. It is most
li kely tJ1e peristalti c co ntractio n of the fallopian LUbe that
determines th e transport of the ovum towards the cavity of
the uterus. T he sperm UHil reac hes the ovum first pene-
trates the zona pell ucicla and norma ll y inhibits enll) ' b)'
o tJ1 er sperms. By tJ1e tim e the fertilized egg emers t11e uter-
ine cavil)', the endo me u·itun has grown under the effect of
progesterone into secretory endome u·ium and is ready tO
receive tl1e egg for implantation and provide itS n utrition.
On general biological principles, tJ1e blame of infertili ty
should be shared between tJ1e two partners. It is not tmcom-
mon for patients to complain of difficulty during coims when
they have little knowledge of the correct metJ1od to be em-
ployed DLLI·ing sexual intercourse, tJ1e erectile tissues aroLmd
tl1e vaginal orifice become engorged and the vaginal o tifice
becomes more There is a discharge of mucous
from the ductS of Ba•·tl10lin 's glands, "hich acts as a lubri-
cant. The female orgasm is induced by stimwation of tl1e
clitoris pat·tJy <luting tJ1e peneu-ation of tJ1e penis and pan.Jy

as tl1e result of tl1e cli to tis being rhytl1mically pressed against
tl1e penis after penett<ltion. The importance of tl1e extm-
genital areas of sex ual stimulation mttSt not be forgotten.
These e rogenic areas val) with the individual and tl1eir sus-
ceptibilit) to stimulatio n is equally variable, but tl1eir aggre-
gate respo nse is cLUnulative and plays a pan in me ulti-
mate achievement of an orgasm. There is so me mat
tl1e mucoltS secretion contained in t11e cervical canal is ex-
u·uded imo tl1 e vagina dul"ing the orgasm. The seminal fluid
is mainly deposited in t11e postetior fomix of the vagina, but
it is possible that some of it is ejaculated directly imo tl1e
cervical canal. It is also believed that the conl)(lctions of tl1e
uterus and tl1e fallopian tubes eluting tl1e female ot·gasm
cause seminal fluid to be aspirated imo tl1e cavity of the
uterus, and it is possible that t11is aspir-ation effect is respon-
sible, in pan at least, for t11e migration of spennawzoa up-
wards into tl1e fallopian tubes. A more li kelysuggestion is that
rhytl1mic cont mcti ons of t11e pelvic muscles direct the semi-
nal ejac ul ate towards the ce rvix, whe re tl1e propulsive power
of the spenn ato:.:oa provides t11e forward momentum. T he
female orgasm is not esse ntia l for conception, and it is not
tmcommon to see women who have conceived witho ut full
consummation of tl1e marTi age and in '''hom tl1e hymen is
intact. ln sud1 cases the spe nn ato:wa, having been deposited
aro tmd the h)•me n, migrate through t11e ir own mo ti li ty a long
tl1e whole lengtl1 of tl1e vagina and
INFERTIUTY
Acco rding to Wo rld Healtl1 O rganization (WHO), positive
reproducti\e health of a woman is a state of complete physi-
cal. mental a nd social well-being and not merely tl1e absence
of disease related to rept·oducti'e system and functions.
lnfet·tility implies appa rent failure of a couple to con-
ceive, while sterility indicates absolute inability LO conceive,
for one or more reasons. If a couple fails to ad1 ieve preg-
nancy after I )Car of 'unprotected' a nd regular imercourse,
it is an indication to investigate the couple. This is based
on tl1 e observation that 80% of normal couples achi eve
conception witl1in a yca t: It is observed tl1at 50% conceive
"1thin 3 months followin g regul ar, unprotected imercourse,
75% in 6 montl1s and 80%-S5% conceive within a yeat:
Infertili ty is termed as primary, if co nception has never
occ urred, and secondary, if the woman fa ils to conceive
after having ac hi eved a previous conception. T he incidence
of inferti li ty in all)' community va ti es be tween 5% and 15%.
Optimal age for co nception is 20-35 yea rs in a woman.
Mter tl1e age of 40 yea rs, the fenilit)' rate is reduced, and
mere is an increased risk of chromosomal abnormali ties
and o tl1er malformations in the For a man age is less
importam, but after 50 years, decreased libido and sexual
dysfunction red uce fertility and predispose to malformed
fetus Therefore, it may be prudent LO proceed witl1 investi-
gations of apparent infertility in a woman near or after the
age of 35 )Cars, instead of waiting fo r a year, if she seeks
gynaecological he lp.
Conception is the result of successful fenilization of the
female egg b) me spe nn. He nce, tl1e couple should be
counselled indh·idually a nd then togemer because botl1
parmers conu·ibute \'llt) ingl)• to me occun·ence of the infer-
tile state. It is mandatot) ' to investigate botl1 tl1e partners
CHAPTER 16 - INFERTILITY - MALE AND FEMALE 203
sim ultaneously, carry out the necessary testS and adopt
appropriate measures 1.0 e nha nce t11 e fertility potential of
each individual parlller.
ISSUES INVOLVED
l11e major goals imo h ed in t11e comprehensive investiga-
tions of the infertile couple are as follows:
• Identification and corre ction of causes conu·ibuting LO
the infertile state 0\'er a sh ort span of time.
• Providing accurate information, education and counsel-
ling to both tl1 e parmers, and explaining the nature of
thera P>' and the cosL
• Counselling about alternative managemem of infertility
if pregnancy fails o r is n ot possible (sterility) sho uld be
provided. T his may include discussio ns o n tl1 e roles of
assisted reproductive tec hniques, a rtifi cial insemination
and the option of adop ti o n. Prognosis and success rate
of each s ho uld be discussed. IL is also importan t to real-
ize tl1e futility of re peating th e sa me inves tiga tions by
differe nt doc to rs wh ic h may be frus u·a tin g LO the couple
apart from tl1e expe nse incurred. It ma)' be p rudent on
the pan of tl1 e doctor to Sllld)' th e previo us records
before asking for a repeaLtest.
Prognosis
The advance age of tl1e woman, long d uration of infertility
and previoLLS failed medical and surgical treaunem are
associated witl1 poor prognosis.
INITIAL COUNSELLING
During the initial counselling, it is imponam to explain LO
both the pat"Ulers, in simple words, the process of reprocluc-
tion with the help of chans and models. Explain tl1at it is
possible to find a faulty function in both partners, and often
overlapping caLtSes exist, h ence the need LO evaluate and
treat botl1 tl1e paru1et-s concurrentl y.
MALE INFERTIUTY
DEVELOPMENT AND GROWTH IN A MALE
SPERMATOGENESIS
Spetmawge nesis occ urs in t11 e se minifero us tubules of t11 e
testis. T he primordia l ge rm cells appea r in the yo lk sac in
the 3rd week of e mbt)'O and migrate alo ng tl1e dorsal
mesenLCl)' LO the genital ridge. These ge rm cells divide by
mitosis into 1300 primordial cells o r spermatogo nia by me
6th week. Th ese re main q uiesce nt in the seminiferous
tubLLies tl1roughout childhood.
Near puberty, spermatogo nia divide by mitosis into
pl"imary spennatocytes. Me iosis occurs o nly at pubeny and
smaller secondal) spermatOC)'l.es co matnmg haploid
munber of chromosomes are formed. These develop into
spe rrnaticls. The develop by acquir;ng an
acrosome cap. elo ngatio n and co nde nsation of spenn
nucleus a nd a tail. The clevelopmem of spe nns take 72 days
(Fig. 16.1 ) a nd entire spermatogenesis including transit
time in me dueL takes 3 lll0l1UlS.
 tells A Bp MM , ihhibin
Fsh → Sertoli
→ ,

cuts testosterone
leydig
→
204 SHAW'S TEXTBOOK OF GYNAECOLOGY LA →

produce androgen-binding protein by follicle-stimulating

Epididymis (head) hormone (FSH) and bind testosterone to this protein caus-
ing a high level of testosterone within the testes compared
Vas deferens
to t11at in t11 e blood. The interstitial cells (Leydig cells) pro-
duce testosterone b) lute ini.cing hormo ne (LH ).

I-# - Internal
spermatic
artery
Semi nile rous
tubules
Rete testis
Figure 16.1 Norm al anatomy of t he testes.
STRUCTURE OF THE SPERM (Fig. 16.2)
T he mature sperm has a head with an acrosome covering,
midpiece and a tail which allows motility. Acrosome
membrane contains en:t)'me hyalu ronidase, acrosin and
other proteases, wh ich a llow ac rosin reac tion, break down
of acrosome membrane and penetration of spenn in to zona
pellucid. 1-l)'aluron idase dissolves coro na radiata cells. The
sperms are stored in the epididymis. One spennatOcyte
produces four spermatids, and one spermatid produces
fo LU' sper·mato.wa.
Spermatogenesis beginning at puberty is a continuous
process unlike ovulation, which occurs once a month, and
continues with senescence though with less efficiency. The
testes show germ cells in differem stages of maturation at
any given Lime, and the spenns mawre in the testes as well
as the accessory or"gl\118, and undergo capacimtion in the
cervix before they are capable of fertilimtion.
The seminiferous wbules are lined b)' germ cells and
Sertoli cells lying adjacent to genn cells. The Senoli cells
ENDOCRINE CONTROL
Hypothalamus is clitical in the development of male orgru1S
and spennatogenesis. Gonadou·opin-re leasing honnone
(GnRH ) in males is produced continuously, w1like in a pulsa-
tile fashion in females. FSH is not essential for spennatogene-
sis; it acts on the Senoli cells and produces androgen-binding
protein mentioned abo,e. The Sertoli cells also produce
Mullerian inhibiting honnone (Mil-l) and inhibin which
inhibit FSH. Mll-1 inhibit de,elopment of Mullerian system.
LH stimulates testoster·one secretion by t11e Leydig cells.
Hypot11 alamic fai lu re leads to loss of spermatogenesis
and testosterone production.
T he sperms are form ed in t11 e lini ng epit11eli um of th e
seminiferous tubrJ es from tJ1c germinal cells -spermatogonia
(Fig. 16.3).
SpermatOgonia are diplo id ge rmin al cells wh ich divide
by mitosis into spe nna tocysts. These undergo reductio n
division (meiosis I) into hap lo id secondary spe rmatocysts,
which b)' meiosis II develop in to spe nnatids. These spenna-
tids develop into compact, virwa lly cytoplasm-free spe nns
with conder1Sed DNA in tJ1e head, capped by ap ical acro-
some and a tail (Fig. 16.2). These sperms are incapable of
fertilization after tJ1ey undergo capacitation in t11e female
cervicru canru. The e ntire process of spermatogenesis takes
74 days. and if we include transport in 1J1e ductal system it
takes 3 months. The) are present in the testes in different
stages of development at an) given time. The testes produce
200-300 million spenns daily.
Capacitation can also be induced following incubation in
a culwre media in IVF. Cervix plays the following role in
reproduction:
I. Nutrition to t11e sper·ms.
2. Alkaline medium for survival of spenns.

Acrosome
Head
Postnuclear cap

Rgure 16.3 Testicular biopsy. Normal seminiferous tubules.

Note spermatozoa in lumen (x250). (Soun;;e: Dh<¥'1nl
u--- End piece MD, Rchmood, VA, http: "Mvwwebpath00gy.comrmag3.asp?case=
Rgure 16.2 Normal sperm. 27n= 1)

3. Sieves out abnormal spenns.
4. Causes capacitation of sperms. Storage unti l upward pro-
pulsion of spenns.
Acrosome reaction is an important component of
capacitation for .£Ona penetration imo the oocyte. Acro-
some is a modified lysosome over the spenn head, under itS
action the overl) ing membrane becomes wlstable, breaks
down and releases hyallll·onidase erlL)Ine, which allows the
penetration of corona radiata and LOna pellucida.
The Senoli cells line the seminiferous wbules and
extend from the base of the membrane to the lumen. They
suppon the spermatids and possess receptOrs for FSH and
testosterone. The u·opic effect of FSH and testosterone on
spermatogenesis is mediated via the Senoli cells. T here are
four sperms per Senoli cell. The Senoli cells produce
Miillerian inh ibitory factor whi ch prevents the develop-
ment of Mt-tll eria n system. T he Senoli cells also p roduce
testosterone-bi nd ing protein whi ch ma inta ins high level of
testosterone wi tJ1in tJ1e testis. T h is is necessary fo r co ntinu-
ous sperma togenesis.
ENDOCRINE CONTROL OF SPERMATOGENESIS
The spermatogenesis depends on Lhe hypo tha la mic-
anterior p itu itary-testicular functions. Gn RH s ti mulates the
anterior pituitary gland to secrete FSH and LH. FSH actS on
tJ1e Sertoli cells, and LH u·iggers testosterone secretion by
tJ1e Leydig cells (interstitial cell5). The concentration of
testosterone is higher in tJ1e testes tJ1an in tl1e plasma. The
testosterone in turn exertS a negative feedback on tl1e
pituitaJ') gland, as well as tJ1e hypotJ1alamus.
A total of 60% of serum testosterone is bound tO sex
SHBG hormones binding globulin (SHBG) and 20% to albumin.
601 .
A small portion is comer·ted to oesu·ogen. Two per cent
albumin free testosterone is converted to dih)drotestosterone by
201 .
S.alpha reductase erupne which actS on hair follicles and is
responsible for male phenOt)pe.
The Senoli cells also secrete inhibin B which in LUrn
inhibits FSH but stimulates LH secretion.
Fertilization
Following capacitation, a mature sperm meetS tJ1e ovum in
tl1e ampullar-y portion of the fallopian tube. By acrosomal
reaction and hyaluron idase release, it pe netrates the zo na
pell ucida, whi ch in turn prevents enu-y of othe r sper ms
(polyspermi a). It is possib le to asp irate the pola r body or a
blastOcys t cell fo r ge ne ti c study of tlte e mbryo, witho ut
distu rbing furtJ1er deve lop me nt of the embryo.
MALE FACTOR INFERTIUTY
In one-tl1ird of a ll cases, tJ1e male is d irec Lly responsible, in
one-tJ1ird both paru1ers are at faul t and in the remaining
tl1ird the cause of fai lure is attrib uted entire ly to the female.
These figures are perhaps exu·emes and it might be more
appropriate to disu·ibute tJ1e fault evenly between tl1e two
parU1ers.
Faults in the Male
Following factors in males contribute to infertility:
• Disorders ofspennatogenesis- 50%
• Obsu·uction of tlte efferent duelS- 30%
CHAPTER 16 - INFERTILITY - MALE AND FEMALE 205
• Disorders of spem1 moti lity- 15%
• SexLtal dysfunction
• Unexplained- 15%
For adequate spennatogenesis, the testicle must lie in itS
con-ect posit.ion in tl1e scrowm, where t11e temperature is
slighL.ly cooler than elsewhere in the body. The factOrs
which raise the scrotal temperature can adversely influence
spermatogenesis, e.g. the occupation of men who work as
stokers or in blast fur·naces and are to excessive
heat, the wear·ing of a ugh t scrotal support and the presence
of a varicocele. The ectopic or undescended testicle pro-
vides the best example of the adverse effect of temperawre
on spermatogenesis. The collecting apparatus of tl1e epi-
didymis ma)' be damaged by trauma or inflammatory dis-
ease, notably gonon·hoea or tuberculosis. T he vas deferens
itself may be occluded, and this is specia ll y tO be s uspected
if tl1ere is a herniorrhaphy scar and do ubly so if tl1 e scar is
bila teral. Chron ic inflammatory d iseases of tl1 e prostate and
se min al vesicle may be assoc iated witJ1 male infe rti li ty. Co n-
ge nital lesions of tJ1e pe nile urethra such as hypospad ias
provide an obvious mec hanical expla natio n for imperfec t
insemination. A histo r')' of mumps, venereal d isease, d iabe-
tes, Ul)•roid or tuberculosis rnay suggest testicular atrop hy or
obs u·uction. The occ upation of the ma le, histo r-y of exces-
sive smoking, indulging in excessive alco ho l consumption
and d1ewing tobacco and gutha may also suggest poor sper-
matogenesis. Accidental or operative trauma, e.g. blow on
L.l1e testicle with haematoma format.ion and subsequent
atrophy. or operation for hernia, varicocele or hydrocele
may suggest a degenerative lesion of tl1e testes or obstruction
to tl1e vas. About 1%-2% males suffer from genetic defectS
such as Klinefelter S) ndrome with 47XXY chromosomes.
Aetiological Classification
I. Genetic- abnonnal Ychromosome and XXV in Klinefel-
ter syndrome. Mutation of short or long ann Y chromo-
some.
2. Disorders of spermatogenesis.
A Hor·monal (pr·etesticular):
Hypothalamic disorder, Kall mann syndrome.
Pituitar-y secretion of FSH, LH.
Hyperprolactinaemia causing impoten ce or dimin-
is hed libido.
• Hypothyro idism, ad renal gland d iso rder and
d iabe tes. neuropathy impotence 9 retrograde ejaculation
-
B. Prima r-y testicular d iso rders (testi cular):
• Id iopathi c, va ri cocele, absent ge nn cells.
• Ch romosomal defect, i.e. Klinefelte r S)•ndro me.
Ct)•p tordl idism.
Drugs, rad iation, calciu m channe l bloc ker, amicon-
vulsants, antihypertensives, spirono lactone and
cimetidine.
Orchit.is (traumatic, mumps, TB, gonorrhoea).
Chronic illness.
Immunological disorders (5%).
lmmotilit) due to the absence of dynein anns.
Absent cilia in Kartageners)ndrome (15%).
3. Duct obstruction (post-testicular). Congenital absence,
inflrunmatot')' block (gonococcal, tubercular), surgical
trauma, Young S)nclrome (inspissated mucous) associ-
ated with sinusitis and bronchiectasis. Escherichia roli,
206 SHAW'S TEXTBOOK OF GYNAECOLOGY
staphylococci, chlamydia! infection. Mycoplasma geni-
talis causes DNA fragmentation of spenns, decreased
motility and apoptosis. Accessory gland disorders: Prosta-
titis. vesiculitis and congenital absence of vas in cystic
fibrosis.
4. Disorders of sperms and vesicular fluid:
• Sperm antibodies and low fructOse in seminal plasma.
l mmotile cilia S)ndrome (Kartagener syndrome).
• Sperm acrosome defect.
• Zona pellucida binding defecL
• Zona pellucida peneu-ation defect.
• Oocyte fusion defecL
5. Sexual d)sfunctions:
• Low-coital ft·equencies- wrong time, low libido.
• Impotence, hypospadias.
• Premature
• Retrograde
6. Psychological and environmental facto rs such as smok-
ing, alcohol consumption, tobacco chewing, diabetes
and clntgs- antihypertensive, anti psyc ho ti cs, cimetidine,
sex steroids (excess testoste rone and anabolic used b)'
ath le tes) chemotherap)'• ni trofura nto in, beta-bloc kers,
spirono lac tone, oestrogen.
7. Obesit)' increases peripheral conversion of androgen to
oesu·ogen and affects fertilit)'·
8. Chronic illness.
INVESTIGATIONS
I. History. 1-listOI") includes age of the male partner, previ-
ous marriage, duration of infertility and any contracep-
tion practiced and for how long. This gives a ULte picrure
of the duration of infertilit).
• The coital frequenC) and timing related to ovulation.
• The occupation- a frequem traveller or working in a
hot place.
• Habit of smoking, alcohol, tObacco and other drugs
usage.
• History of tuberculosis, sexually transmitLed infection,
diabetes and chronic illness. Diabetic neuropathy can
cause impotence and retrog•-ade ejaculation. Fever of
an)' cause can suppress spennaLOgenesis for as long as
6 months. Chronic respiratOt)' disease.
• Operation on the scrowm, undescended testis or h er-
nia repair.
• Any coital problem such as prema tu re a nd retrograde
ejacula ti on, fa ilure to c;jaculate.
2. General examination in a sta nd ing posture to loo k for
size of the testis, the presence of va ri cocele, th icke ning of
the vas and a per rec tal exam ination fo r obvio us prostate
enlargement or tenderness in sem inal vesicle. A normal
repo11. ru les out all)' m1!jor general or local cause for
ma le infertility. One can move on to further investiga-
tions. Abnormal semen analysis calls for general and
local examination of a male partnet:
• General: height increased in Kallmann and Klinefelter
syndrome is due to late closure of epiphyses of the
bones.
• Weight and obesit) ma) point LO be honnonal
defeciS.
• The seconda11 sex characters are abnormal in
Klinefelter S) ndrome, i.e. ID naecomastia associated
with Tumer-like stigmata.
• Thyroid enlargemen4 enlarged breastS and hirsutism
may be noted. Blood pressure should be checked.
3. Local examination includes examination of penis and
scrottun. and surgical scar. The normal testicular volume
is 15-35 mL (average 18 mL). Testicular volume of less
than 6 mL is seen in atrophic testes and in Klinefelter
syndrome. The testes should be well placed in the
scrotum. The epidid) mis should be palpated for enlarge-
mem and thickness. The \<a$ feels thickened in inflamed
conditions. Rectal examination includes the prostate ex-
amination. The presence of \'llricocele (more often on
left side) can be demonstrated when male is examined in
a standing poswre, and on Doppler ultraSound.
Special investigations comprise the following:
• Semen analysis.
• Hormonal assays.
• FNAC fro m testis
• Testi cular biopsy- fo r histoiOg)', gene tic study and Ct) 'Oo
p reservati on in assisted reprod uctio n (intracy toplasmic
sperm insemi na ti on).
• Immu no logical testS.
• Pa tellC)' of vas.
• Chromosomal stud)'·
Not all of the above investigations are requi red in a ma le.
Stepwise investigations wi ll not only save time but also avoid
tmnecessary and elaborate tests which may turned out to be
not only expensive but stressful and fntstrating for the male
partner.
Semen Analysis
The most imponant part of the male investigation is the
semen anal) sis, and certain pointS regarding the method
and timing of collection of the specimen are notewor-
thy. The best specimen is one obtained by masturbation
in the vicinity of the laboratory, because this guarantees
itS freshness, and avoids changes due to temperature
variation. If this is not possible, coitus interruptus into a
wide necked bottle may be employed. Another method
is the postcoital test described later. T he prod uction of
a condom specimen is to be disco uraged as th e con dom
co ntai ns spenniciclal c hemicals and a fa lse low readi ng
may th ereby be ob ta ined. T he best spec ime n will be
produced if a s ho rt pe ri od of abstine nce of 3-5 days is
observed . A mo re p ro lo nged period of abs tine nce does
no t yie ld be u e r res ultS. A typ ical no rm a l specime n
s ho uld show th e fo llowing featu res whe n exa mined
withi n 2 ho u rs of prod uction (earlie r th e be u e r). T he
semen sho uld coagu late soon after ejac u la tion d ue tO
enzyme in the semina l ves ic le, b u t liq uefy in 30 m in utes
because of prostatic en:tyme. The semen is greyish wh ite
in colour.
In 2010. Wl-10 laid down the latest criteria for normal
semen quality and reference ( I 'able 16. 1).
• Volume: 2 mL (1.5 mL)
• p H: 7.2-7.8
• Viscosit): <3 (scale 0-1)
• Sperm concenu-ation: 15 million / mL
• Total spenn count: > 10 million/ per ejaculate or more

Table 16.1 Latest WHO Reconvnendations for Normal
Semen Analysis Reference Values.
Latest WHO standard for semen analysis- 2010:
• Volume: 1.5-5.0 ml
• pH: > 7.2
• VIscosity: < 3 (scale o-4)
• Sperm concentration: > 15 million/ml
• Total sperm number. > 39 milli on/ejaculate
• Per cent motility: > 32 %
Forward progression: > 2 (scale 1)...4)
Normal morphology: > 4%
Round cells: < 1 million/ml
Sperm agglutination: <2 (scale 0-3)
Source: WHO gucelines.
• Motility: >50% or more with at least 25% progressively
moti le.
• Morp hology: >at least4% normal in morp hology
• Viability: >75% or more (50%)
• Wh ite b lood cells: < 1 million/ mL
• Round cells: <5 mi llion/mL
• Sperm agglutination: <2
Low volume may be due LO following:
• Incomplete collection, poor abstinence
• Abnonnalities in the seminal ,•esicles
• Panial vas obsu·uction
• Retrograde
• Hypogonadism
Pus cells should be absenL T he seminal fl ui d is normall)'
viscous with a p H of7.2-7.8, and con tains frucwse.
Aspenn ia- means no semen.
Azoospermia- implies no sperm in semen.
Oligospermia- low sperm counL
AstJ1enospermia- no motile spenn or diminished motility.
ecrospermia- dead spenns.
Teratospennia- abnonnal morphol<>g> of spenns.
A normal sperm is motile, 50 microns in length, half the
siLe of ovum and consistS of a head covered by an acrosomal
cap, neck, body and tail.
Hypospennia means low volume, less than 1.5 mL.
This may be d ue to improper collection or retrograde
ejac ula Lion.
I lype rspe nnia with more than 5.5 mL means prolonged
abst.inence or inflammation of seminal vesicle.
The most important facwr is the density of tJ1e sperm,
and countS below 15 million/ mL are usually associated
with infenjJity. Oligospermia is mild when the coum is
10-20 million, moderate when 5-15 million and severe
when less than 5 million/ mL spenns a•·e seen.
If one repon shows abnormal findings, the patient should
be instructed to produce another specimen after a momh or
so. During this Lime, tJ1e patient should be advised LO take a
good nuu·itional diet and restrict smoking and consumption
of alcoho l. He should take cold or tepid bath and discard
Light underwear. Only after two negat.ive or below average
co unts, he shou ld be proclaimed azoospennic or o ligosper-
mic. If so, chromosomal stud)' should be done
72 below
average counts
CHAPTER 16 - INFERTILITY - MALE AND FEMALE 207
A few normal spenns and normal testosterone suggest
reu·ograde ejaculation. Cenu·ifugecl specimen can be used
for intrauterine insemination (l UI), IVF.
Postcoital Test (Sims' or Huhner's Test, PCT)
The couple is advised imercourse close to ovulation Lime
preferably in tJ1 e early hours of the morning. T he woman
presents herse lf a t the clinic witJ1i n 2 ho urs after the in-
terco u rsc. The muco us is aspirated from iJ1e ce rvical ca-
nal and spread ove r a glass slide. Another smear made
from iJ1e posterior fornix serves as a control. Normally
10-50 motile sperms are seen per high-power field in
cervical mucous. If there are less than I 0 sperms, proper
semen anal) Sis should be undertaken. The sperms should
show progressive, but not rotatory movementS. The pres-
ence of antispennal antibodies in the cervical mucous
leads shaky or rotatory movementS to tJ1e sperms or may
totally immobilize them. The cervical mucous is simulta-
neously exam ined for iLS quantity, viscosity and fern test.
T he advantage of this test is iJ1atthe cervical mucous can
be simul taneo us ly s tudied for oes u·ogenic effect and ov u-
lation, iLS capability to allow sperm penetration and th e
presence of any an tisperm antibodies. The test is useless
in the presence of cervical infection, which sho uld be
treated before performing the postcoital test. Immuno-
logical facLOr is encountered in 5 % cases. This test is less
emplo)ed lately, and many gynaecologistS consider this
obsolete. This is because the)• resort to I Ul, if semen
analysis is abnonnal. Miller kuryrok
A test called the Miller-Kurzrvk test consistS of placing
ovulation mucous on a glass slide alongside the specimen
of the husband's semen and studying the penetration of
sperms under iJ1e microscope. Normal cervical mucous
permitS invasion by motile sperms. Penetrat.i o n less iJ1an
3 em at30 minutes is abnormal.
Sperm Penetration Test
The physiological profile of the sperms can be studied in
vitro b) using the zona-free hamster egg, which resembles
the human ovum. A normal spenn is capable of penetrating
the LOna-free hamster egg, showing iLS fertiliJ:ing capacity.
The test is expensive and not reliable.
Sper·m agglutination testS, immobilil8tion testS and
immunoglobuli n specific assays are avai lable to detect
immunological defectS in the semen.
Semen-cervical Mucous Contact Test
Equal quantit)' of semen and mucous is mixed, so iJlat there
is no interface. In the presence of antibod ies more than
25% sperms show jerky or shaky movements by 30 minutes.
The cross-d1eck with the donor semen will indicate
the source of antibodies, whether it is cervical or seminal
antibodies.
'Ji!!.tiwlar biopsy. Testicular biopsy is indicated in
aLOospermia to distinguish between testicular failure and
obstruction in the vas deferens. It also re,•eals whether iJ1e
seminiferous tubules are no•·mal but unstimulated by tJ1e
anterior pituitary gland, or whetl1er tJ1 ey are incapable of
function clue to p rim a •) ' gonadal fai lure. Tes t.i cul ar b iopsy
wi ll estab lish whi ch of the facwr is at fau lt (Figs 16.3 and
16.'1). The biopsy can also diagnose genital tuberc ulosis.
The tru-cut biopsy under local anaestJ1esia is simple tO
208 SHAW'S TEXTBOOK OF GYNAECOLOGY
Rgure 16.4 Testicul ar biopsy. Tubular atrophy showing the Sertoli
cell s only (x250). (Courtesy: Dr Sandeep Mathur, AIIMS.)
perform. One to tJ1ree per ce nt ma les have e ndocrine
dysfunction. In recent tlw has a very big
role to f>l«)•. IIJmrt from chromosom(l[ and histolo[.,riWl st·tuly, the
testicular in assisted -ref>roduc-
tion. The sperma tozoa as we ll as spe rmatids exu·acted from
tl1e testicular tissue ca n be used in imrac ytOp lasmic semen
insemination (ICSI) in assisted reproduction. Sperm mor-
phology is studied b) preparing a slide, air-drying, fixing it
witl1 70% alcohol and staining with Pap stai n.
FSH level. A high FSH level denotes primary gonadal
failure. A normal level in uoospermia suggesiS obsu·uctive
lesion in the vas or epidid) mis. A low FSH level indicates
pituitar)' or h) potl1alamic fai lure and a need for FSH/ LH /
Gn RH u·eaunenl. Prolactin level more than 30 ng/ mL
indicates h) perprolactinaemia requiring u·eaunenL Low
testoste•·one IC\el indicates low LH or Leydig cell dysfunc-
tion. No •·esponse to GnRJ I suggesiS pituita•)' failure.
Chromo:.o11UJl 5/udy. Ka•')Otyping should be undenaken in
azoospennic men, as 15%-20% of t11em have chromosomal
disorde•:s. The most common disorder is Klinefelter
syndrome witl1 47XXY ka •)'Otype.
l mmwwlogiml A recent interest in immunologi-
cal aspects of infe 11.ility has led to the detection of various
sperm antibodies, both in the se minal plas ma and in the
cervical mucous. Immuno logical factors may be important
aetiologicall y in up to 5% of patients witl1 male infe rtili ty.
An immuno logical test is req ui red in of an abno rmal
postcoital test, abnorma l semen profile and unexp lained
infertili l)'. ELLSA and RIA LeSts determ ine antibodies to
sperm, seminal p lasma and ce rvical secretion.
Ultrawwul The ul u·aso und scanning of the
scrotum deteciS SCI'OLal volu me a nd varicocele and is useft.LI
in ultrasound-guided biopsy. Colo ur flow Doppler and scro-
tal thermograph) detect varicocele.
• Vasogram. It is required when normal FSH level is associ-
ated witl1 at.oospermia to rule out obstruction in the vas.
• Urine examination. In suspected reu·ograde ejaculation,
postejaculatOI') urine is made a lka line and centrifuged.
The presence of spenns in the lll·ine proves retrograde
ejaculation.
• Fragmentation of sperms suggests infec tion. Chlamydia!
and other infections sho uld be investigated.
• Sperm fertilization poten Lial.
In !VF. tl1is test is useful in selecting the best spenn for
fertilization. This is called h) p<K>smolic swelling test (HOS).
The spenns are u·eated witl1 h)p<K>smotic saline. If the
spenn membrane is intact, the sperms swell up and coiling
occurs. These are the best spenns.
MANAGEMENT OF MALE lNFERTlUTY
Management is based on t11e assessment of coital function,
semen examination repon and the result of tl1e postcoital
and immunological tests, as well as hormonal repo•·IS
(Fig. 16.5).
!. Ed ucation. This involves: (i) sexual counselli ng- coital
frequency and timin g, (ii) coital position and (iii)
masturbation leading tOsperm d ilution.
2. Substance ab use. Advi ce on avo idance of tobacco (smok-
ing, chewing), modera ti on in co nsump tio n of alco hol
a nd avo idance of drug ab use. Antioxidants, vitamin E
imp rove semen parameters. Pentoxifylli ne 400 mg Li.d.
imp roves sperm mo ti li ty.
3. Red uce heat around tl1 e scro uun. Avo id ho t baths, wear
loose cotton 1mderwear (cotton clotJ1ing LO enco urage
ventilation) , avoid stren uo us aCLivities and occupation in
hot environment and control obesity.
4. Correct endocrinopatl1ies. Prompt attention to diabetes
and tl1yroid disorders.
5. SLLrgical. Surgical correction of varicocele after t11e diag-
nosis has been confirmed on ultrasound scan ning helps
tO improve spenn motilit). Though recently percumne-
ous embolit.ation of va•·icocele is atLempted, damage tO
the testicular artel')' and recun·ence of \ll\l·icocele make
microsurge•')' the gold standard and the best option for
\'llricocele. Lately, tl1e beneficial effect of \ll\l·icocele sur-
gery is questioned by many who feel that the surge•')' for
correction of valicocele has no rol e in improving male
infertilit)'· Surgical con"ection of the undescended testes
in childhood improves the semen quali ty in 60%-70%
cases. The obstruction in the vas by mi cro surgical vaso-
vasal or vaso-epididymal anastomosis wi ll restOre patency.
Ephedrine 60 mg orall y four Limes a day for 2 weeks or
a-adrenergic drug such as phenylep hrine (2.5 mg) is
tried in retrograde ejacu la Lion. If tl1is fa ils •-econsu·uctio n
of the b ladder nec k is reco mm ended. in
the reversal ofvasecLOI'n)' operation yie lds a poor res ult if
an interval of more tlHin 5 years has e lapsed s ince vasec-
LOm)', because of the forma tion of sperm antibodies.
6. Antibiotics. Infec tion ind icates the need for appropriate
antibiotics to treat prostatitis and
sexually transmitted diseases. Doxycycline 100 mg b.i.d.
for 6 weeks is beneficial for chlamyclial infectio n.
7. Role of oxidating su·ess on sperm func1jon t11rough pro-
oxidants liberated b) leuCOC)Les, and ab normal spenns is
now reali£ed. Some have observed improved spenn
coLUH b) prescribing I)COpene 2 mg daily and vimmin E.
AntioxidaniS contain vitamin E 100 mg, C 500-
!000 mg, -acet) lcysteine 200-500 mg Li.d., carniline
3 g daily, selenium 225 mg, pentoxif) lline 400 mg Li.d.
L)copene 2 mg daily for 6 months is repo•·ted to
 CHAPTER 16 - INFERTILITY- MALE AND FEMALE 209

I Male Infertility I
1
I Semen examination

I
l 1
[ Normal
findings ] r
Abnormal
findings l
1
1 I Investigations J

l lUI
3-6 cycles

!
I 1 1
If sperm count> 10
million/ml
Hormonal.
FSH, LH, E2,
I Ultrasound I I Biopsy I
• Without ovarian prolactin,
stimulation testosterone
• With clomiphene I
or letrozole
• WithhCG

I Failed lUI I I Correction I

!
I Failure I

I ICSI. If count O.Sx 106,

I
IVF.
If count> 1 o6 progressive sperms
progressive motile
05×106
sperms
progressive
<
KSI
Figure 16.5 Management of male infertility.

IVF 106
progressive
>

improve quality of the spenns and preo.·e m spenn 0 A
damage, but data-based eo.•idence is lacking at presenL
8. Premature ejaculation. Selective serotonin reuptake
inhibitors take 2 weeks to reach the therapeutic level, but
dapoxetine works within I hour; 30-60 mg is taken
I h our befo•·e imercolJI-se.
9. Hormon es. Testosteron e, piwitary honn ones and GnRH
h ave all been u·ied to improve spenna10genesis with
variable res ults. Bromoc riptin e is useful in hyperprolacti-
naemia.
HORMONAL THERAPIES FOR MALE INFERTIUTY
I. 1-ltunan cho rionic go nadotrop in (hCG) 3000 IU i.m.
thri ce wee ki)' for 12 weeks. Alte m ati ve ly, 5000 IU twice
weeki)' may be given. l...'\tely 2500 IU dose has been rec-
ommended. The reafte r, 37.5-75 mg FSH subc utaneous !)'
is added thrice a week. Follow-up wi Lh testosterone level
and seme n analysis. It takes 6-9 months to prod uce nor-
mal seme n co un ts. Stop FSH, but continue hCG.
About40% pregnancy •-ate is reported.
2. Testosterone- An oral daily dose of25-50 mg improves
testicular function. A larger dose of 100-150 mg daily
suppresses spermatogenesis. After a 3-momh course of
treatment. rebound phenomena occur with improved
spermatogenesis.
3. Clomiphene- A daily dose of 25 mg for 25 days followed
by •·est for 5 days is gi,·en C)clically for 3-6 cycles. It is
recommended in h) pogonadal infertility, but is not
effective in h)pogonaclal h)popiwita•·ism. Instead of
clomiphene, letrowle 2.5 mg may be e mplo)ed.
4. Human menopalLSal gonadou·opin (hMG) 150 IU thrice
a week for 6 months is recommended in pituita•)'
inadequacy, but it may take as long as I year to induce
spermatogen esis.
5. GnRH- is indicated in hypoth ala mi c failure.
GnRH 5-20 meg subcuta neously 2 h ourl y for 1-2 years.
Nasal spm y is also available.
6. Tamoxifen- A daily dose of I0 mg for 6 months has been
found effective in so me cases.
7. Dexa me th aso ne- A dail )' close of0. 5 mg o r 50 mg pred-
nisone daily fo r 10 da)'S in eac h cycle for 3-6 months is
recomm ended in the presence of spennal antibodies.
About 25%-40% pregnancy rate is obse rved, Lhough
avasc ular necrosis (AVN) of th e head of Lhe fem ur and
osteopenia as side effecLs have to be borne in mind in a
prolonged therapy. Cyclosporin A- A daily dose of 5-10
mg/ kg for 6 monLhs is better than corticosteroids in
T-cell suppressio n. If corticosteroids are contraindicated,
an anli-i nflammatO I)' age nt such as naproxe n 50 mg
twice dail) ma) lower the antibody levels.
8. Sildenafil (Viagra)- A dose of25-100 mg I ho ur before
imercourse imprO\es erectile functio n but recem repons
o n ischaemic heart disease is alarm ing, and should be
presc1ibed with care. Colour ' 'isual disLu•·bances,
headache, rhinitis and dyspepsia have also been re-
poned. It is contraindicated in men on antih)penensive
210 SHAW'S TEXTBOOK OF GYNAECOLOGY
drugs. Sildenafi l dye is used only in erectile dysfunction,
and does not improve libido. With 25-100 mg orally
1 hour before imercourse, the effect lastS for 1-2 hours.
The drug is effective in 50%-SO% cases. It is contraindi-
cated in the following:
• Retinitis pigmentosa.
• Diabetic re ti no palll).
• Patient on antih)penensive drugs, nitrates.
• Cardiac disease, m)ocardial infarct, stroke.
Local self-it1iection of \'li.SOOCtive drugs for erection is
taken 5-10 minutes before intercourse and is 50o/o-
70% effecthe. Side effects are penile fibrosis, infection
and prolonged erection. Prostaglandin E1 causes pe-
nile vasodilatation. Urethral pellets are also available.
Penile vasctdru·surgery and penile proSthesis im planta-
tion rods are also available for erectile dysfunction.
Pe nile implant AMS 700 is three-piece inflatable pe-
nile prosthesis whi ch is now available.
9. Artificial insemination. An artificial insemina ti on with
husband's semen for four cycles yielded 30% overall
success witl1 10% success pe r cycle. T he resultS are better
if co mbined witl1 ovul ati on inducti on for multiple ov ula-
tion, and this is tJ1c practice recommended today. lt is
indica ted in the fo llowing:
• Chronic medical disorder.
• Oligospermia im potency- ejac ulatory failure.
• Pre mature ejac ulatio n, re u·ograde ejac ulation.
• Hypospadias.
• Antispermal antibodies in tJ1e cervical mucous.
• Unexplained infertilit).
• It is also possible to free.te the semen if tl1e husband is
a frequent traveller and not available at the time of
ovulation for lUI. The semen can also be frozen and
used later in case the husband needs to undergo radio-
therapy or chemotherap)'·
• HI V-posithe male or female.
Techniques used for artificial insemination include
(i) intrauterine insemination (lUI) (ii) intracervical, (iii) peri-
cervical and vaginal and (iv) vaginal insemination. The se-
men is washed, concentrated and its quality improved by the
'swim-up' technique or by use of Percoll gradienL The semen
\\i th notm al spe rms witJ1 good moti li ty Ull.tS obtained is then
inseminated into tl1e female ge nital u·acL Obviously, artificial
insemination is done aro und ovul ation. About 1/2 mL of
semen is iJ'!jec ted 36 hours afte r hCG injection
whe n tl1e ovarian follicle reac hes 20 mm. Semen wash ing re-
moves tl1e abno nn al sperms, sem inal containing anti-
bodies and otl1e r debris, as we ll as prostaglandins.
I Ul is nonnally done once around ovulatio n, some
prefer to do twice in eac h cycle. lUI is repeated up to 3-6
cycles. The lUI should be done witJ1in 90 minutes of collec-
tion of semen, for optimal resu lts. Prophylactic progester-
one is recommended to tJ1e woman in tJ1e luteal phase.
The artificial insemination witJ1 donor's semen is now
legalized in India and should on ly be undertaken in infenil-
ity centres after appropriate counselling and explanation of
itS implications to botJ1 the parlllers.
Indications are as follows:
• ALoospennia.
• Immunological factors not con·ectable.
• Genetic disease in tJ1 e husband. Homozygous Rh -positive
husband witl1 previous pregnancy losses.
• Chronic ill healtl1 and disease.
The donor for insemination is screened for H IV, sexually
u-ansmitted infection and hepatitis B, and good quality of
semen confirmed The froLen semen is sLOred for 6 months
LO minimi.te HIV transmission. If tJ1e donor remains HIV
negative b)r tlle end of this pe•·iod, tlle insemination is
thawed and used.
Management of Azoospermia
Obstructive aLOospennia requires vasogram to study tl1e site
and nature of blockage. Vaso-vasal an astOmosis has been
successful in a few cases. The advantage of surge•)' over
ICSI is that it is a one-time treatment and cost effective, if
successful with permanent effect. Subsequent spo ntaneous
pregnancies are possible.
Five per cen t ma les suffer from azoosperm ia. Depending
upo n its ca use, especially in hormonal defic ie ncies, GnRH
a nd pituitary horm ones have been used LO induce
spermatogenesis.
Other methods of trea tme nt for ma le infertility are as
follows:
• IVF.
• Gamete inu·afallopian transfer (GIFT) techniq ue.
• Microassisted fertilization (MAF ) techniq ue.
• Microsurgical epidid)mal sperm aspiration (MESA) or
percutaneotLS epidid)lnal sperm aspiratio n (PESA).
• Testicular biops). sperm reuieval and MESA supersede
otJ1er metl10<ls in modern u·eaunent of male infenilicy
and wilh improved success. Even spermati<ls have been
utili.ted in assisted reprO<Iuction.
IVF
In tllis, induction of ovulation is done witJ1 clomiphene,
FSH/ LH or GnRH depending upon tlle woman's response
LO tlle drug. The aspiration of mature oocytes is done under
ultrasonic guidance. The oocytes are kept in tl1e specific
culture for a few h our-s, to complete oocyte matUt-ation.
About 50,000 selected sperms are used for insemination .
About 18 h ow'S afte r insemination, oocytes are observed
for tl1 e presence of pronuclei (sign of ferti li za ti o n) and
cultu red for a further 24 hours. At two- to four-cell stage,
two embt)'OS are u·ansferrecl (e mbryo transfer [ET)) into
the uterine cavity I em be low the fundus. T he woman is
a llowed LOgo home 2-3 ho urs fo llowing ET. T he indicatio ns
for IVF are as foil ows:
• Idiopathic or unexpla ined male a nd fema le infertility.
• Immu no logical factor in male and fe male.
• Blocked fallopian Lubes or failed tubal surgery.
• Failed intrauterine or fallopian insemination.
• Mild endomeu·iosis.
• Abnonnal semen findings.
• Donor semen or sperm.
The indications for fVF are expected to expand witll a
t-apid improvemem in its success and improved ted1nology.
ComplicaJio11s. Apart from h) pet-stimulation S) ndrome,
multiple pregnancy and its complications, IVF can cause

ectopic pregnancy in 5% and heterotrop ic pregnancy (ectO-
pic + uterine) in 0.4% of cases.
Three to four C)cles of IVF )-ield 15%-30% pregnancy
rate. The best results are seen in women with blocked tubes,
whereas poor results are seen in oligospermia, teratOsper-
mia and asthenospermia. Some clinics claim 40% and above
success rate with IVF.
Although IVF avoids laparoscopic surgical procedure
and general anaesthesia, and gives considerable infonna-
tion on fe•·tili.tation process, it requires an expensi\'e and
an elaborate laboratory establishmenL IVF is a costly
therapy not affordable to many couples. Because of multi-
ple pregnancy ensuing from two ETs with associated
increased fetal loss through abortion, ectopic pregnancy
and preterm delive1-y, many European cemres believe in
only one ET at a time, Ll1ough it takes longer for the
woman to conceive. T he cost of IVF therapy and the older
age of women see ki ng assisted rep rod uctive Ll1erapy in
Indi a have co mpelled Ll1c IVF specialis ts LO continue to use
two-ET meth od as of toda)'·
Gamete l nu·a Fallopian Transfe r
GIFT was fi rst descri bed by Asc h e t al. in 1984 . It invo lves
asp irati on of oocy tes following ovu lation induction e ither
laparoscop ically or under ultrasoun d guidance transvagi·
nail)'· Laparoscopic rome is preferred as it is a n)<way
req uired for sperm and oocyte transfer into the fallopian
tube. Two hours before asp iration, the semen is prepared,
washed from the seminal plasma and left in culu.u·e medium
at 37•c. The OOC) tes (two per tube) are mixed with 50,000
spenns and transferred to each ampullal')' portion of the
fallopian tube 4 em from Ll1e fimbria! end. The volume
transferred is 10-20 microns.
GJFr technique allows in vivo fertili.tation in the natural
site (fallopian tube) unlike IVF, but needs laparoscopy tech-
nique (invash·e). It is not a common!)' done procedure now.
Lately, u-ansfer of OOC) tes and spenns is aLtemptecl by
transute•ine catl1eteri.tation of Ll1e tube (fulloscopically)
and lapa•·oscopy is avoided.
The intlicationJ for Gl as follows:
• Unexplained infertility.
• Failed IU I.
• Male infertility.
• Immu nological factor in male.
• Immu no logical factors in Ll1e cervix.
• Do nor seme n req ui red (rare).
Bo tl1 the fa llopian wbes must be pate nL T he results
are beuer with GIFT Ll1an IVF, i.e. 45% success versus
15%-20%, but s uccess rate with IVF is imp roving; besides
laparoscop)' is not requi red. Abo rtion rate of 10%-15%,
ectopic pregnancy (7%) and multi ple pregnancy (20%-
50%) have been reported witl1 GIFT
Disadvantage- fertilization cannot be con finned.
MAF in vitro. These sophisticated expensive
ted111iques are needed for the following reasons:
• rVF or GI}T fails due to fertili.tation failure.
• lmmunologicall) de•ived infertility.
• Spenn binds to Lona pellucida but fails to penetrate
due to either spennal antibodies or antibodies to zona
pellucida.
CHAPTER 16 - INFERTILITY - MALE AND FEMALE 211
• No or weak binding of sperm to zona. This may be ca used
because of receptor defect on the zona, enzyme digestive
defect or defective spenn motility.
• Oligospennia and asthenospennia.
Zona drilling (ZD) to allow spennal penetration has not
been successful.
Partial LOnal dissection (PZD) or puncture followed by
insemination has produced pregnancies, but pol) gamy and
abnormal embqos ha,·e occu•·red.
Sub.wnal insemination (SUZI) into pe•·ivitelline space is
useful if the spenns are immotile or have reduced motility.
ICSI is indicated and proved successful in case of immo-
tile sperms and spenn countless than 5 million / •nL with a
pregnancy 1-ate of30%-40%. A single sperm is inj ected into
the cytoplasm of Ll1e oocyte (under microscope), whid 1 is
then incubated overnighL
Indications for ICSI arc as follows:
• Sperm co unt less Ll1an 5 mi ll io n/ mL.
• Abse m or reduced sperm motility.
• Abnormal sperm morp ho logy.
• Previous IVF has failed.
• Unexp lained inferti lity.
• Failu re to peneu·ate zona b)' sperm as seen in IVF.
lifJididyllwl or or biopsy. This is the latest
technology employed in a:t.oospermia caused by blocked
vas. The former can be done under local anaestl1esia, but
testicular biops) requires general anaesthesia.
Cryopreservalion of semen of Ll1e husband and emb•-yos
for ft1ture fertilit) is required if Ll1e man has to undergo
radiation or chemothe•-ap) for malignancy. Altemately,
epidid)lnal or testicular aspi•-ation technique is employed.
In the Iauer situation, repeat aspi•-ation can be avoided
and spenns cryopresened. ICSI now supersedes LOnal tech-
niques because of following reasons:
• It is more successful in improving fertility.
• Spem1atowa as well as spennatids can be employed.
• Histopatl1ology and karyotype study is possible.
• C•·yoprese•vation saves cost and su·ess of repeated perfor-
mance in each cycle.
T he low success rate is atu·ib uted LO older age of th e
wo man undergoing Ll1e proced ure. Beca use of Ll1e cos t and
stress of Ll1e proced ure, wo men op t fo r U1ese o nly if o th er
me tl1ods fa il.
We have co me a long way in ma le infe rti lity fro m initial
donor insemina tion, artific ial insem inatio n of washed
semen to IVF and ICSI with improved success.
Psychological Considerations
The discovery of infertility or sterility can create shock,
fear and depression in Ll1e couple. Some feel inadequacy
and shame of not being able to reproduce (Fig. 16.6).
Some lose Ll1eir self-esteem and feel U1e social disadvan-
tage. To add to this. the su-a in of investigations and treat-
ment increase the financial burden not affordable LO
all. S)lnpathetic and respectful attitude b)• Ll1e medical
personnel will help in dealing "ith the infe•·tile couple
during their consultation.
212 SHAW'S TEXTBOOK OF GYNAECOLOGY

0
Infertility
Table 16.2 Female Infertility: Causes, Investigations
and Management
Frustration, Ovulatory dysfunction
fear, depression, Tubal spasm Aetiology Investigations Management
anger Coital infrequency
Impotency Tubal Hysterosalpingogra- Adhesiolysis (Lap.)
Emotional Ejaculatory problems cause phy or sonosalpln- Tuboplasty
stress gography Hysteroscopic
Figure 16.6 Psychological problems in infertility. Fafloscopy cannulat ion and
Salpingography balioonoplasty
Laparosoopic
chrornotubation If failed or not feasible
Impotence caused by fatigue, drugs, multiple sclerosis
and diabetes needs correction. Similarly premature ejacula- IVF/Gif-
tion needs physiotherapy and psrchological counselling. Ovulation Ovulation monitor- Clom iphene, letrozole
Erectile failure can be improved by the foll owing ing by ultrasound
metl1ods: (BBT, BBI) Failed
• EB for t uberculosis
I. Local of alprostadil (p rostaglandin ) into the FSH , LH, GnRH
penile vesse l. £ rec ti o n occ urs in I 0 minutes and lasts for Abnorm al
half an ho tu·. T his is pa inful, ca n ca use infection and ! t
Hormonal study Posit ive No response
fibrosis, besides being cli ni call y im practicable .
• FSH, LH, Prolactin
2. Vacuum pump is app lied LO the ti p of the pen is to draw Response If failed
• E2, P level
blood into iL • Thyroid and diabetes IVF Donor egg
3. Prostagland in pellets are inserted in the uret11ra and the
penis is massaged. Adoption
4. Silicon cylinder prosthesis is imp lanted in to the penis. Other Ultrasound, MRI, SSG, Treat the cause
causes hysteroscopy
Compared to the above methods, taking Viagra tablet is
easy. bearing in mind its side effects and contraindications.

FEMALE INFERTILITY u-act ca11 be found on examination. In primary vaginismus,

lnfertilit) can be due to some factOr in female parmer. In
case male is normal, one begins with investigation
of female pa•·mer.
AEllOLOGY
The causes of female infertility are shown in Table 16.2 and
Fig. I6.7:
I. D)'spareunia and vaginal causes.
2. Congenital defects in the genital tracL
3. Infection in t11e lower genital tract.
4. Cervical factors.
5. Uteline ca uses.
6. T ubal factors.
7. O vulatory dysfuncti o n.
8. Peritoneal causes- ad hesions, e ndome u·iosis.
9. C hronic ill healtJ1- especially Ul)•roid d)•Sfunctio n.
10. Hormonal - p illli Lary gland d)•Sfunclion, hyperprolacti-
naemia and hypothalamic d isorders.
II. Hypo tl1 yroidism.
VAGINISMUS
Vaginismus is regarded as h)'Peraesthesia which leads to
spasm of t11e sphincter vagina and the levator ani muscles
dLUing attempted coitus or when an attempt is made to ex-
tlle patient vaginally. In p•·imary vaginismus there is
no organic lesion present, whereas in secondary vaginismus
some ob,·ious painful lesion in the region of the genital
when tlle patient is being examined and an attempt is made
LO inspect tlle ,•ulva b) sepa•-ating the labia, a muscle spasm
is induced whereby t11e thighs are ch-a" n wgetller, the leva-
tor muscles become tonically conu-acted and the paliem
cries out and endem·ours to push the medical aLLendam
away from her. In secondary 'oaginismus, a minor degree of
spasm is induced by painful local lesions such as small
infected lace•-alions oft11e hymen, uretJ1ra l caruncle, vulvitis
or a sequela of vaginal operations for tJ1e repair of prolapse
when, as a result of the operation, the calibre of t11e imroi-
tus and t11 e vagina is narrowed. T he ope•-ati o n scar is
naturally sensiti ve for so me weeks after the repair, and pre-
mature auempts at coiws arc painful. It is thus easy for
organi c dyspareunia to lead LOa protective in o rder
tO avoid t11e pain of coiws. The spasm is no t unlike that seen
in primary vaginismus, altJ1ough it is neve r of t11e same
degree. Removal of the ca use will cure this co nditio n,
whereas true vaginismus req uires a pro longed t11 erapy and
the resul ts are not a lways satisfactory.
Typical primary 'oaginism us always a psychone urotic
basis. Frequently, a history of mental tra uma d uring ado les-
cence can be traced, and in most women witJ1 vaginismus,
there is a subconscious dread of sex ua l intercourse. This
anxiety neurosis is all too often tJ1e result of e ntJ1 usiastic but
a ciLUnsy technique on tJ1e pan of her husband, dating from
the time of the first consummation of her marriage. Some-
Limes, it dates from a guilt complex engendered by an
cla11destine and exuamarital association.
lf tlle patiem suffering f•·om 'oaginismus is examined un-
der an anaestlletic, bimanual pehic examination will most

I Pelvic causes 5% I
Endometriosis
Adhesions
Cervical factor 5%
Fibroid, synechiae
TB, malformations
Rgure 16.7 causes of female infertility.
li ke ly reveal no orga ni c ab no rma li ty whatSoever: T he capac-
ity and calibre of tJ1e vagina is no rma l and it easily admits
rwo fingers. Occasionally, the hyme n is incompletely rup·
tured and tJ1 e inu·oiws inadeq uate!)' d ila ted, but these find-
ings are rare and their correc tion by plastic en large men t,
tl1o ugh logical, does li LLie to relieve the subseq uent spasm
because it is psychogenic rathe r than organ ic. Fortunately,
vaginismus is rarely e ncounte red in the recem times.
TREATMENT
The first essential of treatmenL is to win tl1e confidence
and cooperation of both husband and wife, ime1v iewed
separate!). The imeniew demands great tact a nd experi-
ence, a nd is time-consuming, but if conducted correctly is
most rewarding. Once the confiden ce of tl1e couple is won
over, ilie true cause of the trouble will usually be disclosed,
and simple instruction in iLS rectifi ca tion may often suffice.
lf the patient is obsessed with t11e idea that her geni tal
tract is maldeveloped, she should be examined under an
anaestl1etic. At tl1is exa mination , t11 e nonnal ity of her lower
genital u-act is con firmed. The vagina is stretChed w iliree
fingers after whi ch a la1·ge plastic dilator is inserted.
'vVhen the patien Lrecove n; from t11e anaesthetic, this large
di lator is removed and its visual presence demonsu-ates to her
beyo nd argum ent Ul<\L her vagina is of a norm al capacity. She
is tJ1 en insu·ucted b)' demonstration to pa\is a slightl)' smaller
di lator and is supplied with one to be introd uced at will every
clay at home LO ga in e nough confidence and overcome any
tmfounded fears. The regular of the d ilator should
co nvince her that t11ere is no obsu·uctio n to coitus.
lf a rigid hyme n appreciated as a sickle-like band
resistam to stretching is enco untered under anaesthesia,
tl1e operatio n of perineotomy (o r Fenton's operation)
sho uld be perfonned. A lo ngitudinal incision is made in the
midline through the lower Ll1ird o f Lhe posterior vaginal
wall and skin of the perineum. After undercutting the
tissues o n each side a nd dividing the supe rficial muscles of
tl1e perineum, the wound is dosed b)' inte 1-rupted suLUres so
tl1at the scar lies tmns\'ersely. The incisio n should be made
of a lengtl1 such that the ' "'gina! o 1·ifice subsequenllyadmits
iliree fingers. After tl1is operation of plastic enlargemem of
CHAPTER 16 - INFERTILITY - MALE AND FEMALE 213
I Unexplained infertility 15%
Ovarian 30-40%
Dysovulatory
- Anovulation
-Corpus iuteum insuHiciency
the inu·o iLus, it is useful LO pass a med iu m-sized plastic
di lator da il y, and tJ1 e patie nt is suppli ed witl1 one for use.
Coitus sho uld no t be a uc mpted until the pe rineowmy
wo und has healed so undl y, usually in 3 or 4 weeks.
Botulinum ne ui"'tox in t)•pe A into levato r an i
muscle 4 weekly improves vaginism us.
DYSPAREUNIA
The te1m is loose!) tLSed for d ifficult as well as
painful coitus. The following classificatio n of the caLLSes of
dyspa reunia is suggested.
DUE TO THE MALE PARTNER
• Gross congenital abnonnali ty of the penis.
• im potence, usually partial, e.g. failure to maintain an
erection long enough for peneu-ation.
• Premature ejacula Lion.
• Complete and surp1ising ignoran ce in the technique of
coitus.
DUE TO THE FEMALE PARTNER
1. Painful lesions in the region of the imroitus, such as vul-
vitis (ac ute and chron ic), ure thral ca runcl e, Banholi n 's
cyst or abscess, Le nder sca r from obstetric traum a or
operati on a nd pa inful lesio ns of t11 e ana l canal, notably
fissures.
2. Obsu·uctive co nditio ns at tJ1e vaginal imroiws :
• Rigid or imperforate hymen a nd painful ca runculae
m)•rtiformes giving rise to spasm.
• Narrow inu·oiLLLS d ue to congenital hypo plasia, krauro-
sis or lichen sclerosus - poor lubrication in a meno-
pausal woman.
• Traumatic ste nosis due to obstetric inju ry followed by
scarring, such as painful episiotomy scar, Lightly sewn
pe1·ineal Lear or perineon·haphy opera tio n, mutila-
tion. vulvod) n ia and vuh<ar vestibulitis.
• Cicau·iatio n due to chemical burns.
• The functional spasm of ' "'ginismLLS.
• A large tender Banholin 's C) st is occasionally obsu·uc-
ti\'e Lo en u·y.

214 SHAW' S TEXTBOOK OF GYNAECOLOGY
3. Obsu·uctive conditions above the 'oaginal introiLUs:
• Congenilal stenosis and the \"arious maldevelopmems
-i.e. partial noncanalization of the vagina.
• Acquired stenosis- chemical bums are rare but t11e im-
portant causes here are t11e result of sw·gical operation.
Vaginal h)•SterectOmy a nd pro lapse repairs, Werthe im's
operatio n, radium inse rtio n a nd radia tio n t11erapy result
in a nd s ho n e ning of the vagina. So me times,
the an terior and poste ri o r sul.lll'C lines of a colporrhaph)'
become densely adherem a nd fuse to form a storlt sep-
ttun which allows o nl )' panial pencu-ation.
• Benign and mal ignam tumours of t11e vagina are rare
causes of obstruction. Dry Mgillll in (I menopatual U/()ITUJIL
I. Uterine conditions which are not obsu·uctive but be-
cause the) are painful give r·ise to collision dyspareunia:
• Cervicitis. Chronic inflammatOI") lesions of the
associated with parametritis can cause pain. Deep dys-
pa r'C unia is d ue to:
• C hron ic param etritis a nd parametrial scars.
• Adeno myosis ute rus.
• A fixed re tro ve rs io n assoc ia ted with c h m ni c pe lvic
inflam ma tOI")' disease (PI D).
5. Lesions of th e uterine appendages:
• Prolapsed O\oa ries associated with r·etroversion cause
deep d)spareunia.
• Acute and chron ic salpingo-oophoritis. Ovarian resid-
ualS) ndrome.
• Endomeuiosis of the pouch of Douglas. recwvaginal
sepwm and utemsacral ligaments.
6. Extragenital lesions in the bowel, such as diverticulitis of
the sigmoid colo n us ually ad herent to t11e left appen d-
ages and uterus, and cystitis.
DiHicult Coitus
Difficu lt coitus m ay be ca used by ma ny of t11e same fac tors
that are r·esponsible for painful coiLUs. Lf t11e cause is
insuper-able, such as bony ankylosis of t11e hip in extreme
adduction, consummation may be impossible and the
correct Lel"ln is not dyspareunia but apareunia. The Iauer
naturally occurs severe developmemal defects of the
'oagina such as failure of ('oaginal aplasia).
INVESTIGATIONS
Investiga tions s ho uld be cond uc ted along sim ilar lin es to
that of vaginismus. C linicall)', d )•Spa re uni a is di vided into the
fo llowing:
I. Superficial: T he pain occ urs when pe netratio n is
attempted and the causative lesion is therefore to be
expected at or near the inu·oitus.
2. Deep seated, when t11e pain is not associated witl1
penetration but is felt only after this has occurred and is
usuall) locali.ted in the depth of the 'oagina.
3. Postcoital dyspareunia, a less well-known entity, some-
times associated with t11e deep-seated variety. Here the
patient complains of an ach in g soreness which Lasts for
several ho urs after the completion of the acL
Deep-seated d yspare unia is us uall y o rga ni c a nd is assoc i-
a ted witl1 ovaria n pa tho logy s uc h as prolapsed a nd te nde r
ovaries in associa tio n witl1 re u·oversion, e ndo metriosis or
ch ronic PLD.
KY
jelly
Rljois vaginal moisturize
TREATMENT
The treatment consists in dealing with the cause. Local
abnormalities at tl1e vulva can us ually be cured b) an appro-
priate treaunent, but when dyspareun ia is caused by abnor-
malities in t11e po uch of Do uglas, an abdom inal operatio n
is necessa ry. T he ovaries may be freed fi·o m adhesio ns,
e ndo me ui osis a nd c hocola te cysts ca n be excised a nd
the uterus ca n be fixed in a positio n of a nteve rs io n b)' a n
operation of ven trost.rspension . O esu·ogen ct·eam is effecti ve
in a m enopausal woman.
• K-Yjelly (lubricant) and Rejois vaginal moistur-iLer two to
three Limes a week rel ieves cJrspareunia due to lower
genitalu-acL A postural change ma) help.
• Lignocaine oin unem is an anaest11etic drug that relieves pain.
When all possib le organic causes of the dyspareunia have
been eli m inated, psyc hogenic possib ili ties rnr rst be cons id-
e red; patient enq ui ry may the n e licit the tm e ca use, s uc h as
fea r of pregna ncy, frigidity, ma rital d isha rm o ny o r so me
unhapp)' sex ual experie nce in t11e past.
Congenital Defects in the Genital Tract
Absent or septate vagina, hypoplasia and absent uterus aJ'e
the obviotrs causes leading LO sterility.
Infections in the Vagina and Cervix
Although mild infection may not prevent sperms fast
getting in to tl1e cervical canal, it is prudent to clear the
infection before any therapeutic meas ures are app lied in
treatmen L of infertilit:y.
C hl a m)•d ial cervicitis is now recognized to im pair sperm
func ti o ns (fragme ntatio n) besides ca using bloc ked Lubes
due to PID.
Cervical Mucous
As mentioned earlier, cervical factOr can be assessed by tlle
postcoital test. The test also provides an opporwnity to
assess spenn-mucous inter-action and whether satisfactory
COituS OCClU"S Or noL
• The finding of leucocytes in the mucous is suggestive of
infection commonly d ue to Cul tur'Cs for gonor-
rhoea, Chlamydia trachomatis a nd UrmplaMIUI wl!ao•ticum
may he lp in selec ting the a ppro priate a nti b io ti c for t11 e
trea un e nt of cervicitis. Large e rosio ns a re u·eated with
electrocau tery/ cryoca ute t) '· Post-u·eaun c nt repeaL post·
coital test often sh ows m arked imp rovemenL
• Nonmoti le, nonpr·ogressively motile sper·ms showing a
'shaking' pattem are h ighly suspicious of the presence of
sper·m antibodies aJld aJl immunological cause. Lf aJl
immunological catrse is strspected, the patient's serum
and cervical mucotrs CaJl be examined for the presence of
antisperm antibodies. Lf the cervical mucous is found w
contain antisperm antibodies, the couple is advised to
use a condom or a diap hragm a barl"ier method for
3 mo nths. Duri ng tllis pe riod, the a ntibodies gradua lly
di sappea r, a nd o nce the muco us is fo und to be normal,
co ncep ti o n is a ue mpted. T he prese nce of se ntm a ntibod-
ies has a poor p r-ognosis, and lUI, IVF or GWr tec hni q ue
is offered.

Cervical Factors
The cervix has an active •·ole in the physiolom• of concep-
tion. The position of the cervix and patency ofthe ce•·vical
canal facilitate the entry of sperms into the uterine cavity.
The cervical canal acts as a sperm resen·oir, and capacira-
tion of spenns occurs here. The cervical mucous is alkaline
and is suited fo•· the semen. The ciliated cells
active!) select the normal motile spenns and sieve out the
abnormal ones b) phagoc)tOsis. so that only the healthy
feniliLable sperms enter the upper genital uacL The cen•i-
cal mucous at ovulation exhibits characteristic changes
whid1 help in eas) sperm penetration. These cenical factors
are responsible for about 5% of infertility.
Uterine Causes
Hypop lasia, ma lformed uterus and incompetent os cause
hab iLUal abortion more ofte n than infertiliL)'· In pelvic
tuberc ulosis, in add iLion to b lockage of tubes and endome-
u·ial tuberc ulosis ca using As herman syndrome (adhesio ns)
are respo nsible. Ashe rm an syndrome may also result
from other infections, vigorous cure ttage, postabortal and
puerperal infection, as we ll as packing the uterine cavity to
control postpartum haemorrhage.
As he nnan syndrome is classified as follows:
< iii. • Minimal adhesion involves < 25% of the uterine cavity,
flimS)' adhesions involving the fundus and tubal ostia.
25-70 • Moderate adhesion involves 25%-70% of the endome-
→ Fl
'
u·ial surfaces, but no agglutination of the uterine wall.
• Severe > 75% adhesions with agglutination and thick
adhesions in endometl'ial cavity.
The ute•·ine fib•·oids which ma)' account for infertility are
either com ual fibroid blocking the medial end of the fullo-
pian LUbe, submucous fibroid and cervical fibroid distOrting
the passage of the sperms and preventing implantation thus
resulting in infertilit).
Pregnancy rate of 30%- '10% following myomectomy
proves that other factors may be involved apart from the
presence of a fibroid.
Dyssync hrony between the glandular and stromal growth
in endomeui um or endo me u·ium un recep tive to ovarian
hormones ca n prevent im p lan tation.
Tubal Factors
One of the most im portant and co mm onest cause of infer-
ti li ty is tubal factor salpingitis, when as a result of inflamm a-
ti on, ad hesions form arou nd the abdom inal ostium, while
''1thin the lume n of tJ1e tube, tl1e plicae become adherent,
blocking the passage in tJ1e tube. Gonorrhoea and chla-
mydia! infections or salpingitis following septic abon.ion
and puerperal infections are amongst tl1e common causes
of blockage of the fallopian tubes. Genital tuberculosis has
already been mentioned, and endometrial biopsy shows
tJ1at 5% as)mptomatic infertile women suffer from genital
tuberculosis. Apan from tubal blockage, peritubal adhe-
sions and fimb•·ial end blockage can cause infertility.
Weswnn observed that one episode of tubal infection
leads tO tubal blockage in 12% of cases. The incidence
increases to 23% after two episodes of PlO and 54% follow-
ing three episodes.
I 12%
2 231 .
3 541 .
CHAPTER 16 - INFERTILITY- MALE AND FEMALE 215
Ovaries
An ovulation due to endocl'ine disorders, polycystic ovarian
disease (PCOD) and corpus LPDs is one of the importam
causes of infertility. Perioval'ian adhesion in pelvic infection
and luteiniLC<I unrupwred follicular (LUF) syndrome in
9% of cases are also responsible. Luteal phase effects eitl1er
due to deficient progesterone or shorter duration of luteal
phase occur in 3%-1% of infertile women. This defect is
also seen in lVF programme, pituitar) honnone deficiency
(defective folliculogenesis), h)perprolactinaemia, excess
luteolysis, clomiphene tJ1erap) and h)pOUl)TOidism.
Corpus luteal phase defect (LPD) is associated with low
oestrogen and progesterone levels. Oestrogen is responsible
for progesterone receptOI'S in tJ1e endometri um, so low Oes-
trogen and progesterone levels resu lts in poor secretory
p hase. Thus an inadeq uate response in endomeu·ium.
p us LPD means failure of endo me u·ium to exist in the right
phase at the right time. In lu teal phase defect, histOlogy of
endome u·ium lags behind tJ1e day of mensu·uation by 2 days
o r more. Reu·ieval of ova in IVF by punctw·e can disrupt the
gra nu losa cells. DufJh.oston (dydroge:.termU!) i1· an effective t·mat-
ment in tmpus LPD rvitho'ltt m1.1.1i11g rmy rut verse effect on croulatiun.
Subendothelial Layer
A subendothelial layer in the endometri um can be recog-
nized on ulu-asound scanning and MR1, and this layer has
increased nuclear content and vascularity and is under tl1e
influence of ovarian hormones.
Before menarche and after menopause, this zone is
indistinct, so also in oral combined pill users and during
GnRH therap)'· It is prominent in a menopausal woman on
honnone replacement tJ1erapy (HRT).
ln a menstrual C)cle witJ1 conception, pe•·istalsis of tl1is
zone is upwards from cervix to fundus dll!ing preovulatory
phase and ma) help in sperm migration. This Lone becomes
indistinct in t11e poswvulatOI") period and quiescem and
may help in implantation.
ln lVF programme, increased activity of tJ1is zone may be
responsible for failure as well as occurrence of an ectOpic
pregnancy. l
Peritoneal causes. Perituba l and intratubal adhesions by
kinking the fallopian tubes can cause blockage of the tubes.
More im portantly, these adh esio ns are a result of PLO.
T hese ad hesions ca n also2im pair tl1e peristaltic movements
of tJ1e fa llopian tubes. In pelvic endome triosis, macro-
phages in the peritonea l fl uid may engulf tl1 e ov um and
spe rms, preventing ferti li zation.
Chronic Ill Health
HypotJ1alam ic and plllllta rr disease, hypotJ1yroidism and
adrenal corti cal dysfunction are the important causes of
anovulation. Diabetes and llll:>e•·culosis ma)' lead to infertil-
ity. Smoking is known to impair ova•·ian function and
prevent embrro implantation in to tl1e endometrium.
WORK UP OF FEMALE PARTNER
Approach to a female pa•·u1er of infertile couple comprises
the following:
• Hiswry.
• Examinat.ion.
• Special invest.igations.
216 SHAW'S TEXTBOOK OF GYNAEC OLOOY

History cavity and the tubes. If the tubes are patent, the medi tlm wi ll
Age of the woman, past obsteu·ic history in case of secon d- be seen to spill out of the abdominal ostia and cover the
ary infertility regarding puet·peral infection, coital difficulty adjacent bowel. A h)drosalpinx will show as a large confi ned
and mensu·ual histO•)' gi1e clues to the possible cause. mass of dye 1\ithout peritoneal spill. lf either of the tube is
History of tuberculosis and p•·evious pelvic infeclion is blocked, the site can be seen. During the examination,
importanL HistOry of diabetes and th) roid dysfunction may t-acliog•-aphic picwres are taken for pennanem record of
be evidenL The duration of infe11.ility and previous use and the result. A vis COltS \\'liter-soluble solution, 50% iodine witl1
the type of conu-aceptive ma> be linked to infertility. 6% polyvin)l alcohol in water, is the mediwn usually em-
ployed for HSG. It is •-apidl) absorbed. and the •isk of tissue
Examination reaction and adhesion formation in the pelvis is minimal;
This includes height and weight of the woman; blood even when inu-avasated into tl1e utet·ine venoLLS system.
pressure should be checked. llirsutism. palpation of thyroid Altho ugh an oil-soluble medium gives a sharper and dearer
and lymph nodes, palpation of tl1e breasts, tl1e presence of piCLure and may have improved tl1erapeutic effect, it is not
galactorrhoea suggest hormonal dysfunction. preferred beca use of the occurrence of oil gramtloma, peri-
An abdom inal swelli ng may be d ue to uterine fibroid . LOneal reactio n, formatio n of pelvic adhesions and tJ1e need
Biman ual pelvic examination will reveal an obvious gy nae- for a delayed fi lm LObe taken for detec ti ng peritoneal spill
cological cause for inferti lit)'· (Figs 16.9-16. 12). T he pregnane)' ra te isslightl)' be tter with
the use of o il-based media. Bloc kage of tube may be due
Tests for Tubal Patency pre ovulatory phase tO fib rosis (suicture), spasms or inspissa ted amorpho us ma-
terial p lugging the lu me n.
Hysterosalpingograp h)' (IISG) and di agnostic laparoscopy
with chromo wbat.io n a re two comm on ly used tests for tubal
pa te ncy. A mere pa tency of the tubal lum en is no t the only
Ctiteri a to affect fertility. T he normal p hysiological fun ction
of tl1e fallopia n tube is essen ti al for pregnan cy to occ ur.
The endosalpin x is lined by ciliated epithelial cells and the
secretOry cells. T he cilia help in propulsion of the fertili zed
egg LOwarcl5 the uterine cavity. The secretory cells provide
nutrition to the spenns as well as tl1e ovum during their
passage across the LUbe. The pe•·istaltic movements of
tl1e fallopian tube are under the influence of oesu·ogen,
progesterone and prostaglandins, and S)nchronized move-
mentS help in propulsion of spenns and the fertiliLed egg in
either direction. The 01<arian fimb.-iae are spread over the
ovary at ovulation and bt·ing the ovum into the fimb.-ial e nd.
The loss of an) of tl1ese functions could prevent conceplio n.
The tesling of tubal patenC) and detecting tubal pathol-
ogy are done in the preovulatOI") phase of the menstrual
cycle. If performed in the postOvulawry pe.-iod, insufflalion
miglu disturb a fertiliLed or implanted ovum and may also
cause pelvic endometriosis.
Hysterosalpingography Dal Do
Vis ualization of tJ1e uterine cavil)' an d the fa llopian tubes
after injecting a rad io-opaque d)•e in uterine cavity sho uld
be ca rri ed o ut by sc reening with the use of a n image intensi-
fie r in an X-ray roo m us ing a Fo ley Rubin cann ula
(Fig. 16.8) o r Leec h-Wi lkinson cannu la for insufflatio n.
T he investigation is perfo rmed betwee n the e nd of the
menstrual peri od and ovulati on (usuall y the 9tll or lOth day
of tl1e cycle). After th oroughl y cleaning tl1e lower geni tal
tract and with full aseptic precautions, a radiopaque dye is
injected with the help of the cannula into tl1e uterine cavity
under direct vision under a fluoroscopic screen; 15 mL of
tl1e medium is usually adequate to visualiLe the uterine

Figu re 16.9 (A) Normal hysterosalplngogram. Note both the fallo-

Fig ure 16.8 Rubin's cannula. It is used in hysterosalpingogram pian tubes are patent with spill into the peritoneal cavity. (B) HSG
recording: while the dye is instilled into the uterine cavity, the cone showing a filling defect in the uterine cavity which represent a polyp
prevents retrograde spill into the vagina or fibroid. (Courtesy: Dr K K Saxerla, New Deihl)

catcher leech Wilkinson cannula

foleyg
Rubin's cannula
 CHAPTER 16 - INFERTILITY - MALE AND FEMALE 217

R gure 16.10 HSG showing bilateral dilated fallopian t ubes with

no free spill suggestive of bilateral hydrosalpinx. (Courtesy: Dr K K
Saxena, New Delhi.)

Rgure 16.11 Hysterosalplngogram showing unicornuate uterus.

The fallopian tube is patent and dye is seen in the peritoneal cavity.

Bilatera l cornual block with exu-avasation of the

dye is highl y suggestive of tubercular salpingitis. Other
h)-sterosalpingog1-aphi c findings in tuberculosis are de-
scribed in chapter 28.
Apa n from tubal ana tomy, this examination helps to
di agnose co ngenital ab no rmali ties of the uterus, such as
uten.ts bicorni s, arcua te, se ptate uterus and fibroids. HSG
has th e advan tage tJ1a t it gives a perma ne nt record an d
shows the site of wbal blockage. Amo ng its co mplications
are (i) pe lvic infec tio n, (ii) pain and collapse which can
however be avoided by giving atrop ine half an
hour before the proced ure and (iii) a lle rgic reaction. HSG
sho uld no t be performed (i) in tJ1e postOvulatOry period,
(ii) in tl1 e presence of genital infec tion and suspected
genital tuberculosis and (iii) if the patient is sensitive tO Figure 16.12 Hysterosalplngogram demonstrating a bicornuate
iodine. HSG may help to flushing a nd dislodgement of ut erus. The dye which Is present In the peritoneal cavity demon -
amorphous material that sometimes blocks itS lume n. The strates patency of the left fallopian tube.
amorphous material is an aggregate of h istiocytes.
Laparoscopic Chromotubation
shown blocked LUbes (Fig. HU :l ). Apart from
It is laparoscopic 'isualiation of the pelvic structures - of the tubes and oval), peritubal adhesio ns a nd unsus-
uterus, fallopian LUbes and ovaries and injecLion of metlly- pected endometriosis can be diagnosed. The laparoscopy
lene blue through t11e ce rvix to ,·isualiLe tlle spill of dye. It is indicated in patients "ith blocked fa llopian tubes prior
is indicated in infenility cases to establish patency of t11e to undenaking tuba l microsurgeJ)'· In such cases, planning
fa llopian tubes and to ' erify the findings when HSG has of appropriate surgery can be chalked out a nd prognosis
218 SHAW'S TEXTBOOK OF GYNAECOLOGY
Figure 16.13 Hysteroscopic cannulation of the fallopian tube.
offered LO the cou pie. L."'pa roscopy demonsu·ates the ex-
ternal condition of th e fallopian tubes as well as its pa-
tenC)'· lt is, howeve r, a n in vasive proced ure and requires
hospitalization. The greatest advan tage of laparoscopy to-
day is that one can proceed with th e therapeutic proce-
dttre if adhesions or fimbria! block is recognized. Indica-
tions for laparoscop) are as follows:
• HSG showing abnormal findings.
• Prior to planning tuboplast).
• Prior to LUI.
• Prior to induction of O\ulation.
• Removal of h) dmsalpinx p•·ior to IVF.
• PCOD to puncwre the C)'SLS to improve the pregnancy
rate of assisted reproduction and avoid hyperstimulation
S)•ndrome.
• Suspected cases of endomeu·iosis.
Sonosalpingography (SSG)
It is a safe and practical method of evaluating tubal pa-
tency and to stud y t11e uterine cavity. Under ultrasound
scannin g, a slow and deliberate of abo ut 200 mL
of physiologica l saline into the ute rine cavity is accom-
p lished via a Foley ca the te r, the infla ted bulb of which lies
above the inte rna l os and preventS lea kage. It is possible to
visua li ze th e Aow of sa li ne alo ng th e wbe and obse rve it
issuin g o ut as a shower at t11e fimbria ! end. T he ultraso und
scan a lso shows th e presence of free Auid in th e pouch of
Doug las if tJ1 e tubes are patent. lqjec tin g a small amo unt
of air faci litates th e visua liu·uion of air-b ubble movement
in each fallopian Lube.
SSG is also a very good tec hnique for detecting submu-
COLIS fibroid pol)'P and intrauterine lesions. Many prefer
SSG to HSG for following indications:
l. Abnormal uteline bleeding to swdy the e ndometlium
and detect pol) pi.
2. Amenont10ea due LO Ashennan S)ndrome.
3. Pan of infenility im·estigation.
4. Repeated pregnancy losses for utetine anomal ies.
Salpingoscope
Figure 16.14 Falloposcopy and salplngoscopy. The flexible fall opo-
soope is inserted via a channel In an operating hysteroscope, while
salpingoscopy (usually rigid) Is pertormed transabdomlnally during
laparosoopic evaluation of the pelvis.
Newer Modalities of Tubal Tests
T ubal pailiology can be assessed b)' newer diagnostic
techniques. These are as follows: Interstitial end
H ysteroscopy and falloscopy. Whe n HSG shows a
cormtal block, this may be due LO wbal spasm (25%, can be
avoided by prior atrop ine injection), mucotiS or inspis-
sated material (25%), pol)p (10%), synec hiae or istJHnica
nodosa. The interstitial end of t11e fallopian wbe is best
studied b) falloscop) 'ia tJ1e h)Steroscope.
The mucous plug or inspissated material can be flushed
and patenq• restored. POI)ptiS can be removed. To break
srnechiae, a soft pliable cannula is passed through hystero-
scope and its Lip directed at t11e tubal ostium and gradual ly
advanced while breaking t11e flimsy adhesions, and the
fallopian LUbe fltLShed. DeliSI' camwt be dealt wilh in
this way (Fig. 16.11).
Ampullary and fimbria! salpingoscopy. (Fig. 16.15).
Salpingoscopy can be utili :ted to swdy t11e mucosa of the
Figure 16.15 Principles of fertilosoopy: Introduction of Veress nee-
dle into the pouch of Douglas to study the tubes. (SoUtce: From Figure
2. Watrelot A and ChaMn G Current practice in surgery and ad-
he500 management: a raviaw ReprodJclille BoMedcine Onine 23,
53-62, 2011 .)

A
Rgure 16.16 Tubal surgery at t he fimbl'ial end (fimbl'ioplasty).
fallopian wbe to choose tubal microsurgery and fVF.
Colour Dopple r ul trasound fo r assessing wbal pathology is
tmder swdy.
A descendin g test us ing starch is injected imo the pouch
of Douglas. The presence of starch in Lhe cervical mucous
24 hours later indicates patenC)' of one or both tubes.
Laparoscopy is now combined wi Lh hysteroscopy as a
comprehensive one-stop infertility work up, tO detect the
cat.t.Se of infertility and treat the cause in one go. This is now
considered the gold standard in the investigation of tubal
infertilit).
Fertiloscopy (Fig. 16. 111). Following the initial work by
Cordts. fertiloscop) is now introduced as a combined tech-
nique parallel to h)dropelviscopy, and other methods in
infertilit) work up. IL can be done under local or general
anaesthesia.
Fertiloscope consists of two inu·oducers, one for uterine
cavity and the second to study the genital organs through
the pouch of Douglas. The uterine introducer is provided
"1th a balloon for a good seal in the dre test and the vaginal
feniloscopy has tlwee channels.
Technique of fertiloscopy is as follows:
I. Lithotom y position.
2. Local/general anaesthesia.
3. Insertion of Veress needle and creation of hydroperito·
neum wi th sali ne.
4. Insertion of two ferti loscopes.
5. Chromowbation.
6. Inspection of organs.
7. Therapeutic, if it is needed.
MANAGEMENT OF TUBALINFERTIUTY
Tuboplasty
Tubal microsu'1,1l'l)' (Fig. 1(). 16). It is advocated for tubal
blockage. Depending upon the site of block, a ntunber of
tuboplast) procedure have been performed with successful
pregnanC) rates vaq ing from 27% for fi mbrial surgery to
50%-60% for isthmic blockage. The success of tuboplasty
can be imprO\ed "ith (i) gentle handling of tissues; (ii) Lt.Se
of magnification; (iii) a'·oiding mopping or mbbing of the
tissues but using cominuous in·igation and suction to re-
move the clots, and prC\ent desiccation of tissues; (iv) hae-
CHAPTER 16 - INFERTILITY- MALE AND FEMALE 219
mostasis sec ured by ca uter)' or laser; (v) use of fine suture
material (Vicryl, Pro li ne) and (vi) use of Heparin solu tion
for hydroflo ta ti on to prevent postoperative ad hesions.
Restoration of latency of the fa llopian tube should be
checked b)' HSG 3 mon tJ1s later.
The tisks of tubop lasty are (i) anaes t11etic complications,
(ii) postoperative wound infection, chest infection and
embolism, (iii) failure and (iv) a s ubsequem ectopic
pregnancy. OtJ1er indications for surget)' are reversal of
wbectomy, conservative ectopic pregnancy and salpingitis
isthmica nodosa.
Advantages of wboplast):
• One-Lime therap).
• Low cost compared to JVF. Successful surget')' avoids JVF.
• Saves time of repeated ,-isits to IVF centre.
• Subsequem spontaneott.S pregnancies possible if surgery
is successful.
In-vitro Ferliliutlion
Toda)', IVF and £T are offered to women in whom
tuboplasL)' has failed or to women with extensive and
irreparable wbal damage. The overall success rate of
20%-30% is obtained. This is a n expe nsive t11erapy, bu t
may be only hope for severe tubal damage. Contraindica-
tiuns to fVF are ex tensive pelvic ad hesions and inaccessi-
ble ovaries clue to ad hesions- ova re u·ieval in suc h cases
may be impossib le o r da ngerous to the bowels. Laparo-
scopic adhesiol)•s is fo llowed by IVF may be possible.
Normall)•, three atte mpts arc made and if IVF fails, other
MAF processes offered.
Extra embq•os can be cryop reserved for subseq uent
→
WFZ
cycles. MAF
Thbal cannulation done through transcervical route
under hrsteroscopic guidance restores patency in 75% of
cases, and pregnancy rate of 40% is reported if tubal block-
age is due to AimS) adhesions.
Medial end tubal blockage is seen in 10%-15% cases
eluting HSG. Common causes ofmedialwbal block are as
follows:
• Amorphous matet·ial organit.ed as a plug
• inflammatory exudates
220 SHAW'S TEXTBOOK OF GYNAECOLOGY
• Tubal spasm
• Polypus
• Fibrosis by PID, endomeu·iosis, ist.hmica nodosa
Treaunem options for proximal and mid LUbal block are
as follows:
• Tubal cannulation
• Balloon wboplasty
• Surgery- wboplasty
• IVF
Pregnancy rate of20% is reported.
Lateral end block ca n be u·eated by following:
• Fimbrioplasty- 50%-60% success rate
• Salpingostomy- 20%-30% success rate
• Adhesiolysis of external adh esions
Uterine causes, s uch as a septum, As he nna n sy ndrome
and a fibroid need s urgical co rrec ti o n. Most of these can be
treated by operati ve h)•Steroscopy ca rri ed o ut under ge neral
anaesthesia.
TESTS OF OVULATION
BASAL BODY TEMPERATURE
Basal body temperature (BBT) falls at the time of ovulation
by about I/ 2°E Subsequenlly, during l11e progestational
half of tJ1e C) de, t.he temperature is slighlly raised above tJ1e
preovulatol") level, and the rise is of l11e order of 1/ 2-1 •r.
1l1is phenomenon is due to the thermogenic action of pro-
gesterone. and is t.herefore presumptive evidence of the
presence of a funct.ioning corpus luteum and hence ovula-
tion. Accurme recordings "ill therefore indicate whet.her
tlle O\oa•·ian qcle is ovulatory or not and will also denote t.he
timing of ovulation. The patient must be capable of reading
tlle tllermometer to I I I Oth degree. Oral temperatures are
accurate, p•·ovided the patient does not take hot or cold
drinks before taking th e temperature, and t.his should be
done first thing after waking up in the mom in g. The patiem
must be instructed to record tJ1e temperatures on a graph
(Fig. 16. 17). BBT is reu·ospective and does not indicate
impending ovulation and is not useful in IVF. It, however,
does reveal co•p us luteal phase ins ufficiency and defective
fo lliculogenesis.
BBT has now become obsolete because offollowing:
l. Tedious dail)' record ing.
2. Not veq• acc urate.
3. Reu·ospective diagnosis and not useful t.herapeutically.
4. Better moda li ties of ovarian monitoring by ultraso und
being available.
ENDOMETRIAL BIOPSY 112 -
menstruation
Endometrial biops) consists of curetting small pieces of the
endomeu·ium from the uterus wil11 a small endomet.rial
biops) curene, preferabl) I or 2 days before t.he onset. of
menstruation. The mat.erial removed should be fixed
immediat.ely in fonnalin saline and subminecl for hiswlogi-
cal examination. Sec.-etOI)' changes prove tllat.t.he cycle has
been O\'ulatOI)'· The incidence of anovulat.ion varies
Normal cycle
'C
:lllll.lltll
7 u 21 28
'C Pregnancy
. 7 14 21 28
Polymenorrhoea
'C
!fll .l;llll
:::1 111 1 7 14 21 28
An ovular cycle
Figure 16.17 Specimen charts of BBT recordings. Arrows indicate
ovulation time; the dark zones Indicate the days of menstrual bleeding.
bet.ween 10% and 25%. Endomeu·ium should be subjeaecl
1.0 cullllre, PCR and staining to rule out genital tuberculosis,
which is presem in 5o/o-IO% of Indian women complaining
of sterility. Co•pus LPD can also be diagnosed b)' endome-
t.rial biopsy, which shows a lag of 2-3 da)S between t.he
calendar and histological dating of tlle specimen. Enclome-
t.rial biopsy is now omiued as a routine investigat.ion for
infertility and ovulation is monitored by se•·ial ulu-asouncl
scanning. Jilulometrial biops·y il Uthm only in SIL\j:N'ctnl tubercular
elllliJmetritil, wul the tiMJ.te il lllbject('(/ to a PCR test as well as
CJ.dture.
FERN TEST
A specimen of cervical mucous obtained using a platinum
loop or p ipe tte is spread on a clea n glass slide and allowed
to cl•1'· When viewed unde r the low-powe r microscope, it
s hows, du ring the oestrogenic phase, a charac t.eristic pat-
tern offern formaLion (Figs 111. 18 and \ 6. 19). T his ferni ng
d isappears after ovulation, and if previo usly present irs
disappearance is presumptive evidence of corp us lu te um
activity. The ferning is due to the presence of sodiu m chlo-
ride in the mucous secreted under oesu·ogen effecL The
physical character of ce1vical mucous also alt.e•-s witJ1 t.he
elate of the cycle. At tJ1 e time of ovulation, l11e cervical mu-
COLIS is tJ1in and profuse that tJ1e patient may notice a clear
discharge. tJ1e so-called normal ovulation cascade. 1l1is ovu-
lation mucous has the properL) of great. elasticity and will
withst.ancl stret.ching up to 10 em. This phenomenon is
called spinnbarkeit. or the th•·ead test for oest.rogen act.ivity.
During the secretOI)' phase, tJ1e cen ·ical mucous becomes
tenacious and its 'iscosity increases so t.hat it loses tJ1e
thread test
spinnbarkeit /
 CHAPTER I 6 - INFERTILITY - MALE AND FEMALE 221

INFERTILITY
COM PONENTS OF A TYPICAL ART CYCLE

Short (flare) GnRH-a protocol

, 1111111:
CD 1 CD 1

i
uts JsJs]tL
Ovulation
Embryo transfer
,........---------., Harvest, GIFT
• Menses US, hCG
• GnRH agonist
0 Gonadotropins
• l uteal support
Flgure 16.18 Dried cervical mucous showing ferning at the t ime of
impending ovulation.
Long (luteal) GnRH-a protocol

F .. ....

I Js Js JsJ,fL
Ovulation
Embryo
Harvest, GIFT
US, hCG
Flgure 16.20 GnRH protocols.

ruplllre and ovulation occur at miclcycle. The sudden

Flgure 16.19 Mucous secretion during a menstrual cycle.
pro pert) of spin nbarkeit and fractures when put under ten-
sion. This propeny is called tack. The observation of this
change in the mucous pauern in a mensu·ual cycle
is another evidence of ovulation (Fig. l li.20). lnsler
a scoring system which takes into account the various cervi-
cal mucous properties such as the amount, spi nnbarkeit,
feming, viscosity and cellularity. The maximum score is 15
and a score of less than 10 is considered unfuvo urable. Cer-
vica l infection, if any, needs to be treated prio r to perform-
ing tJ1is test. Posteoital test and detectio n of a ntibodies in
tJ1e cervical mucous can be integra ted with this test into o ne
composite study. Ct.Lrrently one does not rely much on this
Lest as a test of ovulation.
DIO -96
ULTRASOUND FOLLICULAR MONITORING
Ultrasound lws 1ww berome the standard and indispensable proce-
dull' for monitoring maturation of tile Crtwfian follicle and in de-
tecting immint>nt ovulation in lUI all(/ in timing inlercourse.
This requires daily ul trason ic visualization of ovaries from
the IOtJ1 tO 16th day of the mensu·ual cycle. It is noninvasive,
acc ura te a nd safe. Apart from fo llicular study for ovulation,
pelvic pathology if any can be picked up and endometrial
tJ1i ckness measured. The foll icle grows at the rate of
1-2 mm daily to reach 20 mm or more when follicular
disappeara nce of the follicle, presence of free flu id in tJ1e
pouch of Do uglas and growth of corpus lute um are evident.
Endometrial thickness of 8-10 mm is tJ1 e norma l response
of endometrium to progesterone. A lesser thickness
indicates corpus luteal phase deficiency (CLPD).
HORMONAL ASSAYS
Plasma Progesterone
Plasma concenu-ation of progeste1·one rises after ovulaLion
and reaches the peak of 15 ng/ mL aL mid-luteal phase
(22-23t·d clay) and then declines as the corpus IULeum
degenerates. A low level of the plasma progesterone below
5 ng/ mL at mid-luteal phase, suggests co rptL5 LPD and
pro mpts hormona l therapy. Use of da il )' progesterone
suppository in th e luteal phase or administratio n of hCG
5000-10,000 IU weekly wi ll help to improve the chances of
conception. Oral micronized progesterone 100 mg b.i.d.
or 300 mg vaginal pessary twice dail) is useful in corpLLS
LPD. Weeki) proluton injection (500 mg) and oral dydro-
gesterone are also used.
Cot·plLS luteal phase deficiency
Aetiology:
• Hypopituitar·ism with low FSH, LH
• Poor follicular developmenL
• Hyperp rolactinaem ia.
• Clomiphene citrate (CC) ovulation inducti o n.
• Reui eval of egg in IVF. CLPD is see n in posunenarchal
and premenopat.LSe period.
222 SHAW' S TEXTBOOK OF GYNAECOLOGY
• Poor response of endometrium to endogenous proges-
terone.
Diagnosis:
• BB'[
• Mi d-lutea l progestero ne es1i maLion (normal 15 ng/ mL) .
• l.!:ndome u·ia l biopsy.
Treatme nt: Administra tio n of progestogen or hCG
adminisu-ation i.m. weekly.
LH
LH surge from the ame•·ior piwita•1' gland occurs about
2 1 hours prior LO ovulation. Radioimmunoassay of the
morning sample of urine and blood gives the LH resultS in
3 hours. ot only does the LH surge help in predicting
ovulation, but t11e approximate Lime of can be
gauged and co itus aroun d this Li me can improve t11e chances
of concep ti on. Ga ug in g the time of ovula ti on has tllerape u-
Li c app licati o ns in IVF a nd in a rtific ia l inse min a tio n. LH kiLS
are now ava ilable.
Hyperprolactinaemia
It is seen in pituitary adenoma, hyperplasia, hypot11yroidism
and witl1 tlle usage of drugs, i.e. metoclopramide, cimeti-
dine, Hyperprolactinaemia (more than 25 ng/
mL) w1ll reqlllre X-ray of p•tllltary fossa or CT scan, and a
f·undus examination to exdude a neoplasm. Macroadeno-
mas ma> require surgery. Microadenomas and hyperprolac-
Linaemia respond to Bromocriptine and allied drugs (see
chapter on Hormonal T herapy).
FSH
Ra ised FSI-l leve l is seen in ova li a n fa ilure. Low FSH le ve l
in d ic.ates pitui tary dysfun cti o n a nd anovulation. Norm al
FS H level in the preovulatory p hase is 1-8 m lU/ mL, a nd
LH level at ovulation is 1-5 mJ U/ mL FS H level> 25 IU/ m l
clomiphene on day 3 fu ils ovulation.
Thyroid Tests
These should be done especiall) in case of h) perprolacti-
naemia. l-l)pot11yroidism witl1 raised TSI-l level is related to
hyperprolactinaemia.
Ovarian reserve o r premaLUre failu re incl udes bo tll
q ua lita ti ve a nd q uantitative esti mation of FSl-1/ LH.
MANAGEMENT OF ANOVUlATION
Anovulation is a common problem encoumered in
inferti lity. Several endocrin e disturbances contribute to itS
occu•-rence; hence, d ifferent drug combinations are
required to obtain optimal resultS.
Following are the common!)' used drugs for ovwaLion
induction:
Clomiphene Citrate cltomgld
Dido
Xtdoup
Ovu lation should be ind uced with CC, with a dose of
50 mg/ da)' starting fro m da)' 2 to day 6 of the cycle fo r
5 clays. Ov ula ti o n is mo ni tored by mo nito r-
in g of the foll ic ula r size, a nd occ u•Te nce of ovula ti o n. If the
response to 50 m g CC is no t s:uisfactOI)', the d ose o f CC
should be increased to 100 mg/ day from da)' 2 to day 6.
tail >6
cycles
Fun.her increase in dosage dose of CC, if •·equired, should
be undertaken in an infertility set-up, where monitoling
facilities b) sonography and honnone estimation are easily
available. If clomiphene t11erapy fails following six cydes,
other regimen of ovulation ind uc tion is recommended.
T his regime requi res constant mon ito ring, so t11e u·eaunent
s ho uld be initia te d in s pec ial inferti lity c li ni cs. T h e risk o f
mu lti ple ovula ti o ns a nd mu lti p le pregnanc ies with this
regim e is aroun d IO%. In hypo th a la mic d isorder, GnRH
is g iven to stim ulate the pitui ta •)' FSH and Ll-1 and tll e
foll iculogenesis monitored. T he pituita •)' and hypotl1alam ic
stimulation is often emplo>·ed in in vitro and Gl}! tech-
niques to avoid peripheral suppressive oesu-ogen action on
cervical mucous and endometrium by clomiphene, and to
improve the fertility mte.
Letrozole 1.
imgld Doextday 20mg As
Leu-o:wle 2.5 mg (nonste1-o idal a•-omatase in hibitor) is fo Lmd
s u perior LO c lomip he ne, whic h has no suc h adverse actio n.
With lc u·ozole, ovu la tio n occ urs in 90% of cases a nd with
a p regna ncy ra te of 40%-50%. Le trozo le is g ive n 2.5 mg
da il y fo r 5 days starting on th e seco nd da)' of the cycle or
20 mg single dose o n day 3.
Letrozole has no adverse pe•·ipheml action on endome-
u·ium and cervical mucous as witl1 clomiphene (antioestro-
gen action). It, however, causes drowsiness (no <hiving).
Half-life is 50 hours. It is contraindicated in severe hepatic
dysfunction. It enhances tlle action of FSI-1, the dose of
which is therefore reduced by 50% . At presem it is an
off-label drug and banned in India.
In case of clomip hene failu re, some have u·ied clomi-
p he ne 50 mg witll 20 mg Tamox ifen (doub le d ose if
necessa t)') in a novu la to ry infe rti li ty. Ta mox ifen, unlike
c lo mi p hene, has no a nti-oesu-ogeni c ac ti o n o n e ndo me-
trium a nd cervical mucous.
In PCOO, if tl1e first line of treatment with clom ip hene
or other drugs fui l, laparoscopic drill ing of follicles is done
by monopolar cautery or laser.
Octreotide is a peptide (somatostatin analogue) secreted
b)• tl1e h)potllalamus; it inhibitS tlle growth hormone and
insulin. It enhances t11e effect of clomiphene and reduces
t11e lisk of ovalian h)perstimulation syndrome (01-lSS).
In PCOO witl1 ins Ltlin resistance, pregnancy rate can be
improved by adm inistering metform in 500 mg daily at nigh t
for I wee k, and gradua lly inc reas in g th e close twice a d a)' up
LO Lhrec tim es a d ay for 6 mo nths. T his avo ids vo miting.
Progestero ne or hCG can be adde d fo r pregna ncy s upport
Combination of CC + hMG 7510 1M DITA
In PCOD, ovulation is idea ll y induced with a combination
ofCC and h MG. The patiem is advised CC 50-100 mg/ day
from day 2 to day 6 of tl1e crcle for 5 clays. hMG
75 units is added on clay 3, 5 and 7, and
more if so required.
Anovulator> women who fail to respond to CC +
h MG treaunem as well as amenorrhoeic women wit11 low
oesu·ogen levels need to be treated with hM G + hCG as
deta iled be low.
Combin a ti o n of hMG + hCG
l. Pe rform baseli ne oestradio l assay and ulu·asound
scanning.
 CHAPTER 16 - INFERTILITY- MALE AND FEMALE 223

2. Administer hMC, two ampoules (75 IU each) per day for

3 days. Table 16.3 Grading of OHSS
3. RepeaL oestradiol. If it is doubled, monitOr hMC dosage; Degree Grade Clinical Features
if noL increase hMC dosage by 50% for 3 days.
<l RepeaL step 3 until oestradiol doubles. Mild stimulation Grooe I Abdominal distension, pain
5. Perform ultraSound scan every 2-3 days until Lhe domi- (10%-30%)
nam follicle is 2:: 14 mm. Thereafter, daily moniwring till Grooe I - diarrhoea, ovarian
sue 20 mm is reached. nausea enlargement less than 5 em
6. Administer i.m. injection of hCC 5000 IU. Recommend
Grooe II Weight gain < 3 kg
artificial insemination, otherwise ad,·ise natural imer-
course. Moderate Grooe Ill Features of mild OHSS -
7. Admin ister injection of hCC 3000 IU 7 dars later. (3%-4%) ultrasonic evidence of ascites,
8. Await onset of menses or perfonn urine pregnancy test. hyponatraemia, hypokalae-
mla, hypoproteinaemia
GnRH Reduced renal o utput, ovarian
ln h ypothalam ic dysfunction. T his is also used as an alterna- size up to 10 em, weight gain
tive to adminisu-ation of hMC. C nRH is a decapeptide, so it of 10 pound
cannot be administered o rall)'· Because cominuo us admin- Severe (0%- 5%) Grade IV Features of moderate stimula·
istration of C nRH will sawra te th e recepwrs a nd thus lion + clinical ascites and/or
inhibit gonado u·opin re lease, GnRH is ad ministered in a hydrothorax, adult respiratory
p ul sa ti le fas hi on pre fe rab ly s ubc utaneo us ly. Ovulatio n rates diseases, ovarian size > 12
of 75%-85% and pregna ncy ra tes of 25%-30% have been em, weight gain > 5 kg
reponed. One adva nL<"'gc of Cn RH is tha t the risk of hyper- Grade V Grade IV .,. hypovolaemia,
s timulation is greatly red uced ( I%) compared to hMG hyponatraemla,
(20%-25%); hence, less mon ito ring is required. T he drug hyperkalaem Ia, Increased
is very expensive (Fig. 11).20). blood viscosity,
hypercoagulabllity, decreased
Prednisolone renal perfusion, oliguria,
In women with anovulation and increased androstenedi- hypotension,
one. the administration of 5.0 mg prednisolone at night hypoprotelnaemia,
+ 2.5 mg evel') morning is advised until spomaneous thrombosis, coagulation
failure, electrolyte Imbalance,
OVlLiaLion sets in. In case tJ1is treaunem does not succeed,
leucocytes > 15,000/mml,
iliis can be combined with an) other O\'ulation induction
hepatic, renal failure
regime. Haematocrit > 55% and se·
rum aeatinine > 1.6 mg%
Hyperprolactinaemia
H)'p erprolactinaemia is u·eated with Bromoc•·iptine 1.25 mg
at bedtime daily for 7 days, dose increments of 1.25 mg per
week is recommended until the hyperprolactinaemia gets
corrected when spontaneous ovulation is likel y tO occur and OVARIAN HYPERSTIMULATION SYNDROME
pregnancy often follows. Cabergoli ne 0.5mg t"vice weekly is OHSS (Ta ble 16.:l) is a compli cation of assisted reproduc-
more convenienL tive technologies and an iau·ogenic complication occurring
in t11e luteal phase or ea rl)' pregnancy. It is a poten ti all y life-
Laparoscopic Ovarian Drilling threatening condiLion, occu rring in I %-10%. It results
In women wi th PCOD in who m induCLio n of ovul atio n with fr om inductjon of ovulation in infertility cases. It is m ore
med ica l li ne of u·eaw1 e nt fa ils, lapa roscop ic ova ria n drillin g co mm on in FSI I/ LII the rap)' than c lo miphe ne a nd
of fo ll ic les witl1 monopo lar ca ute ry/laser has yie lded satis- pu lsatile GnRl-1 drugs. Its inc idence is hig he r in PCOS a nd
factOry resu lts. a novulatory infenilit)' com pared to infertility ca used by
Co•p us LPD is u·eatcd e itJ1er witJ1 intram usc ular progester- amenon·hoea. Raised Ll-1 in PCOS is responsible for hyper-
one 100 mg or micronized 301}-600 mg vagina l tab let daily in s timula tion, and hCC sho uld not be incl uded in the ilierapy
ilie postovulatory phase. Om! micronized progesterone tab lets in these cases. hCC adm inistration increases th e risk, so also
are not recommended. They cause drowsiness, poor absorp- the dose of drugs, size and number of ovarian follicles. It is
tion and bypass effect in tJ1e live.: hCG is also employed. also common in a conceptional cyde if m ulti ple ovulation
Poor response LO induction of ovulation is indicated by: OCClli'S. It is characteri:t.ed by ovarian e nlargement, pleural
and peritoneal effusion, oliguria, liver damage and throm-
• Less than fi 'e foil ic les on da) 5. boembolism. Severe form of O H SS occ urs if Lhe woman
• Oestradiol level less tJ1a n 300 pg/ m L. conceives during tl1at C)cle.

PATHOGENESIS
COMPUCATIONS OF OVULATION INDUCTION The main reason for 0 1ISS is the increased vascular
• Multiple pregnancy permeability leading to Ouid shift from inu-avascul:u· to
• O HSS exu-avascular space. This catLSCS decreased blood volume
224 SHAW'S TEXTBOOK OF GYNAECOLOGY
and decreased a lbum in as we ll as decreased elecu·olyte
levels. lt leads to accum ulation of fluid suc h as ascites and
hydrotJ1orax. The increased vascular permeability is due to
prostaglandin, C) tokines and growth factors secreted by
multiple growing follicles.
The •·isk factors for O HSS are as follows:
• Young age of the woman
• PCOS
• Previous OHSS
• Increased oestradiol level > 3000 pg/ mL
• 20 or more small follicles
• Increased renin and angiotensin Factors
• Vascular endothelial growth Factor (VEGF) causes neovas-
cularization of g•-anulosa cells and increased E2 level
• PCOS hi gh LH/ FSH •-atio, h CG and pregnancy in stimu-
lated cycle
• FSH/ LH causes higher incidence of O HSS (30%) than
clomiphene ( 10%) a nd Gn RH ( I %)
• O HSS can be predicted b)' hig h level of E 2 (>3000 pg/
mL), more Ulan 20 fo lli cles o n ulu·asound a nd in creased
Doppler b lood flow. T he re is in c reased release of renn in
and angio te nsin .
COMPLICATIONS
Complications of OI-ISS are as follows:
• Vascular - cerebrovasc ular accide ntS, t11romboembolic
phenomenon, deep venous unombosis
• Coagulopatll)
• Liver dysftmction
• Adult respiratOI') disu·ess catLSed by ascites/ hydrotllorax
• Renal Failure due to h) povolaemia
• Gasu·ointestinal - Re lated to E2 level
• Torsion and haemon·hage in t11e ov:u·ian C)'St
PREVENTION
hCG should be withheld in a cycle if more than 20 follicles
are seen on ultraSound and E,.lievel rises tO 3000 pg/ mL In
PCOS, it is pi'Udent to withhold hCG. Albumin 5% infusion
in 500 mL la ctated Ringer's solution du•·ing and after oo-
cyte retrieval prevents O HSS. Dopamine agonist Cabergo-
lin e 0.5 mg daily for 8 days sta rting on day I of hCG avoids
OHSS.
O HSS occ urs wi u1 s mall e r u1 an la rger folli c ular size 5
to 8 days after hCG ad ministra tio n. It is a n ia troge nic condi-
ti o n of in creased vasc ula r permeabili ty resulti ng in e xuda-
tion of fl uids from the in travascu la r LO t11 e ex tracellular
comparun ent. Progesterone suppo n he lps.
TREATMENT
OHSS requires hosp ita liz.'ltion. Med ical therapy includes
following:
• l.v. fluid... for Colloids, plasma expanders or
human albumin infusion 5 % in 500 m L Ringer's lactate.
Half-life of albumin is 3--10 days. Fifty grams of albumin
(25% albumin in 50 mL) 1-aises blood volume to 500 mL
H uman albumin 20% with 2 L of dextrose may be
needed. GeloftLSine fo•· h) povolaem ia ma)' be required-
continuous autotransftLSion of ascitic fluid (C\TAF) is
performed for 5 hours each day.
• Diuretics and NSA!Ds sho uld be avo ided beca t.LSe of
hypovolaemia and poor renal perfusion except in
pttlmonary oedema and to correct e lectro lytes.
• H igh thigh venous support stocking preventS deep
venotLS thrombosis.
• l mmtuloglobulins i,,, ma) prove to be effective.
• Glucocorticoids.
• Anticoagulants- hepa•·in.
• Dop:unine improves renal blood flow, o ligu•·ia :u1d
prevents renal failure.
• Correction of elecu·ol) tes.
INVESTIGATION AND MONITORING
Investigation and monitor·ing are done by u1e following:
• H b%, T LC, platelet count- T LC 15,000 and haematoc•·iL
• Urea, electrolyte estimation, se rum protein level.
• Repeat ultrasound to mo nitor size of ovarian cyst a nd as-
cites.
• Weight recording.
• Re nal function tests.
• Liver function tests.
• Coagula ti on profi le.
• Central venous press ure reco rding.
• X-ra)' chest for p le ural effusion.
Surgery is required if tJ1e ovarian cys t ruptures, un dergoes
tOrsion or haemorrhages. Aspi•-ation of ovarian cyst, ascites,
plettral and pericardia! effusion may be required.
PERITONEAL FACTORS
Pe 1itoneal disorders include periwbal adhesio ns :u1d
endomeuiosis, and are diagnosed on laparoscop)'·
Therapy consists of ope•-ative laparoscop)' for adhesioly-
sis, ablation of endomeu·iosis, incising the c hocolate
C)'St and removing its lining at laparoscopy. Dilatation of
fimbria! phimosis, opening of the terminal e nd of a h)dro-
salpinx and microsurgery for restoring wbal patency :u·e
also possible with laparoscopic methods.
ENDOMETRIOSIS
Endomeuiosis, associated with inferti li ty, is treated m edi-
call y, s urgicall y or as a combinatio n of t.h e two.
LliTEINIZED UNRUPTURED FOLLICULAR SYNDROME
LUF S)'ndrome is see n in 9% cases of infertility and is diag-
nosed on l)' on ulu·asow1cl scannin g. Micro nized progester-
one or hCG is needed in these cases (Table 16.2 ).
UNEXPLAINED INFERTILITY
Infertility is labe lled as unexplained when no obvio tLS
facwr is found in male and female partner. Approxi-
mately 10% of infertilit) accounts for this subcatego•·y of
infertility. H owever. the more we investigate in depth
lesser becomes the proportion of unexplained infe,·tility.
Common conditions which may account for unexplained
infertility a•·e immunological factors, clinical or subclinical

hypothyroid ism, hyperprolaCLinaem ia, functional disor-
ders in the partner.
Many a Lime, infertilit) is unexplained, but this could be
attributed to inadequate or inefflcien t investigations and
inabilit) to detect biological capability of the sperms tO
fertiliLe an ovum.
Spe•m dysfunction and its biological function are now
detected on computer-assisted semen analysis (CASA).
Abnormal acrosome reaction and fusion
defects ha'e been identified by CASA and male infertility
problems better understood.
It has been observed that 20% of such unexplained
infertile couples succeed in having a baby in clue cow-se of
waiting. Perhaps newer and advanced technology in this
field may yield a bener pregnancy rate of 40%-50% in
future, albeit at a high cost.
When all fai l, and the couple is desperate tO have a baby,
adopti on is recommended.
ASSISTED REPRODUCTIVE TECHNOLOGY:
AN OVERVIEW
Assisted rep rod uctive tech no logy (A RT) comprises a group
of procedures t11 at have in common the handling of oo-
cytes and sperms ou ts ide of the body. The gametes or em-
bryos are replaced into t11e uterine cavity tO establish
pregnancy.
These procedures, although benefited many infertile
couples (20%-10% pregnancies), are stressful and very
expensive with complications such as O HSS, multiple
pregnanC). abortion and ectopic pregnancies. Although
no gross fetal malformations have yet been reported, a
long-tenn study is requi•·ed to detect subtle and late com-
plications.
DEFINITION
AJtr refe1-s to any fertility u·eaunent in which the gametes
(sperms and ova) a•·e manipulated. Accordingly, ART p•·oce-
dures in volve sw'gical removal of eggs known as eggmtrieual.
IVF is tl1 e most common ART procedure. It was fi 1"St success-
full y used by Steptoe and Edwards in tl1e UK, leading to the
birtl1 of first IVF baby Louise Brown in I978. Since then,
mi llions ofbirtl1s have been ac hieved witll tl1e successful use
of these techni ques.
INDICATIONS
The co1runon indications for ART proced ures include the
following:
• Abnormal fallopian tubes: Blocked wbes or absent tubes
(surgical removal).
• Endometriosis-related infertility. ldiopatl1ic or Lmex-
plained infertilit).
• Male factor infertilit).
• Immunologic infertilit).
• Failure of o,·ulation - donor ovum. Bilateral oophorec-
tomy for diseased oval'ies, i.e. endomeu·iosis and ovarian
cancer.
CHAPTER 16 - INFERTILITY - MALE AND FEMALE 225
INVESTIGATIONS PRIOR TO ART
• Semen analysis, semen culture and sensitivity.
• Complete work up including t11yroid function tests, blood
sugar. serum prolactin level.
• Serum FSH on cia) 2/ 3 of C)cle. Serum oestradiol on day
2/ 3 of C)cle.
• Test for ovarian reserve: Measurement of anli-
Mulle•·ian hormone (AM II ) is considered the best test.
This is indicated in women older than 35 ye:u-s, smok-
ei"S, presence of only one ovary and unexplained infer-
tility. It invohes standard day 3 laboraoory testS as
mentioned abo,e, along with administration of IOO mg
clomiphene citrate (CC) from clay 5 to day 9, repeat
FSH on day I 0. FSH va lues must be the same as on day
3 of the eye! e.
• Serologic evidence of chlamydia ! infection. Zona-free
h amster oocyte penetration test to asses fe rti li zing capac-
ity of sperm (op ti onal).
• En hanced sperm peneu·ation tes t using TEST-yolk
b uffer.
• Tes ting both partn ers for antispe nn an l.ibodies.
• Assess uterine cavil)' h)' hysteroscopy/ u·ansvaginal sonog-
raph)'·
• H)•drosalpinx reduces IVF success rates by 50%. Success
rate increases to expected rates after surgical tying off or
excision of hydrosa lpinx. Tying t11e medial end of the
tube also reduces the risk of ectopic pregnancy.
• Diagnostic laparoscopy to assess tubal patency and treat
any subtle causes of infertility such as lysis of adhesions,
treaunent of endometriosis etc. Excision of hydrosalpim:
or ligation of medial end of the LUbe.
TYPES OF ART PROCEDURES IN CURRENT PRACTICE
I. IVF. This is the most commonly done ART procedure. It
im·olves ovulation induction, OOC) te reu·ieval :u1d
fertiliation of the oocytes in the laboratO•)'; embryos are
then culwred for 3-5 da)S followed by their transfer to
the endomeuial cavity (ET).
2. GIFT. This involves ovarian stimulation and egg
retrieva l, followed by lapa•-oscopicall y guided transfer of
a mixwre of two ova and 50,000 sperms imo each of the
fallopian tubes. This procedure came witl1 a big bang
and popularity, is no longer in use.
3. Zygote intrafallopian transfer (ZIFI). T his involves the
laparoscop ic u·ansfe r of da)' I fe rti lized eggs (zygotes)
in to the fallopian tube.
4. ICSI. This tec hnique was developed in the ea rl)' I990s. It
aims at help ing coup les with severe ma le fac tor infertility.
Under microscop)', one sperm directly iruected in to
eac h mawre egg prior to inu·a ute line transfer of the
fertilized eggs. The method yie lds 50%-70% successful
fertilization rates.
LndicaLions of ICSI in male infertility are as follows:
• Spenn count less than 5 million/ mL.
• Decreased or absent motilit) of sperms.
• Many abnormal spenns.
• Previous failed IVF.
• unexplained infertility.
226 SHAW'S TEXTBOOK Of GYNAECOLOGY
The sperms are obmined by one of the following sources:
• Semen washing in a normal male.
• Sperms retrieved by testicular sperm aspiration (TESA).
• Percumneous epididymal aspiration. However, a decreased
m unber of sperms are available (PESA) wi th this teehnique.
T his techni que can also cause u·awna to the epid idymis.
• MJ::SA - the tis.sue can be cryoprese rved fo r fuwre cycles
or fuw re pregnancy.
Cryopreservation
Cryopreservation of embryo, OOC)Les and sperms avoids
need for repeat aspirations, reduces the cost of tl1e proce-
dure and can be used in subsequent C) des as well as for
fu•·t11e1· pregnancies. Cl)•opreservation is also useful in
)Otmg men who have to undergo radiotherapy or
chemotl1erapy for cancer, or are frequenL travellers.
1. Ovum donation. Donor eggs are offered LO women witl1
poor egg num bers or q uality and elde rl y wome n. An egg
dono r is sc ree ned fo r HI V a nd othe r d iseases. She is th en
subjec ted to s timula tion p ro tocol for ind ucing superov u-
lation, fo llowed by standard egg reu·ieval. T hese eggs are
ferti li.1.ed by the sperms of tl1e patient's male partner and
tl1e embryos transferred to t11e patient's uterus which has
been simultaneously prepared as per tl1e standard IVF
protocol. 0 \'lun donalion is also required if botl1 ovaries
are re moved or radiate<!.
2. Ovarian transplant is a possibility in fuwre.
3. Surrogacy and posthumous reproduction are extensions
of ART procedures. However, etl1ical, legal, religious and
social issues of these procedures need cla rifica ti on an d
understa nding. T here are grey areas to be ca uti o us about
unti l legal procedu res have been drawn. HysterectO·
mi:t.cd woman needs surrogacy.
4. Adoption. Considering me cost of ART and the su·ess in-
volved, adoption can be a suitable altemative for inferti le
couples. Many, however, prefer to have their own genetic
babies and resort to adoplion when all ot11er measures fail.
IVF Complications
Short-tenn complicalions are as foiiO\\S:
• Failure.
• Oocyte retrieval can cause bleeding u·atnna, infection,
pain, pelvic abscess.
• l::ctopic and hetero topic pregnancy 0.4 %.
• Mu lti ple pregnancies and its co mplications.
• Abortion, lmra uterine Growth Resuictio n (IUG R).
• O HSS.
• Cost.
Long-term complicalions are as follows:
• Premature ovarian failure.
• Ovarian cancer- clue to repeated hyperstimulalion.
• B•·east cancer.
Surrogacy may be indicated for:
• Absent uterus, diseased ute rus.
• Genera l cond itio n of the woman precludes pregna ncy.
• Repeated pregnancy loss.
• Heredita•1' disease.
• Failed 1\IF.
Key Points
• lnferti lit)' affectS 10%-15% of mani ed couples. C hang-
ing lifestyle is assoc iated witl1 increasing incidence of
infertilit)'·
• Male and female parmers are equally respo nsib le for
infertilit).
• lmestigations of an infertile couple begin witl1 semen
anal) sis, a simple outdoor test. ln case of semen ab-
nonnalities flll-tller detaile<l work up of male pa•·tner
is needed in consulmtion witl1 urologist. Considerable
advances have taken place in managing male facwr-
•·elated infertili ty.
• In female pa nner, tubal factor is th e most comm on
ca use of infe rti li ty. HSG followed by cliagnostic-
laparosco py are the bes t tec hni q ues LO evaluate
w bal patenC)'·
• Disorders of ovulatio n ca n be responsib le for infe n.i l-
ity in 15%-20% subj ects. Curren tly ulu·asound moni-
toring of O\ary for follicle sue is most commonly used
test forO\ ulation. In Lndia, premenstrual endometrial
biops) pro' ides additional info•·mation about endo-
meu·ialtuberculosis.
• Peritoneal factors such as pe•itubal, periovarian
adhesions and pelvic en domeu·iosis can also be re-
sponsible for fema le inferti lity. Lapa•·oscopy plays a
diagnostic and therapeutic role in such co nditio ns.
• ART has offered newer hopes for managing w bal
factor infertility, male facto r infeni liL)', cndome u·iosis-
related inferti lity and unexp lained infertility.
SELf-ASSESSMENT
1. Discuss the causes and management of male infe•·tility.
2. A 28-ycar-old woman presentS witl1 in·egular mensuual
cycles and p ri mary inferti lity. How wi ll you investigate
th is case?
3. A 23-)•ear-old wo ma n p rese ntS with p ri ma ry ste ri lity,
sutism and o ligomenorrhoea. How will you investigate
and manage this case?
4. A 32-year-olcl woman presentS witl1 secondary infertility,
regular cycles, last delivery was 6 years ago. I low will you
manage this case?
5. How will )OU investigate and manage a case of tubal
infertility?
SUGGESTED READING
Bonnar J. Recent Advances in Obstcuics and Ovarian
syndrome. Reccnr Advdnccs in Obstetrics and
GynaccoiOI,'}' 21 Ovarian hyper-stimulation synd rome. In: Bonnar ].
Re-cent in Obstetrics and GynaccoiOI,'Y· 6:123, 2000,
Churchill Uvingstonc: Elsevier.

Oa,id K. Gardner ct al. Textbook of Assisted Rcproducth·e Techniques.
5th c"<:in, Vol 2:2017
Otmcanjelfrey S, Shulman Lee P Duncan, Schuman. Year Book ofObsu:t-
rie>. Gynaecology, and llcalth.John Wiley & Sons, 2010.
FOGSI Focm. lntr.t·Utcrinc in.cmination. 2010.
I !art R. :-:orman R. Poi)C)'>tic O\'arian >-yndrome - progno.is and
outcome.. In: Bot Pr.tctkc :md Re.carch: Clinical Obstetrics and
Gpuccol<>g>. Vol 20(5): 751-778, Ebe\'ier, 2006.
K Thoma> ct al. Surgical treatment of male infertility. In: Studd J.
Prugn:ss in Ob.tetric> :md Gynaecolog), 15:363, 2002, Churchill
Lhing;tone: Eb<."icr.
CHAPTER 16 - INFERTILITY - MALE AND FEMALE 227
PO Sutter. In: Rational diagnosis and tre-atment in infertility. Best
Practice and Rc-.earch: Oiniclll Obstetrics and Gynaecology. Vol
20(5): 647-664, 2006.
Shai E Elizur. Ri-01cng Chian, ll:u1ancl EG llolzer, et al. In \itro
matur.uion of OO<.)'l<'> for treatment of infertilit) md presen-ation of
fertility. In: Studd J , Tan, Chc n cnak. Progress in Obstetrics and
C,necolog). bt Edition, 18:375, Churchill u\ing;tone: EJse,ier, 2008.
Studdj. In: Gamete trotn>fcr (GIFT). Wong PC, Asch RH.
In: Prugres. in Ob.tctric> and C,naccol<>g>, 15: 233. Churchill
Lhingstone: Elsc\ier.
 Ectopic Gestation

Types of Ectopic Gestation 228 Interstitial Pregnancy 240

Epidemiology 228 Unruptured Ectopic Gestation 240
Incidence 228 Ovarian Pregnancy 241
Aetiology 229 Cervical Pregnancy 242
Aetiopothogenesis 229 Cornual Pregnancy 242
Pathology 230 Heterotopic Pregnancy 243
Abdominal Pregnancy 232 Caesoreon Scar Ectopic Pregnancy 243
Symptoms, Signs and Diagnosis 233 Persistent Ectopic Pregnancy (PEP) 243
Physical Signs 234 Recurrent Ectopic Pregnancy 243
Differential Diagnosis of Chronic Ectopic Key Points 2 43
Pregnancy 235 Self-Assessment 244
Diagnostic Investigations 2 36
Treatment 237

Implantation of pregnane) at a site other than e ndomeuial lin-
ing in bo<l) of utea·us is called eCtOpic pregnancy. onnally, the
implantation onun takes place in ULeaineca,ity, any
factor that imen-upts the successful migration of conceptus to
the endomeu·ium results in ectopic pregnancy. In pathological
conditions, implantation may occur anywhere outside the nor-
mal uterine ca'h)\ the subsequem gestation being called ecto-
pic. Ln about95% of such cases, ectopic gestation occurs in the
fallopian tube, when it is called tubal pregnancy. In rare cases,
it may occur in the ovary, the n.adimemar-y hom of a bicornuate
uterus, ceavix and peaitoneal cavity. Lately, ectOpic pregnancy at
the si te of previous caesa rea n scar has been repon.ed. Paimary
abdominal pregna ncy is indeed a vea-y rare phenomenon, but
second;u-y abdomina I pregna ncies have been reported.
TYPES OF ECTOPIC GESTATION
Extrauterine
• Tubal (90%-95%)
• Ovarian ( I %)
• Abdominal (I%-2%)- rare
• Heterotopic pregnane): Coexistence of ectopic preg-
nancy with intraute.-ine pa·egnanC).
EPIDEMIOLOGY
I. Ectopic pregnancy may occur at a rate of I:SO pregnan-
cies or more often. The significan ce of ectOpic preg-
nancy lies in the fact that it often goes undiagnosed and
patient ma y have massive intraperitOneal bleeding aisk-
ing her life. It constitutes o ne of the leading causes of
pregnancy-related materna l deaths a nd accounts for
abo ut 10% of maternal mortality.
2. In last 30 yea rs, the incide nce has increased six times,
re lated to increase incide nce of sex ually transmitted
diseases and induced abo rti ons
3. Increasing incidence of pelvic in flammaLOt)' disease ( P!D)
in the coarununity, the use of in tmuterine con u·aceptive
devices (IUCD) and t11e wider use o f assisted reproductive
tec hnology (ART), increase in the detec tion and diagnosis
d ue LO more sensitive ulu·asoun d technology have contrib-
uted significantly to tl1is rising incidence.

Uterine but ectopic locatio n in tl1e uterus INCIDENCE

• LmerSLitial (2%) The incide nce of ectopic pregnane> has been ina-easing
• Rudimemaa1 hom of a bicomuate ULenLS over the past three decades, but t11e number of hospitaliza-
• Cervical (0.5%) t.ions is decreasing because of increasing outpatiem man-
• Caesarean scar agemenL It has lisen from 1:150 pregnancies 1.0 aboUL
228

1:40-1:25 pregnancies in present Limes. TE Go ldner et al.
(1993) reported a fivefold increase in itS incidence in the
USA Racial, geneLic and environmental facwrs have been
implicated. Promiscuit), rising incidence of sexually tranS-
nuLLed infecLions and the practice of resorting to induced
abortions have contributed to this increased incidence.
Social and lifest)le changes such as late marriage and older
age at the time of childbearing amongst career women have
become a common practice. Those women who seek post-
ponemem of pregnancy ma>• have used contraceptives in an
irregular pattem. Modern technolog)• today offers hope to
many infertile couples in the fonn of ART procedures. How-
ever, their widespread use in clinical practice has been ac-
companied by a 5% increase in the incidence of ectopic
pregnancies. The important 1isk factOJ"S for ectopic p1·eg-
nancy are a history of tubal stu•gel)', including tubal ligation,
prior ectopic pregnancy. A few ea rl y ectopic pregnancies
resolve spontaneously and a re not recognized. T herefore,
tJ1e exact prevalence of ectopic pregnancy is d ifficult to
estima te. Repea t ectopic pregnancies are reported in
13%-15% of cases.
AETIOLOGY (Table 17.1)
Tubal pregnancy occurs either because the fa llopian tube
offers the fertili:t.ed egg a congenial environment for im-
plantation or because a delay in the ovum transport across
tJ1e fallopian LUbe causes the fertilized egg LO implant in the
tube itSelf. The risk facLOrs predisposing to ectopic tubal
implantation include- previous salpingitis, ectopic
pregnanq. wbal damage following gen ita! tuberculosis,
previous wbal stu·geJ) such as wbecLOmy (especially Madle-
ner) or wbal reanastomosis, the presence ofiUCD, prolong
infertility and following ART procedures in infen.ile women.
The commonest cattSe is PID including sexually uansmit-
ted infections such as Chlamydia tmchamtJti5 and gonor-
Jiloea. Other leading causes of salpingitis are septic abor-
tion, postabortal sepsis and puerperal sepsis commonly seen
in developing coun u·ies. 'vVitJ1 reduction in the incidence of
gonococcal infection, chlamydia! infection p1·edominates
and causes extensive and a subclinical damage to the
fallopian tube than that ca used by gonococcal infection.
RE Bad ow et al. evidenced the presence of chlamydia! infec-
tion in 50% of women preseming witJ1 ectopic pregnancy.
Table 17.1 Aetiology of Tubal Ectopic Pregnancy
• Previous pel vic Inflammatory diseases
• Genital tuberculosis
Endometriosis In the pelvis causing distortion of the
fallopian tube
Previous ectopic pregnancy
Pelvic adhesions
Congenital elongation, aocessory ostia, diverticula
Transmigration
Previous tubal surgery, tubectomy
IVF programme
tUCO, progesterone containing IUCD
Progestogen-only pills (POP)
CHAPTER 17 - ECTOPIC GESTATION 229
By treating chlamydia! infection in women, a Swedish smdy
showed a drop in the incidence of ectopic pregnancy by 45%.
Almost40% of women suffe1ing from ectopic pregnancy
have evidence of PID. Westrom reported t11at following one
episode of salpingitis, 12.8% of the affecLed women showed
a partial or complete wbal blockage; tJ1is figure rose to 30%
following two episodes of salpingitis and 75% afte1· three
episodes. He reported a sevenfold increase in t11e incidence
of ectopic pregnancy among women found LO have stigmata
of PID at laparoscop)'· The incidence of ectopic pregnancy
following one episode of PID 1·ises from 1:150 pregnancies
to about 1:25. The incidence also increases in women who
have undergone induced abortion and who have suffered
genital tuberculosis. The pelvic adhesions following appen-
dicitis and endometr-iosis may kink or disLOn t11e fallopian
tube so as to inter·fere with ovum tJ'anspon. AcuLe salpingitis
leads to congestion and oedema of t11e tubal wall and exfo-
liation of tubal epi tJ1 elium during the healing process.
Often the tubal musc ul awre is also in volved in fibrosis
following PID, tJws ca using a partial b loc kage of itS lu men,
an impaired wbal pe rista ltic activity and a delay in the
transport of tl1e ferti lized egg.
AETIOPATHOGENESIS
SitLtations favouring delay in tubal transport of the ferti lized
egg. or tJ1ose conu·ibuting to its tubal implantation, are
discussed below:
• Congenital defectS in the fallopian tubes such as acces-
SOt)' ostia. di,erticula, partial stenosis and polyp may
enu-ap the fertili1.ed egg and prevent it from read1ing the
uterine ca\'it). A comual fibroid, b)• naJTowing t11e tubal
lumen, can predispose to tubal pregnanq•.
• Transpe1·itoneal migration of the O\'Um from one ov:uy tO
the opposite fallopian tube has been repon.ed on t11e
basis of the presence of th e corpus ILLLeum in one ovaJ)'
and an ectopic p1·egnancy in t11e opposite fallopian tube.
Berlind obsen•ed this mi&J'ation in 8% of cases of ecwpic
p1·egnancies.
• Delayed transport of the fertili:t.ed ovum along the tubal
lumen may result from impaired ciliary and peristaltic
activity in the fu llopian LUbe as a co nseq ue nce of injury or
inflammation.
• Hormonal contracepLives, especiall y progestOgen-only
pi lls (POP), are known to reduce tubal motility and
thereby favour an ec topic pregnancy.
• Pelvic adhesions and endo me LJiosis ma>• d istort t11 e tube
and cause kinking. Fo llowing the surgical proced ure of
ventrosuspension, kinking at the isthmic portion of the
tube may contribute to ectopic pregnancy.
• SLtrgical procedtu·es such as tubectomy (especially Madle-
ner), by virwe of spontaneous reanastOmosis, and tubo-
plasty may end up in partial stenosis at t11e anastomosis
site favouring ectopic pregnancy. Consen-ative surgery
for an ectopic pregnanq is reponed to cause repeat tubal
pregnane> in 15% of cases.
• Laparoscopic cauteriL.ation in ste1ili.tation operation may
lead to the fonnation of a fistulous opening in itS medial
end of ligated portion of tube pennitting the spenns tO
reach the O\'<lf)'. The fe1·tiliL.ed egg however is large and
230 SHAW'S TEXTBOOK OF GYNAECOLOGY

gets emrapped in the distal segment causing ectopic

pregnancy. GC ·wolf et at. reported that 7.4% of ectOpic
pregnancies occurred in previously sterilized women.
WitJ1 the use of rings and dips for tubal sterilization the
incidence is now reduced. In vitro fertilization (fVF) fa-
votu·s occurrence of ectopic pregnancy on account of
fundal insertion of two or more eggs during embryo
u-ansfer. The number of eggs and the quantity of fluid
medium used dUI·ing emb•)O u-ansfer may push an egg
imo me tubal lumen. This also expla ins me occurrence
of heterotopic pregnane)' in I %-2% of IVF cases.
• ln some cases, it is probable that t11e ovum itself is at
fault. The rapid de\·elopmem of trophoblast may favour
premature implantation in t11e fallopian tube. ln con-
trast, delared trophoblastic development may end up as a
ce•vical pregnancy.
• Extraneous ca uses such as appendicitis and pelvic endo-
meu·iosis may involve t11 e fallopian tubes in adhesions,
impair its mobility o r ca use kinking. T his panJy explains a
higher incidence of ec topic pregnancy on the right side.
Figure 17.1 A large pelvic haematocele from a case of a ruptured
• About 'I % of pregna ncies with IUCD are ectOpic pregna n- tubal gestation. Note how the swelling pushes the uterus forwards,
cies. T he presence of tUCD is effec ti ve in preventing intra- and how retention of urine may develop from elongation of the
uterine pregnancies, but not ectOpic pregnancies. lf urethra. Note the close relation to the rectum.
proper asepsis is not fo llowed at the Lime of insertion of
LUCD, it can predispose to subsequem ectopic pregnane)'·
• Progestogen-containing IUCDs and progestogen-on ly
conu·aceptive p ills decrease tubal pe•istalsis and thereby
contribute to the occ urrence of an ec topic pregnancy.
• Induction of ovulation with gonadotropins may increase
t11e risk of ectopic pregnane) because of multiple ovula-
tion and multiple pregnane).

PATHOLOGY

TUBAL PREGNANCY
Tubal pregnane)' accounts for 90%-95% of all ectOpic preg-
nancies. ln a tubal t11e most frequent site of im-
plantation is Ule ampullary po•tion of tube (80%) because me
plicae are most numerous in t11is pan and pre\•ious salpingitis
is more likely to produce C•)'pts here t11an in the
fallopian tube. lf tJ1e ferti li:t.ed ovum implants on the anti mes-
enteric t11e trophoblast eventually erodes t11rough the
peritoneal sw·face of t11e tube and leacls to intraperito neal
haemon·hage. lfa uac hed ca udally, erosio n of t11e u·ophoblast
leads to fonnation of a broad liga ment hae mato ma.
l n favourable cases, the hae morrhage is slow and slight
blood clo t aro und the trop hoblast dislodges the ovum a nd Figure 17.2 Tubal rupture with Intact gestational sac - a rare event.
(Sowce: C Crum, K Lee, C Crum , Mar1sa Nucci, K Lee. Diagnostic
produces a tubal mole. The size of the mole depends partl)'
Gynecologic and Obstetric Pathobgy. Complications of Pre..;able
on me extent of the haemorrhage and partly upon the stage Pregnancy. Saunders, 2011 .)
of pregnancy. This mole may remain with in the tube and
gradually gets absorbed. More often, it gets expelled
t11ro ugh t11e abdominal osti um into t11e peritOneal cavity- The ampullary portion is the most frequent site of
tubal abortion. The blood may form a clot around the ectopic pregnancy in 80%, fimbria! ends in 6%, ist11mLLS in
n.ptLLre site or near t11e fimbria) e nd - peritubal haemato- 12% and interstiLial portion of LUbe in 2%.
cele. A profuse haemorrhage causes blood to collect in me
poud1 of Douglas to form a pelvic haematocele (Fig. 17.1 ).
The worst form of haemorrhage results when t11e U'Ophoblast
OVARIAN PREGNANCY
erodes thi'Ough all t11e la)e•-s of t11e tube caLtsing tubal rup- Ovarian pregnane)• is relatively an uncommon site of ecto-
ture (Fiw- 17.2-17.7). A •-a•-e rupwre imo the broad ligamem pic pregnancy seen in I %-2% of cases because of
forms a b1'0ad ligament haemaLoma (Fig" 17.8 and 17.9). the increase use of IL:CDs is being seen more often.
 CHAPTER 17 - ECTOPIC GESTATION 23 1

Figure 17.6 Ruptured tubal pregnancy. Note the fetus surrounded by

a haematoma being extruded through the wall of the d istended tube.
(Source: Robbins & Cotran Atlas of Pathology. Chapter 13: Ftgure 13-
104. B sevier.)

CM
Figure 17.3 Actual specimen removed at operation.

Chorion

Figure 17.7 Tubal rupture with rupture of gestational sac - the more
common event.

Rgure 17.4 The fallopian tube containing ectopic gestation on t he

point of rupture, removed Intact at operation. In the lower half of
the picture, the point of erosion Is shown by a blood clot. (Source:
Sciencephoto library.)
Amnion

Ovary

- - = ----+-Broad ligament
Rgure 17.5 Laparoscoplc view of left ampullary unruptured ectopic
pregnancy. The uterus has a subserosa! fundal fibroid . Figure 17.8 lntraligamentary rupture of tube. Gestational sac intact.
232 SHAW'S TEXTBOOK OF GYNAECOLOGY

Amnion

Blood clot
Olary in broad
ligament
Rgure 17.10 Heterotopic pregnancy with ectopic pregnancy in
rudimentary horn.

Figure 17.9 Same as Fig. 17.8, but with the gestational sac
ruptured.
Al though LUCD prevents im planta tion of pregnanC)' in the
uterus, it has no protective effect on the tubal pregnancy
and on ovarian pregnancy. As the fertilized egg lodges in
tl1e corpus luteu m, ovarian pregnancy gives the appearance
of a corpus luteal haernaLOma. Histological examination wi ll
establish the diagnosis. Ovarian pregnancy accounts for
20o/o-30% of all ectopic pregnancy in IUCD users and
0.5%-3% of all ectopic pregnancies.
ABDOMINAL PREGNANCY
PRIMARY ABDOMINAL PREGNANCY
This condition is extremely rare where a pregnancy
implants anywhere in the alx lomen witllout any connection
with uterus o•· tubes. It is possible that tl1e ovum is
implanted in areas of ectopic decidua.
Ultraso und or radiogra ph reveals a n abno rm al and a
high position of a malform ed or a dead fetus outside th e
uterus. Rarely, a norma l live fetus is seen. T he ute rus is nor-
mal in size. Long-st.ancUn g abdom inal pregnancy causes
calcification and shrinkage of the fetus which is tl1en called
a lithopaedion.
INTERSTITIAL PREGNANCY
Interstitial pregnancy is a vet) rare fonn of ecwpic gest.a-
Lion, when the ovum is implanted in tl1e imerstiLial portion
of t.he tube (2%) . Usuall) a muscular sepuun imervenes
between the gestational sac and the cavity of tl1e ut.erus.
Imerstitial pregnanC) usual!) tenninates b)• ntpwre inLO
the peritoneal ca,·it) dltl·ing the 3rd month of pregnancy
(Fig. 17.10).
PREGNANCY IN AN ACCESSORY HORN OF UTERUS
(CORNUAL PREGNANCY) (Fig. 17.11 ) 0
Rarel y, a pregnancy may implant and grow in t.he accessory
horn of a bicornual uterus. The pregnancy may continue up

SECONDARY ABDOMINAL PREGNANCY

Alth ough rare, a seco ndary abdom inal pregnancy results
when a ruplltred tubal pregnancy implants any\\1here on
pelvic or abdom ina l visce ra and a comm uni cati o n with the
tube or uterus ca n be identified eluting surgical manage-
ment. In most cases, this condition ge ts d iagnosed in
second u·imes te r on tl1 e basis of cli nical examination and
ultraso und. On rare occasions, an abdom inal pregnancy
cominues till term when d uring laparoto my for a suspected
ruptured uterus, this conditio n comes to lime lighL In most
cases. fetus dies in abdomen or soon after laparotomy,
profuse haemon·hage ma) occur at surgery to remove
placema implanted on tl1e surface of bowel loops or some
other su·ucture.
A woman ma) suffer mild abdominal pain and tllreat-
ened abortion in the earl) weeks, but pregnancy proceeds
abdominal discomfon tlll'oughout pregnancy. Attenn, Figure 17.11 Ectopic tubal pregnancy - fetus expelled from the
t.he woman goes into splu·ious labour but fails to deliver fallopian tube.
spont.aneously or with a S)lltocinon drip. 0 Scan to play Ectopic pregnancy

LO I 2- I 6 weeks. The condition may get diagnosed by a
routine ultrasound done in earl>• pregnancy of patientS
and may present rupture of accessory horn with resultant
intraperitOneal bleeding. The fate of pregnancy in a du-
plicated uterus depends upon the degree of development
of the horn. In uterus didelph)'S or when both horns are
well developed, p•·egnanC)' usually proceeds to tenn or
and panurition ma> be normal. If one horn is
ill-developed, the muscle wall becomes thinned out and
may rupture during pregnanq. This complication usually
develops during the 4th month and causes severe inter-
nal bleeding. At operation, the condition is recognized
by itS attachment to the round ligament and body of
uterus. Pregnanq• in an accessory horn has been seen
when th e corpus lu teum was present in the opposite
ovary indicating u·ansper itoneal migration of fertilized
ov um.
CO-EXISTING INTRAUTERINE PREGNANCY AND EGOPIC
PREGNANCY (HETEROTOPIC PREGNANCY)
T his combination of ectopic pregnancy with intrauterine
pregnancy is unco mmon; however, in recent years because
of widespread usc of assis ted reproduction techniques this
combination has become somewhat frequenL Combined
ULeline and extrauterine pregnancy is reponed in 1%-3%
of successful IVFs. In a spontaneous pregnancy, the
incidence of combined pt·egnancies is very low ( 1:4000 to
1:30,000). Ultrasound done to diagnose early pregnancy in
IVF qcle may help to discover a heterotopic pregnancy. The
importrma of I'Xtnniltiltg both tubes when opemting on a CllSe of
ectopic l,'I'Jilllion mtl.ll bl' emphasized.
Caesarean sea•· ectopic pregnancy is relatively a newer
t)pe of ectopic pregnancy recently. In this rare
variety of an ectopic pregnane). the gestational sac is seen
embedded and sun·otmded b) m>omeuiLUn and fibrosis of
tl1e caesarean scar.
SYMPTOMS, SIGNS AND DIAGNOSIS
SYMPTOMS
Accurate diagnosis of ectopic pregnanC)' is based on symp-
and clinical signs. To begin with patientS have signs
and symptoms of normal pregnancy; however, soon symp-
toms such as pain in t11e lower abdomen, spo tting PV and
fa inting spell set in. One slwu/1l consider t!UI possibility of an
&-UifJit fJrP{,fiUmcy when a wo11um in tmrly fJrlfbrnancy jJrnsents with
biwrrn tliniml
The key LO a successful outcome is an early diagnosis of
ectOpic pregnancy.
The cli nical picture in ectopic gestation is related to the
patltological anatomy. A tubal •·upture is an acute eme•--
gency associated with internal bleeding and shock. A wbal
mole, witll periwbal and paratubal haematocele, causes
abdominal pain and itTegular vaginal bleeding. This is a
less urgent condition and is called the subacute or chronic
ectopic gestation. The subacute ectopic pregnancy may
eventually rupw•·e and become an acute emergency.
Occasionall), with routine ultrasonic scanning in early
pregnanC), un ruptured ectopic pregnancy can be detected
before the clinical features develop.
CHAPTER 17 - ECTOPIC GESTATION 233
AMENORRHOEA
About 75% of patientS pt·esent witl1 a history of amenor-
rhoea of less man 6 weeks duration. Rarel)•, an ectopic preg-
nancy may rupture e'en before patient misses her periods,
this is more likely to happen with isthmic tubal pregnancy.
ln a rare case of alxlominal pregnancy, amenorrhoea may
proceed into the tllit·d trimester or even be)ond 9 montl1s.
Duration of amenorrhoea ma> be 3-1 months in cases
of interstitial and cornual pregnancies. Earl)' bleeding simu-
lating uterine abortion is seen in caesarean scar ectopic
pregnancy.
PAIN
Abdomina l pain, generally severe, is a consistent feature of
ectopic pregnancy in 95% of cases. Sudden acute pain in
the abdomen is caused by tubal ruplllre resu lti ng in haemo-
periLOneum. Occasionally, internal haemorrhage in perito-
nea l cavity can irritate tJ1e underswface of t11 e diaphragm
and phrenic nerve leading to the complain ts of shoulder
tip and epigastric pain. In a young pati ent brought in a
co nd ition of s hoc k co mpla ining of abdominal as well as
sh oulder pain, t11 e diagnosis of ectopic pregnancy is almost
certain. In subacute variety, t11e patient complains of vague
abdomina l pain but signs of sh ock are absent hence, tile
diagnosis often geLS missed. l>ain is often absent in early
unruptured ectopic pregnancy.
VAGINAL BLEEDING
Vaginal bleeding is usually littJe in amount in the fonn
of eitller clark altered blood or blood-stained fluid. The
bleeding is usuall) as a result of separation of decidua in
the endometrial cavit). Rarel), it ma> come as a uickle from
the fallopian tube. Under the hormonal effects t11e endo-
metrium shows decidual changes, however. there is tile
absence of chorionic villi. When tubal pregnancy is disturbed,
witl1drawal of the hormonal suppon resultS in shedding of
tl1e deciduas. Sometimes, tJ1e whole of the uteline decidt.ta
separates from the enclometritun and is expelled as a
dec id ual cast (Fig. 17. 12 ). Decidual cast has a smooth glis-
ten ing inne r su rface and shaggy maternal surface. The
chorionic vi lli are conspicuo usly absenL The passage of a
decidua l cast is patltognomonic of ec topic gesta tion. Lf a
yo ung woman witJ1 a sho tt period of amenorrhoea com-
p lains of contin uo us or interm itten t but slight vaginal
bleeding, ectopic pregnancy shou ld be considered even if
the abdom inal pain may be slight or might have been short-
li ved and almost fo t'goucn. Vaginal bleeding and pain are
absent in ea rl y unruptu t'ed ectopic pregnancy. Bleeding
may occur very early in cervical and caesarean scar ectOpic
pregnancies.
ACUTE RETENTION OF URINE
In a subacute \>atiety of ectopic pregnancy, the blood
colleciS in the pouch of Douglas to form a pelvic haemato-
cele. This haematocele fonns an it·regular mass of differing
consistency due to a mixture of clot and blood, and bulges
fonvards displacing tJ1e cen ix against tl1e bladder neck
leading to retention of urine.
234 SHAW'S TEXTBOOK OF GYNAECOLOGY
Rgure 11.12 Complete decidual cast extruded from the uterus in a
patient operated for ectopic gestation.
FEVER
If t11e pelvic haemaLOcele gets seco ndarily infected, t11e
patient develops slight fever. It is rare to find high-grade
fever in a case of ectopic pregnancy.
PHYSICAL SIGNS
The physical signs may \'llry in acute tubaln.tpture, subacute
or chronic \'lll·iety of ectopic pregnancy.
ACUTE ECTOPIC PREGNANCY
A patient with sudden wba l rupture with acute intraperi-
tonea l haemon·h age presents in a State of shock wit11
marked pa ll or, tachycardia a nd h ypotension. T h e patient
is cold, the s kin is clammy, the te mpe•·awre s ubnorm al
and th e pulse thread)' with marked tac hycard ia . Blood
pressure will be low. Breast c ha nges of pregnancy may or
may not be prese nt depend in g upo n th e duratio n of
pregnancy and pa ri t)'· The abdomen is us uall y sli g htly
distended and marked ly tende r with restri c ted move-
ments. The d iste nsion is partly clue to ile us of in testine
due to t11e presence of b lood in the peritoneal cavity.
Rebound tenderness can be e licited in the lower abdo·
men, rigidity may or may not be present. Signs of free
fluid in the abdomen are present in a case witJ1 profuse
internal haemorrhage. Cervical movements during vagi-
nal examinaLion causes severe pain. Due to abdominal
tende•·ness. it becomes difficult LO make out exact size of
uterus du.-ing bimanual examination. In a case of pelvic
haematocele. a bulge ma) be felt in the poste•·ior fornix
dUJ·ing pelvic examination.
Clinical feaLUres of va•·ious L) pes of ectopic pregnancies
are explained in Table 17.2.
Table 17.2 Clin ical Feat ures of Ectopic Pregnancy
Acute ectopic Haemorrhagic shock
pregnancy
Acute pain in the abdomen
Amenorrhoea
Vaginal bleed
Abdominal tenderness
Subacute ectopic Amenorrhoea
pregnancy and
Abdominal pain
chronic ectopic
pregnancy Vaginal bleeding
Retention of urine
Abdominal mass and tenderness
Ultrasound
13-hCG level
Abdominal Amenorrhoea
pregnancy
Colicky pain
Postmaturity
Failed Induction
Ultrasound: Abdominal fetal position -
Malformed, dead
DIFFERENTIAL DIAGNOSIS
• Acute PlD: Acute PlD remains the most common differ-
ential diagnosis in a suspected case of ecLOpic pregnancy.
The absence of amenon·hoea, fever, tachycardia and
raised TLC and the presence of bilateral tender masses in
lateral fomices in a young patient following a recent
sexual encounter should raise a possibility of acute PlD.
• Corpus luteal haematoma simulates ectopic gestation botl1
in t11e history and clini cal findings. With a history of shon
peliod amenon·hoea, pain, vaginal bleeding and a Lender
mass with internal h aemorrhage, it is d ifficult to rule o ut
this condition. Ulu·asou ncl gives an idemical findin g in
both condi ti ons. ll owever, a nega ti ve urine pregnancy test
a nd nega tive serum hCG go in favour of co rpus lu te um
haematoma. Ruplltre of in u·aabdominal o rga ns: Sple nic
rupture t11o ug h uncommon in gynae practice can produce
a similar clinical pic ture; however, history of b lum tra uma
to abdomen and the absence of a me norrhoea go in favour
of diagnosis of sp le nic rupture.
• Perforated gastric and duodenal ulcer prod uce ac ute
abdominal pain, but signs of interna l haemon·hage are
absent. Abdominal palpation reveals board-like ligidity
which is absent in ectopic pregnancy. Air may be seen
Lmder t11e diaphragm in gasLric perforation.
• Perforated appendix and acute pancreatitis will demon-
su-aLe high fever and signs of peliton itis. Raised TLC and
serum am) lase level will help in making diagnosis of these
conditions.
• M)rocardial infarct has occasionall)' been considered
when the patient complains of epigastric pain and

collapses. Normal ECG and the gynaecological hiswry
will lead to accurate diagnosis.
• The diagnosis may be much more difficult with ruptured
secondaJ] abdominal pregnancy as the differential
diagnosis of ruptured uterus and concealed accidental
haemo•·rhage have to be considered.
SUBACUTE AND CHRONIC VARIETY Of ECTOPIC
PREGNANCY
ln this condition, there may be some degree of constitu·
tional diswrbance as a result of the localiLed inu-ape•·itoneal
bleeding, but the p•-edominant features are recmTent
abdominal pain and vaginal bleeding. Retention of ul'i ne
may occur due to pelvic haematocele.
The pulse 1-ate is •-aised in proportion to the severity of
the bleeding. It is exceptio nal for the temperature to
be raised to more tha n 99.48"F. T he abse nce of pyrexia may
be of help in d isti nguishi ng ectopic gesta tion from pyosal-
pin x. T he breasts 111tl)' show signs of ea rl y pregnancy. On
examinati on of tJ1e abdome n, tende rness in o ne or othe r
iliac fossa is no ted. Distension of abdome n and rigidity may
be rarel)' no ted in cases with localized pelvic haemawcele.
Th e charac te ristics physical signs are fo und o n vagina l
examination. T he pec uliar brownish uterine b leeding can
be noted, tl1e cervix is found to be soft and the ute n.IS
slightly enlarged. The oL11er physical signs may va•)' with the
type of case. With pelvic haemawcele, an irregular swelling
can be felt through t11e posterior fornix or in the pouch
of Douglas during rectal examination. It has a peculiar
consistenC) which is almost pathognomonic, as it has no
definite outJine, is neit11er fluid nor solid and its consistency
varies in different areas. Occasionally, the haematOcele
may be exu·emel) tender. It pushes the utenLS fon,-ards and
upwards, and on occasions produces retention of urine.
Occasionally, it may extend upwards into the abdomen and
is palpable during abdominal examination. A tubal mole
and the haematosalpinx form a retort-shaped swelling
which is tense, fir·m but smooth, and which pushes the
uten.IS to tJ1e opposite side of the pelvis. Pe•·itubal haemaw-
cele forms a fim1 swelling which may be mistaken for subse-
ro t.IS myoma. Finnness, tenclemess and smoothn ess are
ch aracteristics of the locali zed h aemaLOmas of ectOpic gesta·
ti on. One danger of vagina l exa mination is that it may
possibly d isw rb a qui escent ec topic. Fo r this reaso n, if an
ec topic gestati o n is s u·o ngl)' s uspected, vaginal examination
sho uld be pe •-fo11ned genLI )'· Ultraso und di agnosis may help
in a niving at a d iagnosis in d iffic ult cases.
Diagnosis of ec topic gesta tion is often d ifficult a nd ge t
missed as it is not suspected. In a yo ung patie nt and during
the childbeari ng period of life, wheneve r a woman
complains of pain in the lower abdomen assoc iated with
continuous/ irregular vagina l bleeding, a diagnosis of ectO-
pic pregnancy should be kept in mind.
DIFFERENTIAL DIAGNOSIS OF CHRONIC
ECTOPIC PREGNANCY
Qinical diagnosis remains a challenge as the condition may
simulate other conditions. '11tink of ectopic pregnrmcy when the
tWman pmmls tuitlt (llypic(l} .fr(lturrs in Wlrly P"'K'umcy.
CHAPTER 17 - ECTOPIC GESTATION 235
PYOSALPINX
ln acute pyosalpinx, patient runs high-grade fever, patient
may complain of a vaginal discharge. The signs of internal
haemorrhage are absent; so also t11e history of amenor-
rhoea. tJ1ough sligh Lirregular 'aginal bleeding may be pres-
ent in a p)osalpinx. In chronic p)Osalpinx, the patient may
be afebrile, pain and tenderness are mild and the pelvic
mass is often bilaLeml. In tubercular p)osalpinx, a histOry of
;uneno•Thoea, pain and a pelvic mass may resemble chronic
ectopic pregnancy. lmesLigations such as laparoscopy aJ1d
endomeu·ial biopsy ma)• help tO establish a diagnosis of pel-
vic tuberculosis.
SEPTIC ABORTION
A history of amenorrhoea, pain and bleeding per vagi num
wiLh a history interference by a trained o r un trained person
for Lermi nation of pregna ncy helps in making a d iagnosis of
sep ti c abortion. Fever usuall)' is hi gh with marked le ucocy-
tosis in septic abo rti on . An offe nsive vagina l disc ha rge goes
in favo ur of septic abo tt ion .
PELVIC ABSCESS
Pe lvic haematocele may be misLake n fo r pelvic abscess, espe-
cially if the patient has Culdocentes is t-eveals the true
naLure of Lhe swelling.
TWISTED OVARIAN CYST
Twisted ovari;u1 C)Sl causes acute abdominal pain and some-
times slight vaginal bleeding, but amenorrhoea is absent; so
also signs of internal haemorrhage. Ultrasound examina-
tion is of immense help in such a situation.
RUPTURE OF A CHOCOLATE CYST
AILhough an extremely rare condition, the ruptw·e of a
chocolate C)St can mimic ectopic pregnancy. It causes shock
and collapse, with acute abdominal pain. The absence of
ameno1Thoea and negative 13-hCG and ulu-asound help in
making a con·ect diagnosis.
UTERINE FIBROID
Uterine fi broicls can ca use ac ute pain in the abdo me n
a nd a pa lpab le abclo rni na l mass if a s ubse ro us fi b ro id
undergoes torsio n Ot' if reel dege ne ra ti o n develops
in a fibro id uterus. In s uc h cases, hiSLOI')' is mo re re liable
th an the pelvic find ings. Ultraso und can ma ke a co rrect
d iagnosis.
CORPUS LUTEAL HAEMATOMA
CorpLIS luteal haematoma usually presentS with a short
period of amenorrhoea, acute abdominal pain, vaginal
bleeding and rarel) shock due to haemorrhage. The
pelvic findings resemble that of an ectopic gestation. A
negative urine pregnane) test/ negative serum 13-hCG and
carefully done u-ans,>aginal ulu-asound (fVS) help LO
make a con·ecL diagnosis. At times, a laparoscopy will
clinch the diagnosis.
236 SHAW'S TEXTBOOK OF GYNAECOLOGY

ACUTE APPENDICITIS Failu re of rise in hCC by two folds in 48 hrs is suggestive

Patients usually have fever with leucocytOsis and vomiting,
u1e absence of amenorrhoea and vaginal bleeding helps to
differentiate it from ectopic pregnancy. Tenderness is felt
high up in Ule right fornix.
Risk Factors for Ectopic Pregnancy
• Pre-. ious PlD
• Peh ic wberculosis
• IUCD and POP users
• Pre-.•ious tubal stu·gery
• IVF- gamete inu-afallopian transfer (G IFT) ted111ique
• Previous ectopic pregnancy
DIAGNOSTIC INVESTIGATIONS (Table 17.3)
In Ule management of acute ec topic gestatio n, whe n a
pati e nt presents wiu1 ac ute abdo me n a nd in s hoc k d ue to
severe internal b leeding, tJ1ere is no need a nd no time for
a ny investi gaLi on o tJ1er tJ1an haemoglob in, blood grouping,
cross-matc hi ng and immed iate lapa ro tOm)'· However, in the
s ubac ute/ c h ron ic variety, investigations may be req ui red to
confirm the diagnosis.
of an ectopic pregnancy (Fig. 17.20). In ectopic pregnancy,
u1e doubling rate of is slow wiu1 less u1an 66% in-
crease over 48 hours.
Rapid bedside qualitative hCC test wiu1 a sensitivity of
25-50 ml U/ L should be used, if available, in an acute emer-
gency case (takes I hour). Progesterone level less than
20 ng/ m L also suggests abnonnal pregnancy, but tllis
hormone test has a limited value and takes time (24 hours).
It is not used in a routine work-up of a suspected case of
ectopic pregnancy. It has a sensitivity of only 80%.
ULTRASOUND
Ulu-asound has come to occupy the place of most impo•·tam
investigation in a case of ectopic pregna ncy. At ultraSotmcl,
the uterine cavity appea l'S empty and a mass ca n be seen in
the region of adnexa l. A gestational sac in the ad nexal is
however iden ti fied only in 5%-15% cases of ea rly ec topic
pregna ncy. in th e urine a nd se rum , a n e mp ty ute rine
cavity, a n adnexa l mass witJ1 free fl uid in u1e pe rito neal
cavity is paLhognomo ni c of a n ec top ic pregna ncy. T he
ultrasonic find ings at Li mes may resemble Ul a t of PID a nd
endome tliosis (Figs 17. t:3 and 17. 11 ). T he main advantage

URINARY/ SERUM hCG

A positive urine pregnane) test along wiu1 ultraSOLUld find-
ings and clinical suspicion helps in making a diagnosis;
however. a negati'e urine pregnancy test cannot be relied
upon to rule out ectopic pregnancy. Serum level less
u1an 6500 m iU/ L is seen in ectopic pregnancy and missed
abortion. A slow rise in sen.un hCG level is seen in a case of
ectopic p•·egnancy.

is detected in the serum 9 da)'S (5-10 ml U/ m L) and

in tl1e uline 13 days after ovulation, around the time of
implantation and before tJ1e missed period. T h e level dou-
bles every 18 how'S in a normal pregna ncy. However, in ec-
topic pregnancy t his doubling ofj)-hCG is abse nt ra m er the
increase in may be margin al or absent. T herefo re, in
case of do ubt and if the cond itio n of u1 e woma n re mains
stable, seria l s w dy and doub ling tim e s tudy a re useful. lfthe
level does not rise o r ri ses by less Ula n 66% fro m u1e previ-
o us read ing, ec topic pregnancy o r m issed abo rtio n s ho uld
be s uspec ted (N Kadar et al. ). When hCG level is mo re than
6500 m iU/ L, inu·auterine sac is visib le on abdom inal ultra-
sound. Similarly, witJ1 a serum hCG va lue of 1500 m iU/ L an
inu·auterine gestaLion Sl\C should be visible on TVS.

Ta ble 17.3 Inves tigations

Pregnancy test
Serum p-hCG level; repeat every 2 days
Ultrasound - MRI
Culdocentesis
L.apa-oscopy Figure 17.13 Ultrasonographlc view of adnexal ectopic pregnancy
with a ring of fre appearance on Doppler.

17.14 Ultrasound showing an empty uterine cavity with live
tubal ectopic pregnancy.
of u-ansvaginal sonography lies in making an early diagnosis
of an inu·auterine pregnancy. At 5 weeks of gestation when
L11e serum reaches 1000 miU/L, a gestational sac
a yo lk sac is visible. In an ectopic pregnancy, a pse udo-
sac o r an e mpty sac wiLllOut yo lk is fo 1med by decidua l
L11i ckening and is centrall y placed in uterus.
Other ultraSonic features are ' blob' sig n and ' bagel sign'.
A blood clot with a trophoblasti c tissue is known as blob
sign. An empty gestational sac in Lh e fallopian tube is known
as bagel sign. Corpus luteal haemon·hage shows spider-web
like contents haemorrhagic areas. Doppler uluasound
reveals increased vascuta.;t.y and a sign called fireball ap-
pearance has been described in cases of ec1.0pic pregnancy.
lVS detect.S uterine gestational Sl\C I week earlier than
u·ansabdominal probe (l'AS) and gives a clearer image
because of its proximity to the pelvic organs. Pregnancy can
be detected by TVS approx imately It1 clays after pregnancy
detec ti on by serum hCG at 1000 miU/ L level (5 Lll week of
gestation). Pulsed Doppler ultrasound can add further
information regarding the vascularity of the peri trophoblas-
tic strucwre and reduce false-positive findings (Fig. 17.15).
In a cen•ical pregnancy, t.he ut.erus is empty but a gestational
sac occupies Lhe canal. In a caesarean scar sit.e preg-
nanC), Llle uterus as well as t.h e cen ·ix are e mpty; howeve1;
L11 e sac is located O\'er t.he ist.hmus.
Flgure 17.15 Ultrasonography showing ectopic pregnancy wit h free
fluid In the pouch of Douglas.
CHAPTER 17 - ECTOPIC GESTATION 237
CULDOCENTESIS OR ASPIRATION OF THE POUCH
OF DOUGLAS
In L11e past aspiration from the poud1 of Douglas by placing
patient in a lithotomy position was a co mmonly done test to
make a diagnosis of ectopic pregnancy. Asp iration of2-5 mL
of nonclotting blood was taken as a d iagnosti c of ec1.0pic preg-
nancy. A nee cUe its tip in a "1·ong place o r tl1e presence of
ad hesions in tl1e pouch of Douglas co uld lead to fa lse-negative
results. Ctu't'Cntl)' with the availabili ty of TVS and sensitive
measurement culdocemesis is not a prefe•·red tesL
OTHER HORMONAL STUDIES
Placental proteins, especially PP1 4 (placental protein 14), are
reduced in ectopic pregnancy and t.heir diagnostic value ap-
pears to be useful. Schwangerschafts protein-! (SP1) and
p•'Cgnancy-associated plasma proteiJhA. (PAPP-A 1) appear
late, after 6 weeks of gestation; t.he•'CfOI'C, LJ1eir value in the
ea rly diagnosis of ectopic pregnancy remains doubtful. Nor-
mal progesterone level in earl y pregnanC)' is 25 ng/mL. Less
LJ1an 2 ng/ mL is seen in ectopic pregnancy but its use in clini-
cal practice is limited at presem as it takes 24 hours to perform.
LAPAROSCOPY
When an ectopic p•"Cgnancy is suspected, but LJ1e diagnosis is in
doubt in spite of equhocal finclings of ho•monal tests, ulu-a-
sound, one should proceed witl1 laparoscopic visualitation of
LJ1e pelvic organs. Not only laparoscopy helps to confirm t11e
diagnosis, most cases can be surg ically managed by laparoscopy
ltREATMENT
For long, sw-gery (lapru·otomy) was th e only management
for ectopic p•·egnancy. It is a life-saving measure for acute
wbal ruptu1-e with massive inu-ape•itoneal haemorrhage.
Howe-.e•·. now there ru-e options such as expectant manage-
ment, medical mru1agemem and a conser\'<ltive surgical
treaunent in early diagnosed cases of ectopic pregnru1cy who
are haemod) nrunically stable. Witl1 a diagnosis of very early,
unru pwred ectopic pregnancy made by uiLt-asound, a medi-
cal u·eaLment can give equally good results.
MEDICAL MANAGEMENT
METHOTREXATE THERAPY
The pri nciple for its use is based on the fact that metllotrex-
ate (mTX) is a folate antagonist t11at inactivates dihydrofo-
late reductase enLyme, leading 1.0 a full in teu-ahydrofolate
(essenti al cofuctor in t11e of D A a nd R A during
cell cli,·ision ). A single dose of mTX t11 e•-apy given in a dose
of 50 i.m. cru1 help in a slow decline of f3-hCG ru1d
ultimatel) dissolution of ectopic pregnane).
This form of therapy has a 90% success rate (Tanaka),
although about 4% may requi re one more dose of mTX as
recognized b)' a s low decline in hCG va lue or tJ1e fai lure of
a trea un e nt, wh ich is defined as a fai lure of hCG to fall be-
low 15% in tl1e lst week (4-7 days). A hi gher failure rate
( 18.6%, Lipscomb 2004) has been reponed in women with
previous ectopic pregnancy. About SO% co nceive but repeat
238 SHAW'S TEXTBOOK OF GYNAECOLOGY

ectopic pregnancy is observed in 15% of cases. About • Agranulocytosis: Platelet count 100,000
85% of these cases reveal patent fallopian tubes during the • Thrombocytopenia: Plate let count < 100,000
follow-up. Five per cent patients still require surgery • Hepatore nal toxicit)
because of a failed meclicaltreaunen L • Nausea. vomiting, gastric haemorrhage
• Alopecia
• ll1iection mTX 25-50 mg injected into r.he gestation sac
under uilrasound/ laparoscopic guida nce has also shown Contra indications
a similar success rate. It is an invasive procedure, so it is
• Serum creatinine level > 1.3 mg%
not a commonly tr.secl method of treaunenr..
• Liver function tests, serum SGOT and SGPT >50 IU/ L
• Low l-I b and platelet count
Prerequisites for mTX therapy in ectopic pregnancy for
• Preexisting blood d)scrasias
consideration of suitabili ty of a patient with ecr.opic preg-
• Acute pulmonary disease
nancy for mTX therapy, the follo,,ing uite•·ia should be mer..:
• Peptic ulcer
• Immunodeficiency disease
• The women should be haemodynamicall y stable.
• Breast feeding
• Ectopic pregnancy should be unruptured.
• Known drug sensitivity or the presence of drug
• Sen.1111 !3-hCG level should not exceed 6500-10,000 ml U/mL
allergy
• The si:t.e of the gesta tion sac should not exceed 3-5 em in
• Gestational sac > 3.5 em
its longest diam eter. • T he presence offetal ca rdia c activity
• Fetal cardiac ac ti vit)' sho uld be abse nt.
• Cervical caesarean scar and interstitial pregnancy.
• T he patient sho uld be wi ll ing to come for follow- up.
• T here should be no contra-indicatio n r.o mTX (liver
disease, anaem ia) . Other Surgically Administered Medical (SAM) Drugs
• The patient sho uld be desirous offuLUre fen.i li ty. • MifeprisLOne (RU486)
• Hb%, WBC and liver function tes t sho uld be normal • Prostaglandins
• 20% KCI solution
Side EHects of Methotrexate • Glucose solutio n - a ll injected into the gestation sac
• Anaemia: l-Ib% should be at least 9 g% tmder ulr.rasound/ laparoscop ic con u·ol
• Leucopenia: wee should be at least 4000 • Of all t11ese, mTX has proved the most effective.

Clinical Examination
Pulse, BP, Pallor, U/S Abdomen, TVS, Serum
HCG

Haemodynamlcally unstable
Tachycardia , hypertension, Haemodynamlcally stable
marked pallor
I
1
Gestation Sac<3cm • Gestation sac>3cm
HCG< 1500 units • Live fetus
Minimal free fluid in pelvis • Significant free fluid In pelvis
• Serum HCG>2000unlts
• Muhlparous women

Medical Management
(Injection Methotrexate SOmg intramuscular)
Follow up with serum HCG ( lapa IOSCOIJ'f
1
 CHAPTER I 7 - ECTOPIC GESTATION 239

Postmedication Management
Posunedication rnanagemen t comprises following:

• Avoid use of alcohol

• Avoid pregnane> until ectopic pregnancy resolves and
serum hCC becomes undetectable. Use of banier meth-
ods of contraception is advocated during the follow-up.

Response to mTX therap): Following mTX, a full in t.he

level of hCC to 15% or below the init.ial level is considered
a satisfactory resolution of a trophoblastic tissue. It is impor-
A
tant however to note that there may be an initial 1ise in
serum hCG le,•el in the first 4-7 days before th e decline,
increase in the sit.e of the gestation sac and abdominal pai n
due to release of hCC and sligh t bleeding during resolu-
tion . Ultrasou nd scanning therefore should be delayed
t.mti l after a week. Follow-up with h CG a nd ultrasound
is mandatory. Serum hCC sho uld be do ne every 48- 72
hours initiall y a nd the n weekly until the levels become
undetec tab le.

SURGICAL TREATMENT
8
All patients wi tl1 acu te ectopic pregnancy should be operated Figure 17.16 (A) Salpingostomy. (B) Salplng otomy.
upon at the earliest once the diagnosis is made. The opera-
tion essentially consists of open laparotomy, identifying the
affected tube, clamping the mesosalpinx and perfonni ng
salpingectomy as described by Lawson TaiL in 1884. The
pedicles are transfLxed and the blood present in abdominal
cavity and pelvis is remo,ed. Before removing the affected
fullopian tube alwa>s look at t11e contralateral fallopian Lllbe.
This is imponant in case t11e patient has infertility and it is
desired to presene t11e fallopian tube forsubsequemfertility.
Most patients show immediate improvement in t11eir condi-
tion following su•-gical management.
It is very impo•·tant to inspect the contralateral tube for
two reasons.

I. Rarel)' bilateral wbal pregnancy may be en countered or

the other fallopian tube is diseased/damaged.
2. Condition of t11e LUbe need5 tO be assessed tO ch eck the
prognosis of future pregnancy.

In most cases it is possible to preserve the ovary as it is

separa te fro m t11e gestatio n sac in th e wbe. Rarely, if ovary
is b l.lli ed in a tubo-ova lia n mass, salpingo-oop ho rec to my is
pe rfo rmed . In t11e past t11e b lood in the perito neal cavity
was used fo r auto u·ansfus io n. T he adva mages of autotrans-
fusio n are that b lood is ava ilab le immediately witho ut any
need for a cross-match. Also, there is no fear of u·an smission
of I-I IV, malalia and hepatitis B.
lYPES OF SURGERY ON THE FALlOPIAN TUBE
111e surgical u-eaunent ma) comp•ise salpingec10my, panial saJ-
pingectompalpingostOm) and milking of the tube (Fig. 17.16 ).
• Salpingectom> if the gestation sac is >4 em, most of the
tube is damaged and t11e other LUbe is healtl1y (Fig. 17.17 ).
• Partial salpingectomy if more than 6 em of t.he tube can
be preserved. Later, tubal anastomosis can be perfonned
(Figs 17.18 and 17. 19).
Rgure 11.11 Total salpingectomy for a tubal pregnancy.
• Salpingostomy- Antimese nteric border is incised, co n-
ceptus removed, haemostasis sec ured and the wo und left
open for secondary healing. The pregnancy rate is better
than with salpingotom> (Fig. 17. 16) and repeat ectopic
pregnane> is low. SalpingotOm) - The wound is closed
witl1 fine Vier) I suwres.
• Milking of the tube is possible with fimbria] pregnancy,
bul because of a risk of persistent inu-atubal bleeding
and a persisten l trophoblastic tissue and an increased
risk of recurrent ectopic pregnancy this technique is not
240 SHAW'S TEXTBOOK OF GYNAECOLOGY
Figure 17.18 Partial salpingectomy for a tubal pregnancy.
Rgure 17.19 Removing an ampullary t ubal pregnancy wit h conser-
vatio n of t ube.
popularly used. With im proved tec hnique, lapa roscopi-
cally performed above-mentioned procedures have
become the gold sta ndard in t11e treatment, with early
recover)', less pain and a sho n hospital stay. T he future
outcome is similar to Ul at of laparotomy. Most cases can
be managed by lapa roscopy.
CONSERVATIVE TUBAL SURGERY
Conservative tulk"ll surge!") is justifiable only if the contralat-
eral tube has ah·ead) been removed or is diseased, because
tllis t) pe of surge!") exposes t11e woman to a recurrent.
ectopic pregnane).
Fift) per cent women undergoing conservalive SLLrgery
conceive and have ute rine pregnane>'·
With improved awareness and screening proced ures,
life-threatening ectopic pregnancy has changed to a benign
condition. especially in t11e case of an asymptomatic woman
in stable condilion at t11e time of diagnosis ( Llll ruptured
ectOpic). Conservative medical treaunem then applied is
safe and cost effective. It also improves the subsequent preg-
nancy outcome.
The treatment of seconda•) abdominal pregnancy
includes perfonning a lapa•·otOm)' and removing the fetus
and placenta. Lf tlle placenta is adherent to a vascular organ,
it may be safer to clamp the cord close to t11e placenta, leave
the Iauer in situ and close the alxlomen without a drainage.
Hreschchysh)'n et al. (1965) proposed adm inistration of
mTX to resolve tl1e placental tissue. Ultrasonic monito•ing
and estimating serum 1)-hCG level are mandatory in such a
situation.
INTERSTITIAL PREGNANCY
TREATMENT
Altho ugh an ex u·eme l)' rare variety of ec topic pregnancy,
inters titial pregnanC)' can be assoc iated witJ1 massive intra-
peritoneal haemorrhage, rare ly a hysterec tom)' is indicated
in ruptured inte rs titial pregnancy. In unru pu.1red preg-
nancy, conservative manageme nt may be possib le. Incision
and emptying tl1 e gestaLional SllC following ligation of tl1e
ipsilateral uterine artery, ovarian and round ligament. is
followed by suturing t11e muscular layer. The risk of uterine
rupture in subsequent pregnanC) mandates careful an Lena-
tal monito•;ng and caesarean delive•)· Recently, hysteroscopic
removal oflhe sac has been attempted. Early imerslitial preg-
nancy has been managed witll local or intramtLScular mTX
injection and a follow-up until serum 1)-hCG disappears. In
all ectopic pregnancies if "oman is Rh-negative, it is achisable
to administer 100 meg ami-D gamma globulin to the Rh-
negative patient to safeguard against isoimmuniLation.
PROGNOSIS
Due to a delay in diagnosis or a fai lure to diagnose ectOpic
pregnancy still remains a cause of materna l deatl1s. Ten per
cent deaths in ectopi c gestatio n are primaril y d ue tO h aem-
orrhage. Following u·eaunc nt, 50%-80% of t11 e women
conceive and of these 50% have in tra ute rin e pregnancies,
15% will have repeat ec to pic pregnancy. T he rest remain
infenile, due to tubal damage.
UNRUPTURED ECTOPIC GESTATION
Recent advances in im munoassays for hCG and high-
reso lution ulu·asound have made signifi ca nt progress in tl1e
diagnosis and management of early unruptured ectopic
pregnancy. ln tl1ese cases, t11ere has been a shift from abla-
Live SLLrgery to conservative fertility-preserving tllerapy/
medical management. Schenker observed that 15% of ecto-
pic cases will have recun·en Lectopic pregnancies and 60%-
70% have fertiliL) problems. To improve fuwre fertility, and
LO avoid catasu·ophic haemon·hage, it is necessa•)' to make a
 CHAPTER 17 - ECTOPIC GESTATI ON 241

Pregnancy test

Weakly positive
+ Positive

+
Missed
+
Maternal serum
abortion or quantitative b-hCG
Early EP or earty >1000 lUll
uterine pregnancy
+
US scan of pelvis
+
Repeat serum
b-hCG 48 h
later+pelvic US
I
l +
Titre rising
Ti tre falling, irregular Titre rising
gestational sac buk66% and gestation

+
Blighted ovum or
+
Consider EP
sac in uterus

+
missed abortion Normal
+
TVS repeat+
pregnancy
diagnostic laparoscopy

False+ve Repeat US scan Too early Blighted Emply uterus

scan ovum
pregnancy test or in IVF pregnancy
to exclude
+ + +
+ concomitant EP Repeat Repeat
Laparoscopy
Too ea rly scan
scan+serum scan+ +
Mi ni mal
... quantitative b-hCG value
requisite
Repeat b-hCG b-hCG value
su rgery
and scan
Rgure 17.20 Positive pregnancy test: Features suggestive of ectopic pregnancy (EP).

di agn osis befo•·e the ectopic sac ruptures. This is possible with
Table 17.4 Spie gelberg Criteria to Diagnose
rotttiue tt!Jrruonic lemming in rarly jJrrgntmry. & rty 1iia[,rnOsis is
Ovarian Pregnancy
tfte key to lll(ltWgrmml.
if a woma n in the reproductive age complains of
• Pregnancy is in close relation to ovary.
amenorrhoea, mi ld abdo minal pain and abnonnal uterine • Fallopian tube on affected side Is normal.
bleeding, she should be suspec ted of ectopic pregnancy. • Mass is attached to uterus by ovari an ligament.
Early diagnosis of ec top ic pregnancy allows laparoscop ic • Histologically chorionic tissue Is In Intimate contact with
conservati ve surge•)' or med ica l the rapy. T his not on l)' ovarian tissues.
red uces mortalit)' a nd mo rbidity d ue to haemorrhage but
also improves subseque nt fertility.

EXPECTANT TREATMENT (Fig. 17.21 ) OVARIAN PREGNANCY

The expec tant treaunent comprises follow-up with serial
hCG levels and ulu·asouncl scannin g. It is applicable only if
t11e gestational sac is less than 2 em and hCG levels are no t
very high (< 500 mi U/ mL) a nd the a bse nce o fhaemoperi-
LO neum. in most cases pregnancies resolve witho ut any
surgical o r medical manageme nt Howeve r, due to the
Lmcertai nL) a nd a prolo nged fo llow-up, it is no t practical in
Ia.-ge num be r of cases.
Ova ria n pregnancy co nstiLUte 0.5%- 1% of a ll ectopic preg-
na ncies. T he crite ria for diagnosis o f ovarian pregnancy
we re desc ribed b) Spiegelberg ("la ble 17. 1) in most cases
co nditio n comes to no tice at the time o f surgery for
suspected tubal p regnane). The treatme nt co mprises
e itJ1e r oophorectOm) or panial resection o f ovary with me
reconsu·ucti on of remaining O\oal·ian tissues.
242 SHAW'S TEXTBOOK OF GYNAECOLOGY

Medical management Laparoscopy Laparotomy

• Methotrexate local or • Salpingectomy • Salpingectomy
systemic (1 mg/kg)+ • Milking fimbria! • Salpingo-oophorectomy
leucovorum (0.1 mg/kg) end pregnancy • Study opposi te tube
• Prostaglandin F2a • Salpingotomy
• RU-486 • Salpingostomy
• KCI, hyperosmolar • Resection
glucose • Study opposite tube

Follow-up
With hCG (serial serum quantitative titres)
I
Successful hCG rising or
plateau or
bleeding

Laparotomy

In laparoscoplc salpingectomy, the ectopic tube is removed using a tissue removal bag.
Before removal, endo..foop Is slipped into the mesosalpinx and tightened.
Diathermy knife or laser can be used in salpingotomy and salpingostomy to cut and
secure haemostasis.
Rgure 17.21 A treatment of ectopic tubal pregnancy (ETP).

CERVICAL PREGNANCY
Cervical pregnanC)• is exu-emely rare (0.5%-1 %), though in
Japan, the incidence is I / 1000 pregnancies and it is the second
most common variety of ectopic pregnancy. The woman pres-
ents with profuse painless bleeding following a shon period of
amenorrhoea. Pelvic examination r-eveals a patulous extemal
os and products of conception in the cervical canal; the inter-
nal os is closed and the uterus is finn and normal in size. Ultra-
so und helps in a correc t diagnosis; clinically, the diagnosis of
inevitable abortion is initiall)• made. Dopple r blood flow map-
ping and MRI im prove the diagnosti c acc uraC)'·
T he risk fac to rs are previo us e ndocervical curettage and
Asherman S)•ndrome.
ULTRASOUND
Rubin's criteria for diagnosis of ce rvical pregnancy.
• There should be no fetal tissue in llleri ne cavity.
• There should be opposite the placental tissue.
• The sac and fetal tissue present in cervical canal should be
below the level of reflection of peritoneum in the pelvis.
• lmernal os is closed
• The blood flow in the cenix is increased
• The absence of sliding sign - the pressure over the
cervix causes sliding down of the gestational sac in a
miscarr-iage, whereas the cervical pregnane)' remains
static, because it is auached to the cervix.
TREATMENT OF CERVICAL PREGNANCY
Because of a risk of profused bleeding during any surgical
procedure, the trea un ent co nsists of liga ting the uterine
vessel vaginally, suction evacuation and tampo nade by in-
sertin ga Foley cathe te r in tJ1 e ce rvical ca na l for 24 hours. In
case of profuse haemorrhage occasionally hyste rectOmy may
be needed. I-I )'Steroscopic resection of the cervical preg-
nane)' using resectoscope has been described by Ash and
Fan·oll in the USA mTX has also been locally, fol-
lowed if necessary a week later witJ1 suction evac uation. Un-
like in tubal pregnancy, i.m. mTX injectio n 50 mg may have
tO be repeated weekly until level disappears.
Uter-ine artery embolilation has been auempted to
reduce blood loss. prior to evacuation of cervical and
caesarean scar pregnane).

Ultrasound cr-iteria a r-e as follows:

CORNUAL PREGNANCY
• Empty uterus
• Ballooned cervix Comual pregnancy is a pregnane)• in the accessory horn
• Gestational sac and fetal tissue below the level of internal os. or bicornuate utentS. Pregnancy may continue up LO

14-16 weeks when a sudden rupwre inLO the pe1;toneal
al\'ity resultS in features of acute abdomen. In most atSes
diagnosis becomes obvious at the time of surgical manage-
ment for suspected ectopic pregnancy. Excision of rudimen-
tal)' horn at laparotOmy or laparoscopy is the treaunent. Most
cases in subsequent pregnancy should be managed by an
elective caesarean section as a site of excision of rudimental) '
horn re mains a weak area in the ute line musculawre.
HETEROTOPIC PREGNANCY
lleteroLOpic pregnancy, i.e. combined uterine and ectopic
wbal pregnancy, is very rare in spontaneous conception
C)cles; the incidence is not more than I :·1000 to I :7000 preg-
nancies. The incidence is howe\er higher in IVF programmes
because of the higher number of embi)OS transfe1·red, with a
possibility of one embi)'O migrating to the tube. The possibil-
ity is also related tO the amount of fluid i11jected ''1th the
embi) 'O. At present, fVF centres have reported an incidence
of I %-3% for heterotOpic pregnancy.
T he d iagnosis is not easy. The serum 13-hCG may not be
proportionately high. Ultrasound can visua lize multip le
pregnancy in early pregnancy. A carefully clone lVS in early
pregnancy may help to diagnose this condition.
TREATMENT
Medical treaunent in the form of mTX, mifep1·istone and
prostaglandin is contraindicated because of their adverse ef.
fects on the normal uterine pregnancy. Glucose and KCI have
been if!jected in the tubal pregnancy with the aim of continu-
ation of inu·auterine pregnancy. A surgical app roach in the
form of laparoscopic salp ingectomy mtl)' he lp to manage
conditio n successfull)' allowing uterine pregnancy LO grow.
In IVF programme, the fo llowing prophylactic measures
have been suggested:
• Bilateral tubectOmy prior to !VF.
• Transfer of not more than two embi)OS.
• A small amount of fluid medium to be u-ansfetTed.
• A routine ultrasound scanning in early pregnancy, in case
conception follows.
CAESAREAN SCAR ECTOPIC PREGNANCY
Caesarean scar ectopic pregnanC)' is recen tly reported in
6% of ectopic pregnancies. The ulu·asound shows an empty
uterus and cervix and the gestational sac is attached low
to t11e lower segment caesarean scat: Doppler imaging
confinns the diagnosis. The woman presentS with clinical
feawres of til reatened or inevitable abortion.
The gestation sac is embedded in the m)omeu;um and
fibrosis of the caesarean scar. MRI is a diagnostic teSL
ULTRASOUND
Ulu·asound shows following:
• Gesta tional sac located over tl1e lowe r ante rior uterine
segmenL
• The of sliding sign.
• Increased blood flow over tl1e lower uterine segmenL
CHAPTER 17 - ECTOPIC GESTATION 243
TREATMENT
• mTX injection.
• Surgery - Suction curettage may be risky even under
ultrasonic guidance and the risk of caesarean scar rup-
ture remains. A surgical removal of an ectopic site bear-
ing area in t11e regional istl1mus witl1 reconstruction of
uterus is t11 e preferred treaunent.
• In a )'Oung woman desirous of childbealing, resection
and s uturing of scar can be done but the risk of scar rup-
ture in subsequent pregnancy is considerable. There is an
increased 1isk of repeat scar ectopic pregnancy as well as
placenta accreta. Hysterectomy is recommended in a
multiparous woman.
PERSISTENT ECTOPIC PREGNANCY (PEP)
PEP complicates conservative tl1erapy, especiall y milking
of the wbe, when a portion of the conception productS is
left behind. Following laparoscopic salp ingostomy, PEP is
reported in 16% against l % following laparotomy.
Persistent elevation of serum J3-hCG is a diagnostic. A
repeat iqjection of mTX may help resolution of PEP.
RECURRENT ECTOPIC PREGNANCY
Recurrent ectopic pregnancy is seen in about 15% of cases,
irrespective of the method of previous treaunen t for ectopic
pregnancy. Such an event is more likely in cases with
previous PI 0 .
When a woman suffers from a recurrent ec topic
pregnanC)', it may be pn1dent to perfonn salpingectOmy
and offer IVF as a treatment for subsequent ferti li t)'·
MORTALITY AND MORBIDITY
Ectopic pregnancy is responsible for 11.5% matemal
mon.ality mainl)• due to a dela)' in diagnosis or a failure of
diagnosis. Early diagnosis and management can avoid
maternal death.
Morbidity includes following:
• lnferti li t)'
• Rec urrent ectOpic pregnancy
• Pe lvic ad hesions and chron ic pelvic pain
• Psychological morbid ity and fear of future pregnane)'
outcome
KEY POINTS
• Of all t.he ecwpics, tubal p1·egnanC)' is the most
common. PIO, previous tubal surgery and I UCO
a1·e the common predisposing factors for ectOpic
pregnancy.
• Although an ac ute ectopic pregnancy is life-
tllrea tening conditio n and requires an e mergency
surgery, subac ute and ch ron ic ec topi c pregnancy
may be managed medically or surgically afte r careful
confirmation of d iagnosis.
244 SHAW'S TEXTBOOK Of GYNAECOLOGY

3. A woman presents with 2 months amenor-

• It is now possible LO detect an earl) unrupwred eCLo-
pic pregnancy by uluasow1<l, aided by serum
le,el, and at times by laparoscop)'·
• Conservative smgery and medical therapy can pre-
serve the fallopian Lube for future ferti li ty. However,
15% are at a risk ofrec utTent ectopic pregnancy.
• Cervical pregnancy, pregnancy in a rudim entary horn,
caesarea n scar pregna ncy and abdominal pregnancy
arc rare.
• Heterowpic pregnancy is becom ing co mmoner due
to ART Management requires continuation of intra-
uteri ne pregnancy wit11 an appropriate u·eaunem for
tubal pregnancy. Recun·en t pregnane) remains a
threat to a woman one ectopic pregnancy, and
she needs good monitoring in the subsequent preg-
nancies.
• Early diagnosis is the key to successful medical and
minimally in vasive conservative surgery; it reduces
monality.
• TVS and serial 13-hCG he lp in ea rl)' diagnosis of ec to-
pic pregnancy in a suspected case.
t·hoea. Pt-egnanC)' test is positive, but ultrasound shows an
empty uterus. How will you manage t11is case?
4. A young primigravida presents with 2 months amenor-
rhoea, slight abdominal pain and vaginal bleeding.
Discuss the managemenL
5. A woman is b rough t to emergency ''ith ame norrhoea
2 months and feawres of shock. Disc uss th e manage-
me nt of such a case.
SUGGESTED READING
ACOG pmctkc bulletin. Tubal ectopic pregnane). Feb 2018.
Duncan JcffrC) S. Shulman Lee P Duncan. Schuman. Yeotr Book of
Obstetric>, Cp,aecology, and Women's I leah h. Page 295,John Wile)'
& 2010.
Maya Chcuy, Janine Elson. Treating non·wbai<-'CIOpic pre!,'llancy. Best
Pl"dCticc & Rt>sean:h. Clinical Obstt:trics & Cynaccology, Vol 23(4):
Elsevier; 2()()9.
Sengupla, Challopadhyay, Varnna. Tex1book of Cynaeook>!,')' for
and PntCiilioners, Elsevier; 2007.

SELF-ASSESSMENT
1. What are t11e causes of ectopic pregna ne)?
2. DiscttSS the S)lnptoms and signs of cluonic ectopic preg-
nancy. How will you manage a case of chronic ectopic
pregnancy?
 Acute and Chronic Pelvic Pain
Acute Pelvic Pain 245 Key Points 251
Chronic Pelvic Pain 247 Sell-Assessment 251
Pelvic pain is a fa irl )' co mm o n co mpla int amongst women
resulting in disru ption of th eir day-to-day ac ti vity, personal
life and sex ual life. IL is o ne ofthe co mm o n co nditio ns for
which women a LLend gynaecological OPD. Often managing
these cases is d iffic ult and Lax ing for gynaecologist
Acute pelvic pain is moSU)' due to some s ign ificant
pa tl1o logy such as ac me pelvic inflammatory disease (PlD),
ectopic pregnancy or torsion of an ovarian cyst, and
requires prompt. atte ntion. Urgent investigations may help
in clinching t.he diagnosis. In most cases, a prompt treat-
mem either medical or surgical is indica ted.
Chronic pelvic pain (CPP) mostly a condition witll
significant alteration in da)·to-day of a woman.
Before coming Lo hospital she may have visited several doc-
tors and •na) ha'e undergone large munber of investigations
and at Limes surgical interventions witllout much relief.
Although some mnaecological conditi ons sud1 as endome-
uiosis, pelvic congestionS) ndrome or chronic PlD can be tl1e
cause, in most. cases no obvious pathology is identified
ACUTE PELVIC PAIN
Causes ofacuLe pelvic pain may va ry in different age groups.
Following are Lhe co mmon ca uses of ac ute pelvic pain:
PREMENARCHE
• Congenital ca uses: llae matocolpos a nd haematometra
(C hap ter 5)
• Ovarian cyst.: Torsion, ru pture haemo n·hage and malig-
nanC)' (C hapter 32).
• Abdominal tuberculosis
• Nongynaecological ca uses: UTI, ac ute appendicitis,
gastrointestinal problems, acute porphyria.
ln yo Lm g adolescents, mostly ac ute pain is of a nongynae-
cological origin. The) ma) be related tO urinary tract,
gastrointestinal u-act or abdom inal tuberculosis.
lWISTED OVARIAN CYST
Dennoid cyst is the commonest ov:u·ian cyst seen in young
girls, because of long pedicle tl1is cyst has a tendency tO
undergo torsion resulting in acltle abdo minal pain. Less
commonly o tl1er ge nn cell tum ours of ova ry can be the
cause of acu te abdomi na l pain d ue to to rsion, n.tpwre or
infec tion.
REPRODUCTIVE AGE GROUP
Acute pain may be due LO obsteu·ical, gynaecological and
nongynaecologic:LI conditions.
OBSTETRICAL CAUSES
• Abortio1u. Pain ma) be due to incomplete or
septic abortion. I nevi table abortion is associated with
severe vagi n:LI bleeding and the diagnosis is obvious.
• Septic abortio11. ln septic abortion, t11e wom:m suffers
from high fe,•er, sC\ere alxlominal pain and vomiting.
Foul-smelling vagina l discharge ma)' be present.
• Ectopic Acute ectopic pregnancy is associated
witll severe abdominal pain and short pe•iod of amenor-
rhoea witl1 or witl1out vaginal bleeding. Ultrasound
•·eveals f•·ee fluid in the abdom inal cavity and a pelvic
mass. lt requires immediate surgery.
• Red degeuuation of fibroid. A woman in pregnancy may
develop acute abdominal pain and often vomiting, uterus is
enlarged and Le nder. Ulu·asou nd is of help in differentiat-
ing tl1is conclition from other ca uses. In most cases, a con-
servaLive u-eaune nL in t11e form of •-est and analgesics helps.
• Twistwl warimt T his req uires immed iate surge•)'·
• Acute hydrrmwios. Mo 1-e co mm on in a multi p le pregnancy,
ac ute h)•dramnios prese nts wit.J1 undu l)' enlarged uLerus
in mid-pregnancy and abdom inal pain and respiratory
disu-ess. Ultrasound shows mul tip le p•-egnancy and
hydramnios. Invariably, patient goes into preterm labot.u·
and delivers.
• Molar Jm!t,mmuy. Pain is due LO sudden enlargement of t11e
uterus filled witl1 molar tissue. Occasionally excessive
bleeding ma) occur. Evacuatio n of the mole is required.
• Retention of uri11t. Ret.en lion of urine may occur due LO
acute UTI. reu·o,e•ted g•-a' id uterus or haemato-
cele of ecLopic pregnane). Fibroid or ovarian cyst
impacted in tlle pouch of Douglas can also cause reten-
tion of urine. CatlleLeriation of bladder and u·eaunem
of underl) ing course is warramed.
245
246 SHAW'S TEXTBOOK OF GYNAECOLOGY

• Abruptio plllcmtae. Bleeding in reLroplacemal space in a
case o f abruplio n placentae can cause acute abdomen. It
is accompanied by feawres of shoc k and marked abdom-
inal tenderness. Immediate Lreaunem in the fo rm of in-
duction of labour/ delivel) is indicated tO prevent severe
complications such as Disseminated Intravascular Coagu-
latio n (OIC). renal failure and shock.
GYNAECOLOGICAL CAUSES (Figs 18. 1 and 18.2)
• D)•l'111ttwrrlwea due to pelvic palhoiOg)' such as endome-
Lriosis, fibroicls or a p•·imary dysmeno•-rhoea can cause
acute abdominal pain. Al though p•·imarydysmenoni10ea
is present since me na rche, dysmenorrhoea due to
conditions such as fibroids, e ndo me triosis or adenomyo-
sis begins later in reprod uClive life.
• Mitt.ebclmun. is a mid<)'C le pain, not lasting more than 12-24
hOLLI'S. is noted around lime of O\ulalion. Pain is located in
one of the iliac fossa and ma> be accompanied with slight
wgi nal bleeding. Analgesics ma> be req uired for severe pain.
• PID. Acute pain felt in the lowe r abdome n accompanied
by fever, u•·inal) ' S)mptoms ma>• be due tO acute PID.
Ofte n patie nt co•·relates onset of pain tO a recem sexual
relation or some procedu re on ULerus. Pain is mosLly
bilateral in lower a bdomen.

( Acute Pain In Gynaecology J

( History, clinical assessment and relevant investigations J
( Transvaginal ultrasound
l
l l
[ • No abnormality detected
• No pelvic tenderness
I Normal ultrasound but
tenderness present
Pelvic pathology

l laparoscopy Specific treatment

l
• Observation • Pelvic adhesions • PID
• Urine culture • PID • Endometriosis
• A ule out non- • Endometriosis • Torsion of fibroid , 011arian cyst
gynaecological • Diverticulitis • Rupture of ovarian cyst foll icle
pain • Urine infection • Ectopic pregnancy

Rgure 18.1 Acute pain in gynaecology.

[ Acute Abdominal Pain

J
• Clinical examination
• Hb, TLC
• Ultrasound Examination
• Urine pregnancy test
I

• Marked Pallor • Fever • Tachycardia

• Absence of fever • Tachycardia • Tenderness in abdomen
• Unilateral adnexal mass • Abdominal tenderness • Negative pregnancy test
• Free fluid in pelvis • Negative pregnancy test • Adnexal mass

Ectopic Pregnancy Acute Pelvic Torsion of

Inflammatory Disease Ovarian Cyst
Figure 18.2 Acute abdom inal pain.

• Acute pain in endometriosis is e ither due tO
rupture of a chocolate cyst or due to leakage of blood
into tl1e peritoneal caviL). Ulu·asound helps LO detect the
cause. Laparoscop) or laparotOmy is required.
• Ovarian hyperltimulation spulrome. In a woman witll infer-
tilit) who is undergoing induction of ovulation, acute
abdominal pain ma> be due LO ovarian h)'Perstimulation.
ln most cases, h)perstimulation begins with the injection
of H uman Cho1ionic Gonadou·opin (hCG) for release of
mature ovum from the ovary. It may be noted that severe
case requires hospitalitation, inu-avenous fluid and dose
obser.mion (see Chapter 15).
• Uterine fibroid>. Normally, a fibroid does not cause acute
pain unless a pedunculated fibroid undergoes wrsion or
the vessels on the capsule ruptures causing inu-apel"iw-
nea l haemorrhage. 1i·catment is prompt diagnosis a1Ui sttr·
giwl iulervention.
• Ourtrirm tuiiWUTl. Torsion, infection of haemorrhage in
a cyst and rupture ca use acute pain in the abdomen.
Malignant wmours mOSU)' do not produce ac ute pain
and remain 'si le nt' unti l in an advanced stage (C hapter 32).
NONGYNAECOLOGICAL CAUSES
• Retention of uriue in women can occ ur d ue to an ovarian
tumour or fibroid impacted in the pouch of Douglas.
Acute cystitis and bladder sto ne severe pain in the
sup•-apubic region. In a ureteric colic, pain is felt along
tJ1e course of ureter.
• pain is often colicky and associated witll
gastrointestinal S)lnptoms. Appendicitis can confuse the
diagnosis. but the pain is localized in the right iliac fossa.
• Abdominal wberculosis.
MENOPAUSAL AND POSTMENOPAUSAL WOMEN
• collection of Ptt> in thl' uterine tXJVity, can occur in
endometrial carcinoma or following radiotherapy or
when the cer.•ix gets stenosed due LO tubercular and
senile endomeu·itis. The pain is localited in tl1e cenu-al
portion of the lower abdomen and may or may not be
accompanied with fever. Ulu-asound reveals an enlarged
uterus with fluid in the cavity. Treaunem comprises
cervical di lation for drainage of pus and antibiotics. A
s ubsequent e ndomeu·ial curettage will help tO rule o ut
underlying mali gna nC)' or tuberculosis.
• Ouariau tuiiWUTl iu flderly, fJostmenoprn.t.wl wom(m art mostly
malignrmt. T hey ca n present witlt ac ute abdom inal pain.
• Sarcoma of Afthough mre, .1-rtrcmnrt um develop in a
·t.tleru:, with A diognosis is mrzdil when th11jibroid starts
grawi11g rapidly camiug pain, postmenopausal b leedin g or
low grade fever (Chapter 13).
• Retmtion of urine can occ ur in a postmenopausal
woman due to bkulder 11Hk obstruction, prolapse uterus or
urinary infection and requires drainage and appropriate
management.
CHRONIC PELVIC PAIN
Chronic peh·ic pain (CPP) refers to aqclical pelvic pain of
more than &month dlll-ation. This t)pe of pain has been a
recogni.ted as a spnpLOm of organic conditions such as
CHAPTER 18 - ACUTE AND CHRONIC PELVIC PAIN 247
endomeu·iosis, adenomyosis, chronic PID, uterine fibroids
and due Lo postoperative adhesion formations. It needs
appropriate medical and surgical management.
However. a CPP in the absence of any palpable or
demonsu-able pelvic patllOiog) is more difficult to manage.
It is eas> to attribute this to neurosis, as many of t.hese
women present with neurotic personality. However, it is now
confirmed that neurosis is the result and not the cause of
this CPP. Chronic peh·ic pain S)ndrome (CPPS) does exist.
It is imponam therefore to elucidate the cause of CPPS by
detailed investigations such as u-ansabdominal and trans-
vaginal ultrasound and a diagnostic laparoscopy.
Laparoscopy ma>' re,·eal small foci of endometriosis
and pelvic adhesions which are invariably missed on pelvic
examination. The absence of pelvic pathology and findings
of normal pelvic organs is reassuring LO the woman as well
as tlle doctor tl1at no serious disease such as cancer exists.
At times, the congestion and dila tatio n of pelvic veins is the
only abnorma l finding noted.
INCIDENCE
Abo ut 15% of women comp lain CPP. Abo ut 10% women
visit tJ1e gynaecologists. In so me ce ntres, as many as 30%-
40% diagnostic laparoscopies are performed for CPP.
AETIOLOGY (Table 18.1)
The causes of CPP are diverse. They may be gynaecological
and nongynaecological.
l. Gj?UU'coWgiml must.s are moSt!) organic but can be func-
tional at times.
The well-recogni.ted organic causes are as follows:
• Pelvic endomeuiosis, d1ocolate cyst of the ovaq
(30%-35% )
• Ovaries - ovarian adhesions, residual ovarian syn-
drome, ovarian tumours (benign and malignant)
• Tubal - chronic PID, tubal adhesions, postoperative
adhesions, pa•-ameu·itis due LO infection or malignancy
(24%)
• Pelvic tuberculosis and adh esio ns
• Uterine -uterine fibroids and adenomyosis, pyometra
in menopausal women, nxed re u·ovened uterus
2. Pt.mct.ional include th e foll o"1ng:
• Congestive clys me nordloea, Miue lsc hm erz and post-
coital pain
• CPPS, pelvic varicose o r d il ated ve ins (30%)
3. Nongynaecologiwl a111 as
• lmestinalwberculosis, diverticu litis, colitis, append ici-
tis, initable bowel S)•ndrome which acco unt for 20%
cases
• Carcinoma rectum
• Chronic intestinal obstruction
• Renal - ureteric colic, bladder stone, urinary tract
inJection, C)Stitis, chronic retention of urine.
• Skeletomuscular- joint pains (referred pain).
• Hemias
• Sickle cell disease, porph) ria
• ew·ological- herpes LOSter, nerve enuapment, nerve
compression, refen·ed pain
• Scar- scar site pain, scar endomeu·iosis
248 SHAW'S TEXTBOOK OF GYNAECOLOGY

Table 18.1 Correlation of History of Pelvic Findings and the Possible Diagnosis
History Physical Finding Diagnos is

Progressive worsening of dysmenorrhoea and Tenderness and nodules in the posterior Pelvic endometriosis
fornix and uterosacral ligaments
Pelvic pain (postoperative) Restricted mobility of pelvic viscera Pelvic adhesions
Menorrhagia, dysmenorrhoea Bulky uterus Uterine fibroid or adenomyosis
Shifting pain on body movement Normal pelvic f.ndings Pelvic venous congestion
Dyspareunia, postcoital pain following surgery Tender ovaries at the vault Residual ovarian syndrome
Pain and bulge over the abdomen or scar Hernia
-----------------------------------------
Hernia scar endometriosis
Urinary frequency, dysuria urgency, pain suprapubic Bladder d istension or empty bladder
-
Cystitis
Pain left iliac fossa Tender colon Colit is
Pain ri ght iliac fossa Tender McBurney point Chronic appendicit is
Referred pain, localized pain on t rigger points Trigger points Nerve and muscle pain

NO OBVIOUS CAUSE FOUND FOR CHRONIC PELVIC PAIN
ln q uite a few cases, no cause of C PP can be detected in
spite of d etailed work up (35%). Eve n laparoscop ic find ings
appear normal , and investigatio ns u ndertaken do not reveal
a definite cause. It is a lso observed that even when a lesion
is detected, it may not be th e cause o f the CPP, i.e. loose
peritoneal adhesions, mainly postoperative adhesions do
not cause chronic pain, a nd ad hes io lysis does not cure the
spnptom.
ORGANIC CAUSES
ENDOMETRIOSIS, CHOCOLATE CYST OF OVARY
Endometriosis presents as dull lower abdominal pain associ-
ated \lith dysmen orrhoea, m e norrhagia and dyspareunia. lt
is important to note that sm all lesions with fibrosis may
cause only dull clwonic pain. l e nde r nodules felt in the
posterior fornix a nd tender pelvic masses with the above
history may h elp to recogni ze the clinical cond ition of en-
dometriosis. Ulu-asound co nfirms the presence an d e xtent
of the pelvic mass. Laparoscopic examin atio n is useful n ot
o nly LO confirm th e unsuspecte d clini cal d iagnosis b u t also
to s u rgically manage b)' coagula ti o n o n the lesio n. lf a
c hoco la te cyst is no te d in the ova ry, it ca n be la pa roscop i-
cally managed.
Su rgical re mova l of c hocolate cyst b)' laparo to my may be
necessary if the cys t is huge.
A correlation of macrosco pic find ings with h isto logical
and clinical find ings is rathe r poor: Severity of endometrio·
sis does not always corre late with severity of pain. Small
lesions near me rosacral ligame nts may cause more severe
pain tJ1an caused by large c hocolate cyst.
OVARIAN ADHESIONS AND POLYCYSTIC OVARIAN
DISEASE
Polycystic ovarian diseases us ua ll) do not cause any pe Ivic
pain, however, following su rg ical manage ment in tl1e fonn
of O\oarian ch-illing a nd subsequem ova•·ian adhesions can
cause chronic pelvic pain.
CHRONIC PELVIC INFLAMMATORY DISEASE
C h ronic PLO causes c h ron ic persistem lower abdomi na l
pain, dyspareunia , dysme norrhoea, menorrhagia and
infertility. The uterus is reu·overtecl and fixed. Th ickened
and slightly tender fornices o r a tubo-ovarian ma.'IS is noted.
lf medical treaunent fails, the remo,oal of adnexa or hyster-
ectomy may be needed.
PERITONEAL AND POSTOPERATIVE PELVIC ADHESIONS
ot all adhesions cause pain. Loose ad hesio ns which do not
resu·ict mobilit) of abdominal 'isce•-a remain as)lnpLOmatic
and do not •·equire adhes io lrsis. Rather, breaking tl1ese ad-
hesions may result in reformation of denser adhesions
which may cause persiste nt chronic pain late•: Dense adhe-
sions and adhesions which resu·ict visceral mobility will lead
to CPP. lf these adhesions enu-ap the ovaries, pelvic pain
can result. It is obset·ved tllat som e adhesion tissue contains
nerve fibres, and tJ1 ese adhesions whe n stretChed duri ng
movement ofvisce1-a ca n ca use pain.
PELVIC TUBERCULOSIS
Pe lvic tuberc ulosis is a com mo n cond itio n in Ind ia affec ting
wo men of reprod uc ti ve age. Apart fro m c hro nic pa in, th e
wo ma n ofte n s uffe rs from a me no rrhoea, o ligome no rrhoea
a nd in ferti lity. Endome tria l c u reltings may in some cases
reveal th e tubercular natu re of t11e infec tion. Laparoscopy
ma)' be necessary to confirm t11e d iagnosis. An ti-T B treat-
ment is needed. Po lymerase Chain Reac tion (PC R) on en-
dometria l tissue and biopsies from pe lvic su·uctw·es he lps tO
diagnose tuberculosis when histology fails to do so.
UTERINE FIBROIDS AND ADENOMYOSIS
Uterine fibroids and adenOm) OSis ca use dysmenorrhoea
and menon·hagia. Dull abdomina l pain is due to
and pelvic congestion, a nd at times due tO associated PLD.
Submucous fibroid can cause colic k) pain in the fonn of
spasmoclic d ysme norrhoea. In te rstitial fibro icls can cause
d ys menorrhoea m ore often Ula n subsero us fibro icls which
cause more of hem iness a nd dull pain. Bimanual examination

and ulu·asound wi ll he lp LO establish the ca use of the pelvic
pain.
OVARIAN CYST OR TUMOUR
Ln most cases ovaria n C)St or wmour ca uses dull aching pain
or a sensation of heavi ness in lower abdome n. However,
rapid increase in siLe of the wmour or d1anges such as
haemorrhage, infection or LOrsion can cause pain. A der-
moid C)St may cause dull pain due to infection and gradual
tOI'Sion of iLS pedicle. Malignantw mour is a silemLUmour
causing pain only in the achoanced stage.
RESIDUAL OVARIAN SYNDROME
Residual ovarian syndrome is seen when one or both ovaries
are saved at the time of hysterectomy. These O\>aries develop
adhesions with sun·ouncling su·uctures causing CPP and
dyspareunia. Extensive and dense adhesion may require
surgical remova l of tJ1 e ova lies. WitJ1 tJ1 e availabili ty of hor-
mone rep lacement the rapy (HRT) , some believe in remov-
ing bo th ovaries a t tJ1e time of hyste rectOmy LO avoid occ ur-
re nce of residua l ova ria n syndrome and the remote
possib ili ty of ova ria n ca ncec
DYSMENORRHOEA
Congestive d)'Sme no •,·hoea is present in endometriosis, PLD
and uterine fibroids. I L is felt as a dull ache in the lower
abdomen starLing a few clays before mens u·uation and is
relieved fo llowing tJ1 e o nset o f menses. The woman may
also complai n of backache and heaviness, in tJ1e lower abdo-
men. D)'Smenorrhoea is related to menstrual cycles.
OVULATION PAIN (MITTELSCHMERZ)
Ovulatio n pain occurs in micl-qcle, is often acute, but at
times a sha 1p pain is followed b) a dull pain las ting for sev-
eral ho111'S. It may be clue to rupture of a Graafian follicle,
timing co•·responcls to time of LH peak a nd generally noted
24 hours before O\lllation. It is postulated LO be due to
contractility of ovarian perifollicular smoorn muscle medi-
ated through PGF2a. In such cases, a nti-inflammatory
drugs (nonsteroidal anti-inflammatOI)' drugs, NSALDs) :u·e
effective.
CHRONIC PELVIC PAIN SYNDROME
CPPS is a condition characterized by CPP not associated
"1th any cli ni ca l evide nce of pelvic pa thology. At laparos-
copy, pelvic ve ins a re seen d ilated and some are associated
venous stasis. T he woman is genera lly in reproductive
age and compla ins of d ull ac hi ng pain in the lower abdo-
men; in rare cases, severe pa in which responds to postural
aclj usune nt. Lying flat re lieves o r red uces pain, whereas
standin g, walking o r bending worsens it. Other associated
symptoms are co ngestive dysmenorrhoea (60%-70%), d)'S·
pareunia a nd postcoital ac he. Polycystic ovary syndrome
(PCOS) is seen in 50% of tJ1e cases and menorrhagia is pres-
em in same num ber of cases. Shiftin g locatio n of pain witl1
body movemenLS is characteristic of this syndrome. Doppler
ultrasound and 'enograph) he lp in tJ1e diagnosis.
INTESTINAL CAUSES
Chronic lower abdominal pain related to imestines :uHI
sigmoid colon is seen in in·itable bowelS) ndrome :u1d bowel
S)lnptoms such as constipation, chronic diarrhoea and
CHAPTER 18 - ACUTE AND CHRONIC PELVIC PAIN 249
colicky pain. Sigmoid colo n pain is fe lLin the left iliac fossa,
lasts for a few minutes to a few ho urs. Intes tinal colic is often
related to food and accompanied by flatulence. Appendici-
tis may present with chron ic pain in tJ1 e right iliac fossa. Ir-
ritable bowel S)ndrome and inflammaLO•)' bowel diseases
:u·e nottmcommon in women in age group of30-40 yea rs,
and may be associated with pelvic ve nous congestion (20%) .
Stool examination for amoebiasis, sigmoidoscopy,
colonoscopy and bal'ium enema may reveal the cause of
abdomina l pain. lrl'itable bowel S)ndrome responcls to
drotaverine and mebeverine.
URINARY TRAG
Infection, cystitis and bladder stones cause CPP, but :u·e
associated witl1 udna11' symptoms. Chronic retention of
urine caused by bladde r neck obstructi on or a pelvic
tumour causes chro ni c pain in the suprapubic region and
difficulty in passing urine. A full bladder is palpable in th e
suprap ub ic region. Ca tl le te rizatio n will empty tJ1e bladder
and relieve tJ1e d iscomfort. Ch ro ni c reten ti on of urine with
over flow is not unco mm o n in postmenopa usal wo man due
LO narrowing of ure tJu·a o r senile ure tJ1ritis. Uri ne cul ture,
cysLOscop)', rad iograph)' of pelvis for stone and ulu·asound
are useful diagn os ti c procedures.
PSYCHOLOGICAL FAGORS
Some women with CPP appear neuro tic and this was consid-
ered to be t11e ca use in women witJ1 CPP. As mentioned
before. now it is proved, that in many cases ne urosis is t11e
result of CPP :u1d not vice versa. Some e leme nLS of ne urosis
may eventuall) co ntribute to exaggeration of S)1npLOms.
AntidepressanLS do not relieve pain in majority of these
women, though when given along with medications do
alle,·iate neurosis. PS)Chotherap) ma> also help.
SKELETOMUSCULAR PAIN
Diseases of bone and joints can cause CPP. Llioinguinal
nerve may be trapped in a wide Pfannenstiel incision. Post-
operative muscle pain is also possible. T•·igger points c:u1 be
located b)' pressing a finger where the woman complains of
pain. Pain following su•-ge•)' and accidents are the obvious
causes of chronic pain. Referred pain from the spine is an
identifiable ca use of chro ni c pain (Tahle 18. 1).
WORKUP OF A CASE OF CHRONIC PELVIC PAIN
HISTORY
CPP is common in re prod uctive yea rs. T he onset, type,
d uration and location of pain will provide guiclance to th e
probable cause of the pain. Ra dia tion of pain and its
relation to mensu·uaLio n is important. Obsteuic and sex ual
histo •)' is important. 1-listO•)' of use of intrauterine contra-
ceptive device suggests possibility of pelvic infec tio n. Associ-
ated ttrinary and bowel S)1nptoms should be e nquired into .
Some wome n with CPP also complai n of d)'Smenorrhoea
and dyspareunia.
A histo•') of tuberculosis and psychiatric problem wi U
he lp. Histor> of cancer in the fami l) will suggest probable
can cer phobia in the woman.
General examination may reveal l)lnphadenopathy
(lllberculosis), anaemia and swelling of feeL Abdominal
mass, ascites and tenclemess suggest organic cause.
250 SHAW'S TEXTBOOK OF GYNAECOLOGY
Vaginal discharge is see n in PlD. Biman ual pelvic exami-
nation is necessary to rule out organic pelvic pathology. A
full bladder is felt anterior to the uterus and is tender on
palpation. Rectal examination may reveal a mass in the
pouch of Douglas or a stricture in rectum. Pa in and restric-
tion ofjoint movemems, especiall) hip joint or lumbosacral
spine, suggest refened pain to the pelvis. Tendemess in the
pelvis is caused b) endometriosis, adenomyosis, pelvic adhe-
sion, PlD divea·ticulitis anclu a·inary infection.
Ovarian pain is located at the junction of the middle and
inner two-third of a line between the amea·ior superior iliac
spine to the umbilicus, and tendemess can be elicited here.
INVESTIGATIONS
A firm diagnosis and cause of pain cann ot always be elicited
clinically. Ulu·aso und, diagnostic laparoscopy, Doppler
ultrasound for pelvic congestio n, urine tests, barium en-
ema, colonoscopy, sigmoidoscopy, rad iograp hy ofjoin rs and
inu·aveno us pye lograp h)' (IVP) wi ll be needed in accor-
dance with tl1e pa ti e nt's histo ry a nd exa min ati o n. CT and
MRl may be helpful in so me cases. MRI can miss a small
nodule, but it p icks up rcctovaginal endometriosis.
Laparoscop)' detects s ma ll foc i in the pelvis sugges tive of
endometriosis wh ich are undetected cli nically. It can detect
pelvic adhesions and small in nammawry masses apart
from obvious pelvic pathology. Therape utic treatment can
be applied in tl1 e same sitting such as ad hesiolysis and cau-
teri.t.ation of e ndometriosis. Pe lvic venous congestion and
dilated vessels are not alwa)S revealed because of a head low
position and pressure of pneumoperitOneum.
A poor correlation between macroscopic and histo-
logical evidence exists at laparoscop) and the ctiagnosis can
be missed if pe.-itoneal biopsies are not taken. The bw-nt-
out healed areas of endomeu·iosis can also cause CPP due
to fibrosis and entrapment of nerve fibres.
£\en if a pelvic patl1ology is detected at laparoscopy, i.e. fi.
broid or a small ovaaian C)Sl, adhesions, it may not be the real
cause ofCPP; it could bejusta coincidental fincting. 'O:mscious
pain nwj>jJing' at diagn(llfic laj>MUM:ofl)' muiPr local antJJJsthesia is
t11JPfttl in d«iding the wr.Lle mullocatior1 ofrhrrmir pain.
When laparoscopy fails to revea l any pathology and
pelvic venous co ngestjo n is suspected to be tl1 e cause of
pelvic pain, u·ansuterine pelvic ve nograph y is performed by
injec ting tl1e dye myo metria ll )' or pelvic venography using
comrast medium . In pe lvic co nges tio n syndro me, dilated
ova ria n and ute rine vesse ls more t11an 10 mm with delayed
clearance of dye are obse rved. Hyste roscopy p icks up intra-
uterine lesions.
MANAGEMENT
The detection of pelvic pat11ology or cause for pain deter-
!lUnes tl1e therapy appropriate for the case. Negative inves-
tigations at least assure t11e woman that no serious pathol-
ogy exists; this wa), cancer phobia can be eliminated.
Diag11rutic krJxrroM:o/1)' rmwinJ till' gokl sta11dard wlum tr woman
Jails to w lwmtotU'J.
The problem however remains when no cause is found.
Doppler ulu-asouncl or pehic venograph)' will demonsu<ne
the dilated 'eins. Treaunentcompaises progestogen theraP>'
or hysterectomy. SAJDs are effective in mild cases.
Gonadou·opin-releasing hormo ne (G nRJ-1 ) can shrink the
endomeuiosis and the pelvic veins.
The rationale behind progestogen u·eaunent is that oes-
trogen causes dilatation of pelvic vessels and progesLOgens,
by th eir antioestrogen ic effect, constrict the veins, reduce
t11e blood flow and suppress ovulation. Medroxyprogester-
one acetate (MDPA) up to 30 mg dail) (Provera) give n for
9-12 montllS relieves pelvic pain. Unfonu nately, pain may
recur after stoppage of tl1e ch'ug and a prolonged tl1erapy
can produce side effects such as increase in body weight,
pain, bloating and menstrual irregularity; t11us, it is not de-
sirable. Micronit.ed pa·ogesterone is a natural progesterone
available in lndia as uu·ogestan 100 mg oral and vaginal
tablet. ln a patient with liver disease, a vaginal route may be
pa·eferred. lt causes diainess in a few cases, so one tablet
daily is advocated at bedtime for I 0 days in t11e premen-
su·ual phase. For premenstrual tension, one tablet twice
daily is recommended for I0 days premensu·ually.
Mirena IUC D whi ch releases MDPA a t a rate of20 meg
has e merged as an alte rnative LO prolo nged o ral progesto-
gen tl1erapy. Mirena is very effec tive in relieving pain and
effec tive for 5 years. 13esides, it acts as a co mracep tive when
the woman is not desirous of pregnancy.
Selec tive serotonin re uptake inhib ito r (SSI) nuoxetine
10-60 mg dail)'• or se rtrali ne mg dai ly are drugs use-
ful in some cases.
ln tl1e past, people have u·ied dietl1yl ergotamine in tab let
and if1jection fornlS to reduce pelvic pain ca tL5ed by dilatation
ofvessels. Dieth) l ergotamine causes vasoco nstriction of veins
and reduces pelvic congestion. Long·tenn use of this drug is
not recommended because of serious side effects. Ligation of
ov:uian ve i11S has been attem pLed wi tl1 variable results.
Surgery in the fonn of hysterectOmy a nd bilateral
salpingo-oophorectOm) may be resorted to if drug tl1ea-apy
fajJs in elde.-1)' women. Ps) chothea-apy alone or combined
with drugs will be usefu l in peh·ic pain S)nclrome and
irritable bowel S)nclr·ome.
Acupuncture and short-wave diathenny are adjuvantS,
and are effective in some women. Presaca-al neurectomy and
laparoscopic uterosaca-al n erve ablation (LUNA) are recom-
mended in intractable pain in roung women.
LUNA may lead to prolapse and bladder dysfunction.
Ureteric damage ca n also occur. Presacral neurectOmy
causes bleeding and haematoma in presac ral space.
Stati c magne tic the rap)' for 4 wee ks o r transcutaneous
nerve stimu lati on helps in so me cases.
Varicosity of pelvic ve ins have been trea ted witl1 e mboli-
zation of ovarian vesse ls o r laparoscop ic ia'Uection of scleros-
ing agents (sc lero tl1 erapy) using 5% e t11 ano lam ine maleate.
Ge l foams and coils are also used.
pain rtwj>j>irtg. Conscious pain mapping involves
laparoscopy under local anaesthesia a nd interaction with the
woman on touching individual o rgans LO localize the organ
of pain. This method he lps in improvi ng diagnostic accumcy.
Backache is one of the S) mptoms ofte n accompanying
CPP and is due to following ronaecological diseases:
• Pe lvic endometriosis
• Pe lvic adhesiotlS
• Pl D and fixed reu·overted uterus
• Prolapse of uterus
• Uterine fibroids
 CHAPTER 18 - ACUTE AND CHRONIC PELVIC PAIN 251

• In orthopaedic conditions, pain is limited to below the

fourth lumbar spine; it is diffuse and ca nnot be pin- SELf-ASSESSMENT
pointed to a spot
I. Discuss the causes of chronic pelvic pain in a young
nulliparous woman.
KEY POINTS 2. A 30-yca r-old woman, para I +0, prese ntS with chronic
pelvic pain for 6 months. How will you manage?
• Ac ute pelvic pain is an e me rgency, and requires 3. A 28·)'Ca r-old woman, nulliparous, comp lains of dysmen-
immediate aue ntion and treatm ent. o rrhoea, meno rrhagia and chron ic pelvic pain. Disc uss
• C PP is a we ll-recognized e nLiL)' in clinical prac tice the d ifferen tial d iagnosis.
often d ue to obsc ure causes. 4. A 32-year-old woman presentS with acute abdo minal pain
• The pain rna)' be of functional origin without any and vomiting. A lump is felt per abdo men. Disc uss t11e
recognizable evident patholog). differential diagnosis and manage me nt.
• Common underlring causes of CPP are PID, pelvic
adhesions, endomeu·iosis and ad enom)osis, uterine
fibroids, fixed r-eu·ovened uter·us, O\oar·ian enlarge- SUGGESTED READING
mentS due LO benign causes and neoplasia, genital
Arull:.urmtr.tn S. Clinics in Obstetrics and GynaccoiOj.,')' 2006;20:5.
tuberculosis and residual oval'ian syndrome following Su.r ddJ. Acute alxlomin al pain. Progress in Ob>tctric>and Cynaecology
hysterectomy. 1998;13:3 II .
• Blood investigations, ESR, pelvic ultrasonograph y Sn rdd J. Chronic pelvic pain. ProgrL'SS in Ob;tctrics and Cynaecol<>!,')'
199 1;9:245.
with colo ur Doppler, CT/ MRI scan, laparoscopy,
hysterosCOP)' may be necessar)' to estab lish a diagnosis.
• Conscious pain mappin g at laparoscopy is emerging
as most important diagnostic tool.
• Treaunen L consists of proper counselling, an tibiotics,
and anli-inflammawry drugs such as SAIDs, analge-
sics, honnones, shon-wa'e diath erm) and sLU·gery in
selected cases.
• Presacral neurectomy and LU A a re reserved for
intractable pain in young wom en.
 Temporary and Permanent
Methods of Contraception

Birth Control 252 Mole Conlroception 277

Mole Hormonal Conlroceptive 263 Key Points 277
WHO Contraceptive Wheel 276 Self-Assessment 278

BIRTH CONTROL DEFINITION OF CONTRACEPTION

A metltod or a S)'Stem wh ich allows inte rcourse and yet
There a lwa)'S been a need fe lt for avo id ing unwanted
preven LS conception is called a con u·acepLive me mod.
P.regnanctes and restricting fami ly size among the mar-
This contraception ma)' be temporary when Lhe effect of
n.ed couples. Such a desire and need has always been
preventing pregnancy lasLs, whi le the co uple uses me
htgher among women than men. The risks associated
metl10d but the ferti li ty returns immediately or within a
with repeated and unwanted pregnancies have serious
few month.s of discontinuation of its use. The permanent
long-term effects on the health of women and at times
comracepu.ve methods are surgical approaches such as
t11e. famil) .. Nowada)S, there is a pressing need for tubectomy m a woman and vasectOm) in a man wit11 penna-
luntung the famtl) siLe at a personal level and for me
nem conu-aception.
control of population at the national level. The need of
ln spite of great advances in technology, all metlwds of
birth control at a personal level has arisen tluough an
conu-aceptions have a small undesirable t·isk of failure.
mcreased cost of Ji, ing, scarcity of accommodation a
Unfot:tunately, no contraception has proved perfect and its
desire beuer education of children in the
effecuveness, safety and techniques vary. This therefore
compeuuve world and an O\erall desire for an improved
requires counsellin.g, screening of the couple and offering
standard of living.
the. best SUited to the couple. It also requires moni·
!he in India has been growing rapidly. The tormg whtle me woman uses any conu-aception.
sociOeconomic problems of ovet·population are felt all
Choice of conu-aception depends upon me following:
around. The world population is also a major problem wim
more than 6.3 billion li ving on this ean.h and 26 children
• Age and parity of1he couple.
born every second.
• Availability, cost.
Reproduct.ive hiilllth and mnlimlgromuls are other consid·
• Reliabi lity (failu re rate).
erations for c hoosing a bi n h co ntrol. A woman yo un ger
• Side effects, contraindications to a panicular met11od.
18-20 yea rs is not ph)•Sicall y grown up to have a
• Advantages and disadva nta ges.
chtl.d. If she does rep rodu ce, she becomes a hi gh-risk case
• Need for follow-up.
dunng pregna nC)' and labo ur, and is like ly tO deliver a
• Co unselli ng and allowing the coupl e 10 make a sui tab le
low (LBW) baby. Spac ing b inhs, 3 years choice. The couple may need to change from one
apart, ts constdered beneficia l fo r bo th th e mother and
comracepLion. to from time LO Lime during
t11e child. Birth control tlms Sffn ns r1 henlth measure for
the reproducuve penod. Perso nal, med ical and socia l
these )'Otmg women. Mu ltiparo us women from low-income
factors should also be taken into consideration d uring
gro up are generally anaem ic and ma lno u rished and are
counselling.
predisposed to prolapse, stress incontinence chronic
cervicitis of the cervix. The spacing of child·
btrth and luntung the number of pregnancies are su·ongly METHODS OF CONTRACEPTlON
desirable for this reason. I. Natural me th ods:
. There are following three approaches to limiting family • Abstinence during the fertile phase.
SI.te: • Withclt-awal method (coiws interruptus).
• Contraceptives- prevent fertiliLalion • Breastfeed ing (lactational amenorrhoea method [LAM)) .
• EmergenC)' contmception- prevents implantation 2. Barrier contraceptives:
• Medical tennination of pregnancy (.MTP) - abot·tion • Condoms by male and females.
However, use of ejjl'clrol' C01llra.ctptwn remains the best choice. • Spennicidal agents
252
 CHAPTER 19 - TEMPORARY AND PERMANENT METHODS OF CONTRACEPTION
• Diaphragm, or the cervical cap in the vagina, use of a
female condom.
• Hormones which alter the cervical mucous and
prevent enU") of sperms imo ll1e cervical canal.
3. Intrauterine contraceptive devices (IUCDs).
4. Suppression of ovulation with hormones - hormonal
contraceptives.
5. lnterceptive agents (postcoital contraception).
6. Immunological methods.
7. Suppression of spermatogenesis in males.
8. Surgical sterilization.
Failure rate of any contraceptive method is desuibed in
tenns of pregnancy t"ate per 100 woman-years ( Pearl index).
Ideal conu"aceptive methods should be effective, long
acting, safe, coital-independent and reversible. Besides, they
should be easily ava ilable and affordable with minimal side
effects.
Refer to Fig. I9. l for vario us s ites of actio n of contracep-
ti ve techniques.
1. NATURAL METHODS OF CONTRACEPTION
Abstinence during the Fertile Phase
"Fenili t)' awareness' means the woman Ieams to know when
the fe11.ile tim e starts and when it e nds. The fertile phase of
tl1e mensu·ual cycle can be predicted in vario us ways.
The Calendar Method or the Rhythm Method. This
depends upon the avoidance of sexual intercourse around
ovulation. In a 28-da) qcle, ovulation generally occurs on
the 14th da) of the qcle, but may occur anytime between
the 12th and 16th da). SpermatOLOa deposited in the female
genital tract ma) survive for 21 hours. The ovum iiSelf may
live for 12-2 1 hours so that intercourse between the II tl1
and 17th day may result in a pregnanq•. The safe period is,
Anterior Pituitary
_ . . . _ f H j L - - - - - - - - - - - - - Spermicides
- -'IH- - - -- - - -- - - -- - Coitus interruptus
19.1 Sites of action of modern contraceptive techniques.
253
therefore, calculated from the first day of the mensr:n.tal
period until the IOtl1 clay of the cycle a nd from the 18th tO
ll1e 28tll day. An alternative method is 10 calc ulate ll1e risk
period. which is from 3 da)S before ovulation tO 3 days after
ovulation. ln a 35-da) menstrual cycle, therefore, ovulation
will occur on the 21st da) (i.e. 14 days before ilie next
petiod) so that the .-isk pe•iod is from day 18 to day 24.
Various methods are available to help a woman know about
the approaching unsafe pet·iod. However, cost, p•·ivacy and
low sensitivity limit use of these methods.
Persona. This is a mict-ocomputer attached to a micro-
laboratory. It measures t11e levels of oesu·one-3 glucu•·onide
and luteiniLing honnone (LH) in the moming urine by dip-
ping a test stick in tl1e ul'ine 'green light' shows conception
unlikel y and 'red light' shows fe11.ile period and wan1S the
probable ovulation a nd conception. The fai lw·e rate will1 tl1is
technique is appt-oximatel)' 6 per I 00 woman-year.
Calendar Method. In Knaus-Ogino method, the fertile
period is determin ed b)' subu·acting 18 days from the short-
est C)'Cle and 10 days from th e longest cycle whi ch gives the
first and the last day of fertile period, respec tive ly.
This method will res ult in app roximate!)' 25 pregnan-
cies per 100 woman-years. The fa ilure res ul LS from irregu-
lar ovulation or from irregula r menstrua l cycles.
Some couples prefer Lhis rneLhod o n re ligio us gro unds or
because they find otJ1er methods unacceptable. The
methods of predicting ovulation have been described in
chapter 16.
Mucus Method (Billings or Ovulation Method). The prop-
enies of the cervical mucus change under tJ1e influence of
the ovarian honnones on different days of t11e mensu·ual
cycle. The woman auempLS LO predict ilie fe•·tile petiod by
feeling the cen ical mucus. Under oesu·ogen influence, tl1e
Tubal ligation
Safe period
Female
Cap, diaphragm
}-
254 SHAW'S TEXTBOOK OF GYNAECOLOGY

mucus increases in quantity and becomes progressively secreted prior to ejaculation, frequently contains active
more slippery and elastic until a peak is reached. Thereaf- spermatozoa. This practice at Limes im poses a great mental
ter, the mucus becomes thicke r, scanty and dry under the strain upon tl1e husband and can cause considerable
influence of progesterone until the onset of menses. Inter- anxiety. It is also a cause of failure in the wife to enjoy
course is considered safe during the 'dry days' immediately intercourse full). Some couples seem to prefer this metl1od
after the menses un Lil mucus is detected. Thereafter, the and make no complain IS of suffe ring from strain or anxiety.
couple must abstain until the <lth day after the 'peak day'
(Fig. I9.2). Advantages. Adva11tage.s of fenilit) awareness metl10ds are
(i) no cost, (ii) no comrainclications, (iii) no S)Stemic side
Temperature Method. P•·ogesterone is known to exert a effectS, (iv) no effect on lactation and (v) no need to a
thel"lnogenic effect on the body. Therefore, if the woman health personnel.
records her basal body temperature (BBT) daily after
waking up in the morning and plotS the readings graphi- Disadvantages. Diuulwmtagrl are (i) failure rate is high,
call)•, the BBT chan will be biphasic in an ovulatory (ii) requires motivation and (iii) no protection against
cycle (Fig. 19.2). The day of temperature shift indicates the human immunodeficiency virus ( HIV} and sexually trans-
time of ovulation. Avoidance of intercourse during the fer- milled disease (STD).
til e clays can prevent an unwanted pregnancy. This method
is cumbersome method, hardl)' practised. Breastfeeding (Lactational Amenorrhoea Method)
Regular breastfeeding with at least o ne feed at night is
Symptothermal Method. This combination method is more shown to prevent pregnancy for initial 6 montlls after
effective. T he Fi rst da)' of abstinence is predicted either de livery, wi tl1 a fai lure rate of on I>• 0.5%-1.5%. T his occ urs
from the calenda r, b)' subtrac ting 2 1 from the length of the due to prolactin preventing Ll l surge and ovulaLion. T here-
shortest menstrual C)•clc in the preceding 6 momhs, or the after, the protective effect wears off. Apart from tlte benefi-
first cia)' mucus is detected, whichever comes first. The end cial effeciS of lac tati on on the newborn, iL is advocated as
of the ferti le period is predicted b)• use of Lhe ' BBT' chart the natural metltod of fami ly plan ning in Lhe first6 months
The woman resumes in terco urse 3 days after the thermal after childbirth. Beyond 6 months of breasL.feeding, prolac-
shift. Apart from the long periods of absLinence required, tin level falls and ovulation can occuc It is th e frequency
tl1is method is not reliable if the woman is lactating or has rather than tl1e duration of feed that decides an ovulation
irregular cycles or develops fever. in a n Ltrsing motl1er.
Withdrawal Method (Coitus Interruptus)
2. BARRIER METHODS
Coitus interruptus is a co mmon pracLice among mal"lied
couples. Coitus takes place in a normal manner but the pe- Condoms
nis is wilhdrawn immediate!) before ejaculaLion. The unreli- In this metllO<I, the erectile penis is co mpletely covered by
ability of this method is o b,ious, but it has the advantage a vef)' thin rubber (condom ) which is LLSed only once. It is
that it cosiS nothing and it requires no device. evertheless, desirable to use a condom with a water-based spermicidal
it has a failure rate of approximately 25 pregnancies per agent to impro'e the efficacy of the method (Fig. I9.3).
100 woman-> ears. The main cause of tlle fuilure is not that Condoms are made of latex \\ilich can be damaged b)' oil-
ejaculation occurs inside the vagina but tllat prostatic fluid based spenniciclal agents; therefore, water-based spennicides

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116.8 37.00
116.7 38.115
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116.5 38.85 ®
116.• 38.00 lA. ® 1\
116.3 36.75 1
116.2 38.70 If \
116.1 38.65 l<i:
116.0 38£0 l ... k

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l't.
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87.3
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-
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lle.t

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,.,,.
... OAV 1 •3 •s •7 • 8 10 II 12 13 14 IS 16 17 18 19 20 21 2223 .. 25 2e71 a a 30 31
1 2 3 • [X

FigLR 19.2 Basal body temperature chart.

 CHAPTER 19 - TEMPORARY AND PERMANENT METHODS OF CONTRACEPTION
Rgure 19.3 Condoms roll ed and unrolled.
should be used. Because of initation by latex in some women,
nonlatex polyurethane condoms are a\'<lilable. T hey, however,
slip and break easily and arc more costly tha n the latex condoms.
Advantages
• It is easily ava ilable, chea p, easy 10 ca rry, free from side
effects and req uires no instntction.
• Male invo lvemem in contraceptive effort and is immedi·
ate I)' effec tive.
• lt has no adverse effect on pregnancy, should the method
fail. Ninxlh brand is disu·ibuted free of cost in the govern-
ment hospitals in India.
• Prevent transtn iss ion of STDs from one parmer to the other.
• Decreased incidence of cervical cancer: ln women whose
paru1ers use condom, sexual transmission of the viral infec-
tion cattsing this disease is pre,-ent.ed. Condom has also a
place in checking t11e spread oft11e dreaded AIDS infection.
Disadvantages
• High fuilure rate, pregnancy r:ne of 10-14 per 100
woman-)eai'S. This is partly due tO bu1'Sting of the
condom or slipping and partly due to noncompliance.
• Vaginal i1Titation or allergy to tlle latex. To avoid allergy to
latex rubber, polyuretllane condoms and TaCLylon material
are used; howC\•e•; t11ese are slightly more expensive.
• inability to obtain full sexual satisfaction.
• Method is coitus-dependent.
Other indica ti ons for use of condoms:
• Following vasec tOrn )•: For 12 following vasec-
tomy, as these ejac ulatio ns may co nta in spe rms from the
ejacula tOr)' duct.
• ln t11e past use of co ndo ms for 3 mon tl1s was advocated,
if sperm antibod ies are th e cause of infertili ty. T he anti·
bodies clear by end of this period. However, with in tra-
ute•in e inse mination need for such a therapy is reduced.
• To prevent u·ansmission of gonococcal, chkmryditt, syphi-
lis. trichomonas and fungal infection. Use of condoms
has an important role in preventing transmission of HIV
from one parU1er to t11e other.
Spermicidal Agents
The spermicidal agents kill the sperms before tl1e Iauer gain
access to tlle cervical canal. These chemical contraceptive
agents contain surfaaants, such as nonox)nol-9, octoxp1ol
and menfegol and en.t)lne-inhibiting agents, and are
255
available as foam tablets, solub le pessaries, creams, jellies or
as films along with other contraceptives such as the
diaphragm, occlusive cervical cap and co ndom. Used alone,
failttre rate is high, approximately 30 per 100 woman-years.
When ttsed in conjunction with a mechanical barrier, tlley
give a reliable contraceptive effect. The spennicidal agent
remains effective for 1-2 hours after the application.
By causing irritation and abrasions witl1 chronic ttse, tlley
can cause vaginal ulceration and perhaps increase the risk
of Hf\1 spread rather t11an preventing it. Therefore, tile
spermicidal agents should not be recommended to HIV
couples. A nC\v spermicidal cream, Tenofovir, prevents viral
attachment to t11e vaginal mucosa and is nonin·itam and is
under dC\•elopment.
The use of condoms ,,;th spennicidal agents and postco-
ital agents as back-up ted1nique is effective in avoiding
pregnancy.
Praneem from neem is spennicidal and prevents
transmission of sexually transmiued infec tio ns. T his is
under u·ial in India.
Occlusive Diaphragms
T hese provide a barrier in the vagina aga inst direct insemi-
nation. The diaphragm is effective when used in coru unc-
tion \\ith a chemical spermicide in Lhe form of a jelly or
cream, and when sufficient time is allowed for complete
desu·uction of the sperms before the diaphragm is removed.
ln practice, the diaphragm liberally smeared with spermi-
cide can be inserted at an) convenient time and is left. in
place for a minimum of 8 hours after coi u.ts. It cattses
no discomfort and no doud1ing is required when these
precautions are obsened.
Alterations in t11e si.te and l)pe of diaphragm may be
required as a result of changes in weight, illness, delive•·y.
Initially a visit to a doctor or u-ained nu1'SC is required to
choose a suitable si.te of diaph•-agm and to leam how to
insert it. Subsequently, repeat visit at6 mont11s and I )eat· is
desirable. A refitting of t11e diaph•-agm is a lwa)S required
after childbirth, and t11is can be done about6-8 weeks after
childbi•·th.
The woman needs initial trnining in insertion and
removal of diaplu·agm.
Typ es
I. The Dntclt cap or diaphragm. This consists of a dome-
shaped diaphragm of thin rubbe r, with a n.tbbe•'covered
metal rim whi ch ma)' be either a watch sp ring or spiral
spring. T he diaphra gm is made in a wide range of sizes
varying from 50 LO 95 mm d iame te r (th e ones in com-
mon ttse range between 65 and 80 mm) and fit obliq uely
in the vagina, stretc hing from j ust behind the p ubic
ramus into t11e posterior fornix, thus covering the cervix.
lt is held in position by the tension of the spring rim. ft
is t11e easiest t)pe of cap for the patient to use, fits in t11e
majority of cases, causes no discomfort to either parlller
when correctl) fitted (Fig. 19. 1). Conu-aindications 1.0
ttse of diaphragm are (i) prolapse, cyswcele, rectocele
becattse accurate fitting is not possible; (ii) recun·ent
uri nat") tract infection; and (iii) a llergy 10 rubber or sper-
micidal agent. Toxic shock S)ndrome (TSS) may occur
if the diaphragm is left in the '"'gina for a long pe•iod.
TSS is caused by staph) lococcal p)ogenic infection.
256 SHAW'S TEXTBOOK OF GYNAECOLOGY
A B
c
Rgure 19.4 (A) Two strips of contraceptive paste are placed over the dome of the cap. (B) The rim Is squeezed together so as to enclose the
paste. (C) Insertion of Dutch cap - first stage. (D) Insertion of Dutch cap - second stage. The anterior rim Is pushed up well behind the
symphysis pubis.
The failure rate with the use of the Dutch cap is about
<1-6 per 100 woman->ears and is nearly always associated
wilh poor fitting and noncompliance.
2. cerviml mp. This is a cup-shaped rubber somewhat
like a thimble, with a solid rolled rubber tim. It fiLS
closely to the cervix and is suitable where the cenrix is
long and finn. When a woman has a prolapse of uterus
and 'oagina, a cervical cap is prefet-red to the ' oaginal dia-
phragm. Cht·onic cen•icitis, erosion and cervical lacera-
tion contraindicate iLS use. The cervical caps are available
in four sit.es, varying from 22 to 3 I mm (Fig. I 9.5).
3. mp. It is a cup-shaped rubber \\ith a thickened rim
"11ich fiLS well into the vault of the vagina so that it encloses
the cetvix. The sire varies from 55 to 75 mm diameter.
4. Femshield (fmwle co1ulom.). IL is kn0\\11 as ' FEM' or Femidom.
It is a newly developed fe male ba ni er comracep tive and is
wo man orien ted. IL is a loose-fi tting 15-17 em long sheath
Rgure 19.5 Types of cervical caps.
made of polyurethane prelubricated It has a polyurethane
ring at the closed end of the sheath, as an insertion
and anchoring and the second end is open and lies
outside the 'oagina after insettion. It has the combined
featmes of a diaphmgm and a condom (Fig. 19.6). It
covers the entire 'oagina, cenix as well as the external
genitalia. It is highly protecti'e against spread of STDs,
and AiDS in p;u·ticular. It can be removed immediately
after intercourse. The advantages of the Femshield ru·e
(i) it is coital-independent and can be wom well in advance
of the sexual act; (ii) it does not slip off easily, and the
fai lure rate is expected to be low; (iii) it is stronger than the
condom and does not bunlt easily; and (iv) it can be worn
during the puerperal period unlike the diaphragm. Failure
rate is 5-15 per 100 woman·)'ears. T he Femshield is
expensive, costing $2-3 per piece. Besides, its reuse more
than once has not yet bee n recommended. It was ini tiall)'
developed as a safet)' method for women from comrac ting
HLV infec ti on. Only tJ1ose fe male condoms wh ich cover
not onl)' vagina but also skin vulva and perine um can
prevem HIV infec tion.
5. 11xfn)'· lt is a mus hroo m-shaped polyuretJ1ane disposa l
sponge, 2 inches in diamete t; 1.25 inches tJ1ick and con-
tains 1 g of non oxynol-9 (Fig. I9.7). It is provided with a
loop for iLS easy removal. It should be placed high up in
the vagina with the concave side covering tJ1e cetvix. It
catl remain effective for 24 hours. It is used only o nce. It
aCLS as a mechanical barrier and prevenLS e ntry of spe nns
into the cen•ical canal, absorbs semen and contains a
spermicidal agent.
Failure rate is similar to tJ1ose of other bat-rier metJ10ds
and spennicidal agents (9-30 per 100 woman->ears). lt is
 CHAPTER 19 - TEMPORARY AND PERMANENT METHODS OF CONTRACEPTION
c D
Figure 19.6 Femshield or female condom.
Figure 19.7 'Today' vaginal sponge.
however expensive, coital-<lependent, and may cause Toxic
Shock S)•ndrome if left over a long period.
Occlusive diaphragms are cheap and easy to use. One dia-
phragm can be used for o'er a year if it is washed, dried and
kept properly after eac h usc. Like the co ndom, the diaphragm
prevents of STDs from one paru1er to another
and the incidence of ca nce r of the cervix is low in women
using this It does not, however, prevent
Udnsmission of III V, because iL allows vagina l secretion to mix
wi th semen. "!h e lack of baL11room fac ilities and of privacy in
low socioeconomic gro ups preven ts its wider use in India. An
occasional woman develops vaginal in·itation to latex.
Advantages
• Instant contraception. Reversible in 2-4 months
• No toxicity
• No decreased libido
Disadvantage. Scrotal swelling is sometimes reponed
INTRAUTERINE CONTRACEPTIVE DEVICES
IUCD is an effective, •·eversible and long-tenn met.hod of
conu-aception, which does not require replacement for a
257
Open end
long pe•·iod and does not interfere witJl sexual activity. The
device is common I) made of pol)eLh)lene whid1 is impreg-
nated with barium sulphate to render it radiopaque so mat
me presence or absence of the de,·ice in Lhe peh·is can be
easily detected by radiog•-aph or ulu-asound. lnitiaJ inll<l-
uterine devices contained only pol) eLh) lene (Lippe's Loop).
SubsequenLly, medicated devices which contain copper,
progesterone hormone and ot.her phannacologic agentS
have been introduced. The plastic devices are flexible so
that they can be and loaded imo an introducer
by which they a•·e passed through the cervical canal and
gently released within t11c uterine cavity to take up their
original shape. Each device has a nylon thread aLLached tO
its lower end and this thread protrudes through th e cervical
canal into the vagina, where it ca n be felt by the patient and
doctor, and can be re moved b)' pulling it wiLl\ the forceps.
Types of Commonly Used IUCDs (Fig. 19.8)
Inert IUCDs (first-generation I UC D): Lippe's loop is still
common!)' used in Ch ina. In Ind ia, Ll1is was Ll1 e first IUCD
introduced in NaLional Fam il)' Pla nning Programme. Other
inert devices such as Saf-T-coil, Mahua 1ing (C hinese
double-coiled ring) and Ota ring are no longer in use.
I. Copper-carrying devices. In these, copper wire
witJ1 a surface area of 200/ 220/ 250/ 375/ 380 mm
is w1-apped round the verLical stem of a polypropylene
frame. Among these de,ices are Copper-T 200,
Copper 7. Mul tiload Copper 250, Copper-T 380,
Copper-T 220 and ova T. The copper de,ices are
more expensive than inen devices but are reported tO
have a better conu-acepLive efficaq•, wiLh fewer side
258 SHAW'S TEXTBOOK OF GYNAECOLOGY

U.,l -- - - 1 - -- - Copper
beads

Multi load CopperT

Thread-retalt g plug

Figure 19.9 Frameless IUCD.

Progestasert
system
Figure 19.8 IUCDs In common use.
effects. They have an effeClive life of abo u t 3-5 years.
lt is estimated that abo ut 50 meg of copper is re leased
daily in the uterus. Copper-T 380A, known as Para-
Card, has a lifespan of 10 years. ova T has silver
added to the copper wire, thereby increasing its lifes-
pan to 5 }Cars.
2. H ormone-releasing fUCDs: Progestasert and Mirena.
Progestasert is a -r:.shaped device carrying 38 mg of pro-
gesterone in oil reservoir in the ven.ical stem. it releases
65 meg of the hormone per da}'· The honnone released
in the ute•·us forms a thick plug of mucus at the
os which pre,·ents penetration by the sperms and thus
exerts an added contraceptive effect. Mensu·ual prob-
lems such as menorrhagia and d)smenorrhoea noticed
with Copper-T a•·e less with t11is device (40% reduc-
tion). It is expensive and requires yearly rep lacement. A
new device, Mirena, con ta ining 52 mg of levonorgestrel
(LNG) and releases t11e ho rmone in very low doses (20
meg/ day). It acts for a period of 5 years a nd has a low
pregnancy rate of 0-3 per I 00 woman-years. However,
t11e incidence of ecto pic p regnancy is higher with the
use of progesterone-containing devices in co mparison
to copper devices. It ca n be safely recommended for
nursing mothe rs.
Frameless I UCD and fibroplant re leasing 14 meg proges-
togen daily for 3 years is under u·ial. GyneF lex is 3-4 em
long, 1.2 mm in widtl1 and adapts to t11 e shape of the uter-
ine cavity. Because it is small in siLe, complications such as
pain. bleeding, ectopic pregnancy and expulsion are less
reported. It contains six copper beads on a monofilament
poi}'PrOp)lene tluead. The t11read is knotted at one end
which is fixed to the fundus. Frameless ItJCD contains
several copper C} linders tied toget11er on a suing, and it is
anchored I em deep imo fundus (Fig. 19.9). Essure device
placed witl1in the intramural po•·tion ofthe fallopian tube is
being u·ied (Fig. 19. 10).
All LUC Ds fa ll in ca tego ry I or 2 when choosing the ir
use in an}' assoc iated medical o r surgical cond itions.
For a full detail, please see WHO co ntraceptive wheel
(Fig. 19.10).
SELECTION OF A CONTRACEPTIVE METHOD
WHO has given a MEC for contraceptive use revised in
2015, in which the safet} of each contraceptive met11od is
determined b) se,eral considerations in the comext of t11e
medical condition or medicall} relevam characte•·istics;
primarily, whether t11e contracepti'e method worsens L11e
medical condition or creates additiona l health •·isks, and
secondarily, whether the medical circumstance makes t11e
contraceptive method less effecti,e. The safety of the
method should be weighed a long with the benefits of
preven ling unintended pregnancy.
WHO Medical Eligibility Criteria for a Contraceptive Use
1. A condition for whi ch the re is no restriction for L11e use
of tl1e con u·acep ti ve me t11 od
2. A co nditi on where t11e adva ntages of us ing t11 e me t110d
ge nerall y outweigh the theore tical o r proven ris ks
3. A co nditi on whe re the theo reti cal or proven risks
us uall}' outweigh the adva ntages of us ing the method
4. A condition which rep resents an unacceptable health
lisk if the contraceptive method is used.
t
Distal ball tip
and inner coil
Figure 19.10 Essure Device
 CHAPTER 19 - TEMPORARY AND PERMANENT METHODS OF CONTRACEPTION 259

A new MEC conu·acepLive whee l was launched in 2015, • Unhappy or unre liable users of oral co ntraception or
making the method of dloosing contraceptive method barrier conu·aception
easier (Fig. 19.11 ).
Uses of I UCD
Patient Selection. IUCOs are a good contraceptive dwice • As a con u-acepLive
for the following groups of women: • Postcoital contraception (emergency contraception)
• Following intrautel'ine procedure such as adhes iolysis
• Low riskofSTO and septal resection prevents development. of Ashennan
• Mulliparous woman S) ndrome (to be LLSecl afte•· remo,·ing the copper)
• Monogamous relationship • Hormonal IUCO (Mirena) in meno•-rhagia and dysmen-
• Desirous of long-tenn reversible method of contracep- orrhoea, and hormonal replacement therapy in meno-
tion, bm not yet desirous of pennanem st.e•ilization pausal women

2
\ ' 1 3 3
' '\
\ ' J
I

' '\ 1 2 I /
.....
..... ' '\
\
' 2E 3 I /
.... 4
.....':- ....
.....
' '}.
1
I
/ .,.>
..,
.....':- .... 4 1 3
.... "
..?
,.,>< ,.,
1
.....':- ,; ,..1- v>
.....':- li< .,.> v> ....
z .it

"'
3
....
s-,.
.... .... ....

>
> .... "'S
"' ':" > " ""'
N
""' ""'
,...
:i
.... ....
> N N
"' .-
.- r
.....
.- ..... .....
... ... r .... .....
" .... "' "'
<' .....
r <"
/
r I \.
<" <"
I ' I \ \ ....'\,

....
"' "'
<" 1, '\,
<" I wZ t ....
'\,
1,
..I wZ 'ill '\,
E' 1,
I £.
£ £
1,

wZ 't<t

Figure 19.11 (A and B) MEC contraceptive wheel, the method of choosing contraceptive method. (Source: WHO Medcal ootrlCI.)
Continued
260 SHAW'S TEXTBOOK OF GYNAECOLOGY

0 Use the method in any

• 8 Use of the method not usually
circumstance recommended unless other, more
appropriate methods are not
available or acceptable
8 Generally use the method 0 Method NOT to be used

WHO Medical Eligibility Criteria Wheel

for contraceptive use, 2015
These methods oo not protect against STIIHIV. If there is a risk of STVHIV, the
correct and consistent use of conooms, male or female, is recommended.

1 .\ World Health
B -
UlJ Organization

Figure 19.11, oont'd

• ln a woman on Tamoxifen for breast cancer, Mi rena can Technique of Insertion

be used to co unteract endom etria l hyperplasia T he insertion of an I UCD is rela tively simple a nd easy.
However, the person who is go ing to insen a dev ice
Contraindications requires some training in acc urate pe lvic exa mina ti o n
• Suspec ted pregnanC)' a nd in gen tl e inse rtion of the device. A tho ro ugh pelvic
• Pelvic inflamm atO I)' d isease (PJD), lowe r ge ni tal tract exam inati on is pe rfo rm ed LO determ ine the position and
infec tion s ize of th e ute rus. T he presence of an)' uterin e, tubal or
• Presence of fibro ids- because of misfit ovarian pa th o logy precludes th e inse rtion of th e device.
• Menorrhagia and dysmenorrhoea, is used The vagina and ce rvix a re inspected by mea ns of a spec u-
• Severe anaemia lum. Any vagina l or cervical infection must be treated and
• Diabetic women who are not we ll conu·o lled- because of cured before a device is inserted. The cervix is grasped
slight increase in pelvic infection witl1 a vulsellum or Allis forceps. The device with the inu·o-
• Previous eCLopic pregnancy ducer is available in a presterilized pack. The device is
• Scarred ULerus moLmted into the introducer, and tl1e sLOp o n th e intro-
• Preferabl) avoid its use in unmarried and nulliparoLLS ducer is adjusted to the length of the uterine cavity. The
patients because of the risk of PID and subsequem LUbal inu·oducer is then passed through the cervical canal and
infertilit) t11e piLmger is pressed home. This is known as 'push-in
• U G l CD in breast cancer technique·. The better method is '"ithdrawal technique'
• Uterine anomalies such as bicomuate ute1·us, septate with less chance of uterine perforation. In this, the rod
utei'US containing IUCD is inserted up to the fundus. The outer
 CHAPTER 19 - TEMPORARY AND PERMANENT METHODS OF CONTRACEPTION
B c
Rgure 19.12 (A) IUCD inserted. (B) Inserter withdrawn. (C) IUCD
released.
rod is withdrawn followed by inner rod (multiload).
T he device un coils with in the uterine cavity (Fig. 19. 12).
T he nylon thread is c ut to the req uired length. T he
forceps and the spec ulum are removed and the patient
is then instructed to exa mine herse lf and fee l for the
th read ever)' week. The accep1.ance rate of th e IUCDs
varies. The removal rate at the end of 1 beca use of
pain, discomfort, contin uo us o r heavy b leeding or vagina l
discharge, is reported to be abo ut 15%-20%. The
pregnancy rate varies from 2 to 6 per 100 woman-years.
It is advisable to insert I UCD during or soon after men-
struation and after abortion or MTP. Latel)i immediftte
prutpartum imerti011 wit/tin 10 minutes of plaamtal expulsion or
witltiu 24 lwun of lklivt'r)' is practiced ami is found effective.
This saves the woman second visit to the clinic. There is no
clinical evidence of increase in perforation, expulsion.
The failure rate is less than I%. ProgesLOgen<ontaining
IIJCDs ha,•ing a thicker vertical stem require
dilatation in a few cases.
Mechanism of Action
Several mechanisms are responsible for the conu-aceptive
effectofan IUCD.
• The presence of a foreign body in the uterine cavity
renders th e migration of spermatOzoa difficult.
• A foreign body with in the u terus provo kes uterine
con tracti lity through prostagland in release and in-
creases the tu bal peristalsis so that th e fertilized egg is
propelled down th e fa llop ian wbe more rapid ly than
in norma l and it reac hes the uterine cavity before the
developm ent of c horio nic villi and thus is un ab le to
implant.
• The device in situ causes le ucocytic infi ltration in the
endometrium. The macrophages engulf the fertilized
egg if it enters the endometrial tissue.
• Copper-T elutes copper which brings about certain
enz)'lnatic and metabolic changes in the endometrial
tissue which are inimical to the implantation of the
fertilited ovum.
• Progestogen<atT)ing device causes altet-ation in the
cen•ical mucus which prevents peneu-ation of spenn, in
addition to its local action. It also causes endomeu·ial
au·ophy. It prevents O\'ltlation in about 10%.
261
Complications
With improvements in Lhe new devices, the acceptability
and compliance have improved. The complications of an
IUCD are as follows:
Immediate
• Difficult) in insertion
• Vasovagal attack
• Uterine ct-amps
Early
• Expulsion (2%-5%)
• Perfot-ation (I %-2%)
• Spotting, menorrhagia (2%-10%)
• Dysmenorrhoea (2%- 10%)
• Vaginal infection
• Actinomycosis
Late
• PID- 2%-5%. IUCD docs not prevent u·ansmission of
HIV
• Pregnancy- 1-3 per I00 woman-years (failu re rate)
• Ec topic pregnancy
• Petforation
• Menorrhagia
• D)•smenot,·hoea
IUCD can be insened in HI V-positive woman on
medication.
Long-term follow-up of women wearing IUCD has shown
no ill effects on systemic diseases. There is no evidence that the
device predisposes to either cervical or endometrial cancer.
Perforation can occur at the time of insertion, particu-
larly during puetperitun. Its incidence is 1-3 per IOO inser-
tions, latel) reduced with improved devices. Perfot-ation is
mre with withdrawal than push-in technique. Menon·hagia
can be controlled with SAID ch-ugs.
Expulsion may occur in 5%-15% and is due to small size
of It.:CD. It is common during Lhe puet·pet-al pet·iod or
following MTP of a lat·ge gestation siLe.
PlD occurs usually within 4 weeks of inset·tion and may
be due to existing unt·ecogni.ted vaginal infection, or Lhe
tail of IUCD causing ascending infection. Actinomycosis is
an infection commonly associated \\1th IUCD.
IUCD is removed by grasping the thread with an anery
forceps and gen tl y pulli ng it out.
Misplaced IUCD
lL is defined as tl1 e condition when tJ1e ta il of the IUC D is not
seen through tl1 e os. T he ca uses are (i) ULen.ts has enlarged
tluo ugh pregnancy, (ii) tluead has curled inside tl1e uterus,
(iii) perforation has occ urred o r the IUC D is buried in the
m>•omeuium and (iv) it has been expelled (Fig. 19.13).
A plain radiograph or pelvic ulu·aso und will show
whether the IUCD is still inside or has been expelled. If it is
inside, the uterine sound or anotJ1er I UCD inserted in t11e
uterine cavity will show on mdiogmph itS proximity LO
the misplaced I CD and perforation can be diagnosed
(Fig. I 9. I:3). An abnormal shape or location of I UCD on
mdiogmph indicates like I) perfot-ation. Hysteroscopy is use-
fttl notonl) to locate it but also for its retrieval. Iftl1e IUCD
is in Lhe utetine ca,·it), it can be reu·ieved with Shirodkar's
hook, a cut·ette or through a hysteroscope and ulu-asonic
guidance. In case of perforation, a laparotomy is needed,
262 SHAW'S TEXTBOOK OF GYNAECOLOGY

Figure 19.13 (A) Multlload Copper-T 375. (B) Displaced Copper-T w it h calcium depositio n at t ip ofT. (C) Copper-T 380A (D) Pelv ic radiograph
showing Lipple's loop In the pelvic cavity. (Courtesy (B): Dr K.K. Saxena, New Delhi.)

because Copper:r ca uses ad hesions to the ome ntum or a
gut and can no t be retri eved easily thro ugh a laparoscope.
Pregnancy. Pwg1umL)' occ urs with IUCD in s itu in 1-3 per
100 woman-years. If this happe ns, it is important to do
Ldtraso und and ru le out ectopic pregnancy. The uterine
pregnancy can be associated with complications such as in-
fection; therefore, it is mandatory to remove the 1UCD if
tJ1e tail is visible. While doing so, tJ1e risk ofabonion sho uld
be explained to the woman. If t11e thread of t11e 1UCD is not
seen, tenninat.ion of pregnanC) is offered, not because
!UCD has an> teratogenic effect but becaLLSe the risk of
ute•·ine infection is considerable. Allematively, if woman
decides to continue pregnanC)• she may be a llowed to con-
tinue after counselling and explaining the risk.
Ectopic Pregnancy. It occ urs in I :30 pregnancies in
woman wearing IUC D. This is beca use IUCD has a local
contraceptive action o n the uterus and a uterine
pregnanC)' blll does not protect against w bal or ovarian
pregnancy. Progestasert has the highest incidence of ecto-
pic pregnancy (six to nine Limes more tJ1an Copper-T).
P!D caLLSed by IUCD also contrib utes to tJ1 e occ urrence of
an ectopic pregnancy.
Advantages of IUCD
• It is coi tal-i ndepe nde n L
• One-Lime insertion gives continuous protection for a
long period. It is cost-effective.
• It is highly effective, newer IUCDs being as effective as
oral contracepti,es. Three per cent failure rate at the end
 CHAPTER 19 - TEMPORARY AND PERMANENT METHODS OF CONTRACEPTION 263

of 1 year is reduced to less than 1% at the end of 5 years. of approad1es have been utilized to develop a reliab le and
There is no user fai lure. effective male contraceptive, most of these are based upon
• There is no evidence of reduced fenility following itS suppression of spermatogenesis.
removal. About 75% women conceive within 6 momhs of
ilS removal and almost 90% conceive within a year. HORMONAL CONTRACEPTION
• There are no S)Stemic ill effectS, unlike oral contracep- Honnonal contraception comprising use of oest.rogen and
tives. o acherse effect on lactation is observed. progesterone combination in the form of oral tabletS, in-
jectables, vaginal rings, clennal patches has come tO occupy
Copper-T 380A (Fig. 19.12C) is provided free in the most prominem place in the field of female conu-aceplion.
ational Family Planning Programme. In western countries, this has become Lhe most commonly
used method among women. In India, populat·ity of oral
Disadvantages of IUCD pills is not ' 'eq• high t-ather tubectomy remains most often
• A trained medical or paramedical personnel is required used method by tJ1e women. Progesterone alone in tJ1e
to screen and insert an IUCD. form of depot it.Yections, implants, vaginal rings and IUCD
• Certain complications such as mensuual irregulal"ities, has also become popular because of lesser side effects
clysmenonhoea, pelvic pain make woman geLS it removed. yet giving as reliable conu-accption as with combination of
oestrogen and progesterone.
Mirena IUCD Following secti ons describe various types of hormo nal
It is 32 X 32 mm IUCD with the ve rtical rod con taining contracepti ves whi ch are in usc nowadays.
52 mg LNG progestogen in a s ilastic rese rvo ir in ilS vertical
arm: 20 meg ho rm o ne is eluted in 15 minutes after its SUPPRESSION OF OVULATION (HORMONAL
insertion, and tJ1e pea k level reaches in a few ho urs. CONTRACEPTIVE AGENTS) (Tobie 19.1)
T he hormone does not ge t abso rbed imo the general Hormonal contraception is o ne of the most effec tive comra-
circ ulation (or min imal amo unt) so tJ1 e s ide effects of cep tive me thods availab le nowada)'S. Since 1956, when
S)'Stemic adminisu·ations a re not seen. It does not supp ress Pincus came out with an oral co nu·aceptive drug, more than
ovulation, and ilS effect is main ly on the endometrium and 30 mi llions of women have used tJ1is method in one fonn
cervical mucus. Because of tJ1is, Mirena is also used in or tl1e other. A wide variety of ho rmonal preparations
abnormal uterine bleeding (AU B), endomeu·ial hyperpla- are now available for conu·aceplive use. The mode of action
sia. in HRT and in a woman o n Tamoxifen for breast depends upon the hormone used, tlle mode of delivet)' and
cancer to combat h)perplasia of endometri um caused by tl1e Lime of adminisu-ation. The honnones can be delivered
oesu·ogen. It ma> cause irregular bleeding dul"ing the first by inu-amuscular route, subcutaneous implantS, vaginal
3-6 months. The pregnanq rate is 0.5 per 100 woman- tings, inu-auterine de,ices or b) detmal patches.
years (equal to that of tubectOmy).
Oral Contraceptives
• Teratogenic, if pregnancy occurs with Mirena in situ clue There are tllree t)pes of honnonal ot-al conu-aceplives, i.e.
to progestogen. monophasic combined 01-al pills (Table 19.2), u·iphasic
• Incidence of ectopic pregnancy 0.02%. combined pills and minipills.
• 20 meg hormone is daily eluted.
Combined Oral Pills (OCP). Combined ot-al pills contain a
Compared to lltbectomy, Mirena is an effective combination of etJlin)ioesu-acliol (££..!) in a dose of 20-30 meg
comraceptive, t·eversiblc and reduces dysmenoni1oea and
menorrhagia unlike tubectomy. Mi rena, because it cures
menorrhagia and is as effective as tubecwmy, is expected to Ta ble 19.1 Hormonal Contraceptives
red uce the number of hysterectomies. It is safe. Continua-
ti on rate of 80% is repo n ed at the e nd of I year. Oral Insertions Injections
Advantages of Mircna • Vaginal ri ng • Monthly
• IUCD Mlrena • 2 monthly, 3 monthly
1. One-time inse rtion
• Combined
2. Effective for 5 )'ea rs
3. Compliance COG, POP • Implants E2 ... P Injection monthly
4. Red uces meno rrh agia and d)•Smenon·hoea ProgesV
Combined Pills
Fibroplant: ls a frameless LNG IUCD; releases 14 meg • Once daily for
21 days
LNG daily, and is under clinical development.
3 weeks Testosterone Progestogen patch
cyclically implants in Subdennal self-
2 monthly, male administration
MALE HORMONAL CONTRACEPnVE
3monthly injection of DMPA
Yearly on trial in males
There have been several attemptS at finding out an effective Triphasic Testosterone
male conu-aceptive. llo,,ever, due to a number of reasons Emergency injections in males
till date there is no effective male contraceptive otJ1er Lhan pills
condoms which may be achocated for mass use. A number
264 SHAW'S TEXTBOOK OF GYNAECOLOGY
Table 19.2 Types of Monophasic Combined
Oral Pills
First generation Bhinyloestradiol Norethindrone
Second generation Bhinyloestradiol Norgestrel, LNG
Third generation Bhinyloestradiol Desogestrel,
gestodene
norgestirnate
Fourth generation Ethinyloestradiol Drospirenone
(Yasmin)
and an orally active progestogen such as norgesu-el or Nove-
Jon. Mala-D and Mala-N both have same composition contain-
ing LNG 0.15 mg and ethinyloestradiol (EE) 30 meg the latter
is available free of cost in Famil y Planning Cli nics in India.
T he tablets are taken starting o n the first day of the cycle for
21 days. A new course of tablets sho uld be co mmenced 7 days
after the co mp le tion of the previous course. Tablet should be
taken at a fixed ti me of tJ1e day, preferably after a meal.
Mechanism of Action. T he combined oral p ill suppresses
pitui tary honnones, FSH and LH peak and through this
suppression prevents ovulation. At the same ti me, progestogen
causes atrophic changes in th e endomeui um and p t-events
nidation. Progestoge n also acts on the cervical mucus making
it thick and tenacious a nd impe neu·able by spenns.
OCP also increases the wbal mol.ility, so the fertilized egg
reaches the uterine caviL) before the endomeuiLUn is recep-
tive for implantatio n.
Pregnanq rate with combined oral pill is 0.3 per
100 woman-> ears (with perfect use) and 5-8 per 100 woman-
)eal"S (with t)pical use) is the lowest of all contraceptives in use
nowadays. Dua·ing the first C) cle of use, O\'ulation is not always
suppt-essed and as a precaution patiem may be advised LO use
an additional method. Lately, starting the pill on the first day
of the C)cle has reduced such a Failure rate and the need to
take the additional pt·ecaution in the first qcle. lf she forgetS
to take a tablet pill, she should take t\\'0 tabletS the following
clay. lfshe forgets to take the tablet more than in a cycle,
she is no longer adequately protected and must use a ban·ier
method for remaining pan of the cycle. T he majo tity offail-
ures with oral combined pills are clue to the fa il ure to take the
pills regularly. With proper compliance, most wo me n have
regu lar 28-day mensu·ual q •cles. T he b leeding is less in
amount and shorter in d uration than a normal menstn1al
pe tiod. ln a non lac tating woman, OCP ca n be Started after 3
weeks of delivet)', b ut can be given soon after an abortion,
MTP or an ectopic pregnanq•. Following vesic ular mole, one
should start OCP only after serum j3.-hCG i.s Antiret-
roviral drugs (ART) red uce e ffec tiveness of OCP but when
combined witl1 condoms, OCP are effective in protecting
against pregnane).
Noncontmceptitte Benefits ofCombined Pills. Oral contraceptive
pills offer a number of short-te•m and long-tenn benefitS
when used as contraceptives.
l. Use of OCP results in •·egular C)cles and average blood
loss dlll·ing menstruation. It is helpful in women witl1
menon·hagia and polymenorrhoea. It also relieves
dys menorrhoea and premenstrual te nsion.
2. lt preventS anaemia by reducing tl1e menstrual blood loss.
3. lt lowers the incide nce of benign breast conditions such
as fibrocystic disease.
4. lt reduces tl1 e incidence offu nctional ova rian cyst (50%) .
5. Reduce incidence of malignancies. Both ov:u;an and
endometrial malignancies are less com mon among regu-
lar users of OCP. The incidence of ov:uian malignancy is
reduced by 10% a nd uterine malignan q r by 50% if taken
for I >ear, this protective effect lasts as long as 10 )'eal"S
after stoppage of use of OCPs. The incidence of P10 is
reduced, though it does not reach the same low level as
seen witl1 tl1 e barr-ier method. This protective effect is
due to the tl1i ck cervical mucus caused by progestogen,
preventing the mi cro01-ganisms entering into the uteri ne
cavity.
6. Reduced inciden ce of ectopic pregnancy is d ue to
suppression of ovul ation and red uction in PID.
7. 1t protectS aga inst rhe umato id arthri tis.
8. Reduces tl1e risk of anorec ta l ca ncer by 30%-40% .
9. It is useful in acne, Po lyq•sti c Ova rian Disease (PCOD)
and en do metriosis.
Side Effects with the Use of OCPs and Contmindications
• lntermensu·ual spottingiscommon in the first3monthsof
use of the pills, subsequently it gradually disappears. Fre-
q uent spotting can be stopped by choosing a pill contain-
ing higher dose of oesu·ogen or other combinal.ion of
honnones. Often menstrual bleeding becomes seamy and
occasionall) a woman ma> become amenoni1oeic causing
a fear of pregnane). Amenoni1oea lasting more than
6 months requires investigations. Postpill amenoni1oea is
not 1-elated to tl1e t)pe, close or duration of pill imake.
Those with p•-e,·ious mensu·ual irregula•·ity (oligomenor-
rhoea) a1-e mo•-e likely to suffer from amenoni10ea.
• Genital tract candidiasis. Oral pills are associated witl1
monilial (candidial) vaginitis.
• No documented association is seen witl1 carcinoma of
cervix; however, dysplasia is more frequenL Recently
an increase inciden ce of cervi cal adenocarcinoma and
glandular abnormalities has been reported witl1 long-
term use of OCPs.
• No adverse effect has bee n noted on ute•·ine fi broids, and
it is oesu·ogen singly tJ1at increases the ir size.
• Breast. T he combined pills should not be offe red to a
wo man suffering from ca nce r of the b reasL Some have
reported the breast cancer in a nu lli pa rous woman (25%)
who has taken oral contraceptive pills befo•-e tJ1e age
of 24 )'Cars for over a pe riod of 4 )'ears. T h i.s sho uld be
considered whi le presc ribing oral pills tO a young n ullipa-
rous woman. There are some repo rts indicating higher
incidence of breast cancer among users of OCPs. Peti-
odic breast examination and necessary investigations in a
user of OCPs will he lp to detect breast cancer at an early
stage. Progestogen component also conu·ibutes tO the
potential of development of breast cancer. However, if
breast cancer de, elops, it is well differentiated witl1 good
prognosis. The risk of malignancy disappea•-s after
10 >e;u-s of stoppage.
• Pituitary adenoma was att.-ibuted to the use of the pill but
itS exact role in its dC\elopment is not clear and doubtful.
 CHAPTER 19 - TEMPORARY AND PERMANENT METHODS OF CONTRACEPTION
• Breast mil k amount in lacta ti ng woman who chooses tO
use OCPs is reduced. T he combined pills may preferable
be avoided during the first 6 mon ths after delivery if a
woman is lactating. llowever, progesterone only pills
(POP) do not suffer this disadvantage and can be safely
used du.-ing the first 6 months of lactation. ausea and
vomiting are common initiall) mainly due to oesu·ogen
and subsequent!) disappears. It can be avoided by taking
the pills at bedtime. If ,·omiting occurs witl1in l hour of
taking pill, repeat dose.
• Lh·er. Adenomas have been reponed and though they are
benign rarely a napwre of a hepatoma can be futal.
Because tl1e hormones are metaboli Led in the liver,
chronic liver diseases and recemjaundice contraindicate
tl1e use of pills.
• Gall bladder fun ction may be adversely affected.
• Carbohydrate metabolism. Ca rbohyd rate tOleran ce may
be reduced . T herefore, combined oral pills a re con train·
dicated o r given ca uti ously to a d iabe ti c woman.
• Lipid metabolism. Oestrogen tl1e high-density
li poprotein (II DL) a nd lowers low-de nsity lipoprotein
(LDL). Some progestoge ns have a reve rse effec t a nd the
overall effec t o n t11 c myoca rdial function and lipid
metabolis m depends upon t11e co mbined effec t of bo th
hormones. Rifampicin, an a ntib iotic p resc ribed for a
tuberc ular infection, red uces the abso rp tio n of drugs in
the pill; hence, OCPs are contraind icated in a tube rnLiar
patient on .-ifarnpicin. OtJ1er drugs interfering with OCPs
are tetracycline, amiconvulsants, antifungal, cephalospo·
rin and phenobarb. Ritonavir for HIV also interferes witl1
absorption of OCJ>s.
• Headache. migraine, depression, irritability, increased
weight and letharro can occur due to progestogen.
• Thromboembolic disorders. Pulmonary embolism and
cerebral thrombosis, both venous and arte1ial, are 7-l 0 times
mo•·e frequent in the pill u5ers than in the nonusers in
the first )Car of use. This is due to an increased clotting
mechanism (platelet aggregation and increased fib•·ino-
gen factor VII, VIII and decreased fibrinolysis) caused by
tl1e oestrogen component of t11e pill. T he effect is dose-
dependen 1, and the reduction of the oestrogen content
of the pill from the original 100-30 meg in currently used
pills and of late a newe r o ral pill (Femilon) which
co ntains 20 meg 1!.1:: 2 revea l a n improved safe ty a nd toler-
ance profi le, a nd at t11c sa me tim e retain its contraceptive
efficacy. T he incide nce ofthromboe mbolic d iso rders has
tl1Us dropped witJ1out d iminish ing the efficacy of the p ill.
A wo ma n o lder than 40 )'Ca rs, a woman witl1 stro ke, heavy
smo ke •; a card iac and hypertensive pa tien t, a wo ma n with
fami lia l h)•pe rlipoproteinaem ia a re a ll high-risk cases for
tJ1is complicalion. T he pills co ntaining desogestre l and
gestodene (thi rd generation) a lso ca n·y a higher lisk of
venous thromboembolism t11an the pills containing LNG.
• Sickle cell anaemia patients can develop thrombosis and
crisis.
• A woman who wears contact lenses should be warned
of oedema and irritation of eyes (tJHombosis of optic
vessels) - it is a relathe contraindication. Combi ned
oral contraceptive (COC) pill do not protect a woman
against HIV and sexually transmined infections. This is
imponant while counselling a woman at a high risk
for these infections. Barrier methods reduce tl1e risk of
265
transmission of HIVand other infec tions. In HfV patien ts
a d Ltal method of banier contraceptive wi th OC Ps are
recommended.
• Pills have no ad,erse effects on thyroid funCLio ns.
Contraindications to the Use of OCPs
l. Cardiac disease, h) penension, smoker o lder than
35 years.
2. Diabetes.
3. History of thrombosis, m)Ocardia l infurction, sickle cell
anaemia, seve1·e migraine.
4. Chronic liver diseases such as cholestatic jaundice of
pregnancy, cirrhosis ofliver, adenoma, po•·phy•·ias.
5. B•·east cancer, gall bladder disease.
6. G•·oss obesity.
7. Patient on em.yme-i nducing drugs such as rifum picin,
and anti epilepti cs except sodium valp roate.
8. 4-6 weeks plior to a pla nned surgery.
9. Lacta ting wo ma n.
A wo man can ta ke OCPs regularly up to tlte age of
35 )'ears, and thereafte r liiHil 45 yea rs if she is healthy,
no nobese a nd nons mo ker. she s ho uld remain
under th e supervision of t11 e doc to r and have Pap smear
do ne regularl)' to cl1ec k on cervical dysp lasia.
Return of Menstruation and Fertility. Ninety-n ine per cent
of women wi ll have normal menstrual cycles within
6 months after stopping use of OCPs but return of ferti lity
may be slightl) dela) eel due to delayed return of ovulation.
inety per cent ovulate within 3 months of stopping the
drug. There is no evidence of increased fetal malfonnations
or increased rate of abortion in t11ose who conceive while
on pills.
Triphasic Pills. Witl1 tl1e aim of further reducing tl1e
amount of honnones du•·ing OCP use, t11e biphasic and
triphasic pills were intmduced. The composition of pills in
initial part of menstrual crete is different from the pills
given in tl1e last I 0 days, tltis way the total amount of oesu·o-
gen and progesterone in a month is reduced. The triphasic
prepa•·ations cur-rently in usc co ntains an d LNG in an
amount 30 meg ££.2 plus 50 meg LNG durin g tl1e fi rst 6 days
of tJ1 e cycle, for the nex t 5 days 40 meg EE 2 plus 75 meg
LNG, and duri ng tl1 e last I0 days 30 meg EE2 and 125 meg
LNG. Nex t pac k of triph asic pills is sta rted afte r I wee k.
T hese p il ls have no adve1'Se effect on ca rbo hydrate a nd lipid
metabolism; the refore, t11 ey ca n be presc ribed to d iabe tic
wo men and witho ut expecting any increased ris k of myocar-
dial infarc L Th ey are as effective as the monop hasic oral
p ills but no t reco mmended in woman witl1 me no n·hagia
an d for o tl1er ind ications.
How to Maintain Compliance with the Use of Oral Pill?
• Three-monthly course of pills. 'Seasonale' which co ntains
LNG is available as a packet containing 84 tablets
(witJ1 a gap of 7 da)S), which means only four menstrual
cycles in a )ear. and has been attractive to many working
women especial!) in the USA. However, some may face the
problem of prolonged b•·eaktJ1rough bleeding. Yearly con-
tinuous pills are under uial (one pe•·iod a )Car)- L)brel is
effective for I >ear.
266 SHAW'S TEXTBOOK OF GYNAECOLOGY
• OCPs containing only 10 meg Ef...? (ul tra low dose p ills).
• Once-a-montJ1 pill containing 3 mg quinestro l and 12 mg
megestrol acetate, popular in China and Latin America.
Two tablets in tJ1e first montJ1 are followed by one tablet
month!).
• + drospirenone (Yasmin, Tarana,Jan>a) contain 21 tab-
lets in a packeL Janya contains 24 tablets (gap of four
tablets in a C)cle), and contains 20 meg EE2 •
• EE2 + C)proterone acetate (Dianeue) 35 meg EE2 is more
useful in women with PCOD, hirsutism.
• Quackiphasic pills containing E2 + dienogeSL, daily- no pill-
free days, beuer tolerated and a good conu·ot of menses.
• Chewable tablets containing 35 meg EE2 and 0.4 mg
norethindt·one.
• Lybrel-continuous dai ly use for I year contains 20 meg
££2 + 90 meg LNG in a tablet.
Newer Pills with Antiandrogenic Properties. Drospirenone
red uces fl ui d reten ti on and has no adverse effect ofspiro no-
lac tone, has an ti mine ra locorticoid (3 mg d rospire no ne is
eq ui valent to 25 mg of spiro no lac to ne, cures ac ne and hir-
sutism. It reduces fl ui d a nd sodiu m re te m ion, and has no
adve rse effect rn g of Iauer), has anti rn ineralocorticoid and
with an tiandrogenic activity. It inhib its ovu latio n, and has
no effect on bone mineral densit)'· It also prevents obesity
and maintains good li pid profi le. Because of this property
and relieffrom acne, it is also been called 'beauty p ill'.
Main side effect is potassium reten Lion because of which it
is contraindicated in renal and liver disease and in a woman
with previous thromboembolism.
Different Generations of Oral Pills. Depending on the
progesterone co men tin an OCP, oral pills have been called
the first generation, second generation, third generation
and fourth generation.
• Frrst generation - contains norethindrone progesterone
and 50 meg or more of t::E
• Second generation - contains LNG, norgestimate,
norethindrone progesterone fonnulation and 20, 30 or
35 meg EE.
• Third generation - contains gestodene, desogestrel pro-
gesterone formulation and 20, 30 or 35 meg££
• Fourth generation - contains spironolactOne, dienogest
or cypro terone acetate.
Progestogens. Progestogens a lo ne have also being success-
full y used as hormone comraceptives. Besides being devoid
of oesu·ogenic side effect these co ntracep tives can be used
du ring lac tati on, d uring menses and in woman where
oestrogen are conu·aind icated.
Progestogens are availab le as oral pills (minip ills), intra-
muscular implants, pa tches, vagina l ring and
Mirena IUCD.
Progestogen-Only Pill (PO P - Min.ipill). The to,,"C.lose POP
(noretJ1isterone 350 meg, norgesu·el 75 meg or LNG 30 meg)
has been introduced to avoid the side effectS of oestrOgen in
the combined pills. The tablet is taken daily without a break.
The pill should be slatted within 5-7 days of the menstrua-
Lion and taken at tJ1e same Lime with a leewa)' of 3 hours on
either side of tlle fixed time each da)'· If this regime is not
obsen·ed any day, the woman continues with POP but
observes exu·a precaution for next 48 ho urs. The mode of
action of progestogen has ah·ead)' been discussed earlier.
PO P is started 21 da)S postpanum and soon after abot'
Lion. The woman needs LO take precaution in the first
48 hottrs in tJ1e first C)cle.
Minipill does not ha\e some of the major side effects of
the combined pill and it i.s rwll 5uited for u:tetating women;
some progestogens, in fact, increase milk secretion. How-
ever, it has a higher pregnancy rate of 2-3 per 100 woman-
years which is higher than that of the combined pill though
comparable to an IUCD and is higher in obese women.
Strict daily compliance is a drawback. Other drawbacks
are it·regular bleeding (20%), amenorrhoea, depression,
headache, migraine and weight gain, ectOpic pregnancy,
functional ovarian cysts besides a higher fai lure rate.
The use of newer gener·a tion of synthetic progestogen,
namely desogestrel in It has no androge nic effect,
no adverse effect on ca rbohyd rate and lipid metabolism,
and is considered to be safe, especially for lacta ting wome n.
H muever, lite incidmce of thromhoembolimt is higher witlt this
progestogm.
Contraindications. Con u-a ind ica Li ons to PO P are p revious
ec topic pregnane)', ovalian cyst, breast and geni tal cancers,
abnormal vaginal b leeding, active liver and a n e tia l d isease,
porp hyria, liver tumolll; valproate, spirono lactone and
meprobamate. BectlliJe of ruteofJenUI, it is ccmtrt1imliwted in
a rut )'Otlllg women.
AdLmttages of Progestogen-Only Pill. Advantages of POP are
that they can be recommended to:
• Lactating women.
• Women older tJ1an 35 )ears.
• Those with focal migraine.
• Those illloleralll to oestrogen or oestrogen conu-aindi-
cated.
• Diabetic, hypenenshe woman, sickle cell anaemia.
As regat·ds to t·eturn of fenility, it is faster than in COC
users because ovulation is not suppressed in all cases
(suppressed in 40%)
Mode ofAction of Minipills
• Cemzette which contains dcsogestrel in a dose of75 meg
s uppresses ovul ation in 97%- 100%, whe reas otJ1er POPs
s uppress ovu lati o n in onl)' 40%.
• It forms a tJ1ick p lug of mucus in th e ce rvical ca nal and
acLS as a barrier to spe rms.
• It alters tubal pe ristalsis and ferti lized egg reac hes th e
uterine cavil)' too earl)' for imp lant.atio n.
Cerazette containing 75 meg desogestrel has the fo llow-
ing advantages over other POPs:
• Stringent Lime compliance not necessary, as it sup-
presses ovulation in 97%, through pituitary hormone
suppression.
• o androgenic effects such as acne.
• o ectopic pregnanC), no effect on carbohydrate or lipid
metabolism.
• Failure rate only 0.21 per 100 woman-> ears. It acts through
metabolite etonogestrel which binds to progesterone
receptors
 CHAPTER 19 - TEMPORARY AND PERMANENT METHODS O F CONTRACEPTION
ide effects: (I) weight gain, (2) in·egular mensu·ual
bleeding. (3) depression, (4) breast cancer and (5) throm-
boembolism.
Depot Injections of Progesterone. Although not ve1)'
pop ular in Ind ia depot ir\jeetio ns of progesterone (Depot
med rOX)'progestero ne aceta te, DMPA; norethistero ne
ena ntl1ate NET-EN ) are two co mm o n!)' used imramusc ula r
injec ti ons of progestero ne. In fuct, in more than 125
countries these are available in the Family Planning Pro·
grams. Ease of adm inistration, 1·epeating action at
2-3 monthly imervals and high efficacy have made tl1is
mode of administralion of contraceptives 'ery popular. To
overcome the inconvenience of daily compliance, depot
injections of progeswgens have been de,eloped. DMPA is
given in a microcrystalline aqueous suspension and ET-EN
in a castor oil solution, both by deep intramusCLllar injec-
tion (subc utaneous preparation of OMPA is also ava ilable in
104 mg). Late!)' a mo nthly DMPA combined wi th 25-50 mg
of medroxyp rogestero ne acetate combined with 5 mg
oesu·adio l is ava ilab le a nd is co nsidered to be mo re effec tive
"1th lesser menstrual distu rba nces. O ther preparati ons in
usc are tl1e DMPA 150 mg 3-monthl y, DMPA 300 mg
6-momhly and NET-EN 200 mg 2-montl1ly. After stoppage,
the contraceptive effect of DMPA lasts longer than tllat of
lT-E . Menstrual irregularity though common is
accepted by puerperal woman as ph) iological. The injec-
tion should be started within a month of delivel)' in a non-
lactating woman and during tl1e third month in a lactaling
woman because ovulation is delayed up to atleastlO weeks
in lactating mothers. Pregnancy rate is 0.'1 per 100 woman-
yea rs for OMPA and 0.6 per 100 woman-years for NET-EN.
Injecti on DMPA has rece nUy bee n introduced free of
cost in tl1e Na tional Fa mil y Pla nni ng Programme of India
"1th tl1e name of'An tara'.
T he iryection should be adm iniste1·ed wi tl1in 7 clays of
menstruation with a grace period of 2 weeks for DMPA
and I week for NET-EN for a repeat injection. Action lasLS
12-14 weeks of the first injection for DMPA anciS-9 weeks
fo1· ET-£1
Advantages
• Iryections are easy to administer and there is no worry
over 'missing p ill'. They are long-acling and reversib le.
• T he compliance is good and the woman rema ins unde r
regular medical supervis io n.
• The side effects on li p id and ca rbo hydrate metabolism
are avoided. DMPA is least androgen ic.
• It is suited to lactating women.
• The incidence of PlD, ectOpic and functional
ovarian C)SLS is low, so also endomeuial cancer.
• A'oids oestrogenic side effects.
• Can be given LOa woman with sickle cell anaemia.
• Relllrn of fertility is slight!)' dela)ed in DMPA group com-
pared to ET, but 80% conceive within a )Car (5 months
for DMPA and 3-4 mon ths for NET-EN).
• Independent of coitus.
• T hey tu rn o ut to be mo re cost-effecti ve for mass usages.
Disadvantages
• Once ad mi nistered, the side effects, if any, need to be toler-
ated until tl1e progeswgenic effect of tl1e injection is over.
267
• Mensu·ual irregularities are common in the form of
amenon·hoea or in·egular bleeding. Amenon-hoea is
reponed in 20%-50% LLSers of DMPA at the end of
I )Car and are more common with DMPA tJ1an NET.
Heavy and irregular bleeding is repo t1.ed in I %-2% users
and is more commo n with the use of NI::'I:
• Do not preve nt STD a nd 1-1 IV.
• T here is a delay in re turn of fenili ty b ut 80% are
expected to conceive by end of I yea r. WitJ1 DMPA, ovula-
tion returns in 5 months, a nd with NET wi thi n 3 months
of the last injection.
• The side eff'ects in tlle fonn of weight gain, depression,
bloated feeling and masralgia can occur witll injecrable
progestogen.
• Prolonged DMPA LLSe, by vinue of antioesu·ogenic
action, ma) reduce bone densit) mass and induce
osteopenia.
• Conu·aindicated in breastcance1:
• It does increase LDL b ut does not adverse!)' aff'ec t th e
b lood pressure.
• It rn a)' decrease lib ido, ca use d 1)' vagina.
Because of risk of osteopenia, tJ1is conu·acepti ve is
contraindicated in adolescenLS, and should not be used for
more than 2 years in otllers. Lately, subcutaneous
are under de,elopmem to enable self-administration by tJ1e
woman.
Once-a-Month Injections. O nce-a-month intramLLScular
injections of combined oestrogen and progestogen are
available in some CO Ltntries.
T hese are as fo llows:
• Mesigyna - ( 1/2 mL con taining NET 50 mg witl1 oestra-
d io l va lera te 5 mg) is given by deep in tramusc ular irtiec·
tion once a month with :!: 3 days. T he low fai lure rate of
0.4% at the end of 1 year is encouraging.
• Cyclofem and Lunelle - l / 2 mL contains 25 mg DMPA
and oestradiol cypionate 5 mg. The failure rate is 0.2% at
the e nd of I )ear. The menstmal irregularity is less tJ1aJ1
with progestogen-alone i11jections.
• Marvelon - Desogestrel 150 meg with El::-1 30 meg.
• Femovan - Gestodene 75 meg with E£.1 30 meg.
• Anafertin - Dihydroxyprogesterone acetophenide 75 mg
+ esu·ad io l enan tll ate 5 mg.
It should be re membe red that the first me nstrual period
co mes 10-15 days after the firs t i11jection b ut tl1 ereafter
every 30 days and lasts for 5 days. Failu re rate of 0. 1%-0.4%
is reported. Ovulation returns in 6 months.
Subdermal Implants
In the quest to find altemalive routes of gh·ing hormonal
conu-acepti,es. subclennal implams were discovered. Wilh
tl1is me tJ1od, tJ1e progeswgens are delive red in to general
circulation with a slow and StLStained release manner with
lesser side effects. T here are two types of subdennal
imp lants, b iodegradab le and no ndegmclable. Once im-
p lanted Llle)' re lease drug slowly over a pe riod of 1-5 )'Cars
depend ing upo n the implant.
T he subdermal implan t has no 'nuisance value' of
continuous compli;u1ce which often adver'Sely affects
268 SHAW'S TEXTBOOK OF GYNAECOLOGY
motivation. Besides, being nonora l it avo ids 'hepatic
first-pass effect and Llws, reduces systemic side effects'.
Norplant 1. Norplant I (Fig' 19. 11- 19. 16 ) was Ll1e first
subdennal implant imroduced for contraception contain-
ing six silastic capsules, it has now been wil.l1drawn from the
market and replaced b) a single rod implanL
orplant ll (Jadelle) was the second implant system
inu·oduced for conu-aception. It consisted of two rods ead1
..
Figure 19.14 Norplant I and Norplant II.
Figure 19.15 Insertion of Norplant.
Figure 19.16 Removal of Norplant.
containing 70 mg LNC wil.l1 a daily re lease of 50 meg and
provides conuaception for 3-5 )'Cars.
The implants suppress ovulation in 50% of Ll1e cycles
but the main mechanism of action is suppression of
endomeuium.
Insertion of Implants. The implants are insened on Ll1e first
day of Ll1e menstntal C)cle or wil.l1 in 5 days of abonion, and
3 weeks after the delivery. The woman needs to use banier
contraception or abstain in Ll1e first 7 days after inse•·tion.
It takes 5-I 0 minutes to insert under local anaesthesia. It
is best insened on Ll1e medial aspect of the upper arm. The
capsules are nonbiodegmdable, so they need removal at Ll1e
end of its use or earlier, if side effects are imolemble.
The insertion and •·emoval is made easier using a single
rod system called lmplanon (40 X 2 mm), wh ich contains
68 mg etonogestrel and docs not require an incision tO
insert. It releases 30 meg of Ll1e hormo ne dail y a nd is
effective for 3 years. T he re has been no fa ilure tO date.
It preve nts ovul ati o n a nd is reversible wil.l1in I mo nth of
re moval.
With the use of lm planon, a me no rrhoea is co mmo n at
the end of 1 >•ear. Acne is red uced and it has no effect on
bone densit)'·
Advantages. The advantages of imp lants are as fo llows:
• They are long-acting wil.l1 sustained effect- compliance is
good
• Coital-independent wil.l1 no 'nuisance' of daily oml or
frequent
• Pregnanq 1-ate varies between 0.2 and 1.3 per I 00 woman-
years. The failure mte is higher in obese women weighing
more than 70 kg.
• S)stemic side effects are few and Ll1e first-pass effect on
the liver avoided.
• Return of fertility is prompt (within 4-12 weeks).
• Can be used by lactating mothers and women older than
40 years.
Disadvantages
• Breakl.luough bleeding, in·cgular q •cles, amenonhoea
occur as seen with other progesterone onl y contraceptives.
• Other side effects of progcstogens are seen .
• Ec topic p regnancy is reported in 1.3%.
• Local infec ti on at the s ite of insertio n may occ uc
• Req uires insertio n and removal wil.l1 nonbiodegradable
im p lants; however, it is a mi nor surgical proced ure.
• T he imp lants are expensive.
• l nfertili q• may be seen in a few cases after Ll1e removal of
imp lant.
Contraceptive Vaginal Rings (CVR)
Anoll1er route which has been tested and found suitable for
delivery of hormonal con u-aceptive is in the form of contra-
ceptive vaginal rings. In an attempt to reduce the side
effects of systemic hormonal con tracep1ion and the surgical
method of insertion of implants, silasl.ic vaginal rings cany-
ing progestogens in differenL doses have been u;ed. The
ring is 50-75 mm in diamete•· and 5-9 mm thick. 1l1e ring
currenl.ly a\oailable contains L G released at a rate of
20 meg of honnone daily. The •·ing needs a change after
 CHAPTER 19 - TEMPORARY AND PERMANENT METHODS OF CONTRACEPTION
3 momhs. Anotl1er ring which contains both oesu·ogen and
progesterone is available in the market by the name of
NuvaRing cont.'lining 11.7 mg eLOnogestrel and 2.7 mg
ethinyloestradiol. NuvaRing is effective for I montl1. Ad-
vamage of uvaRing is that incidence of breakthrough
bleeding and spotting is less compared to vaginal ring
comaining on I) progesterone. Failure rate is 1.8 per 100
woman-> ears.
Recently, a lot of •·esearch is going on in this field,
some p•·ogestin<ontaining rings (3-keLO desogestrel
10 mg) have been left in for 3 monlllS at a time. The
pregnancy rate witl1 this is reponed to be 3.5 per 100
woman-> ears (WI 10, 1985). A ring releasing 30 meg E£2
with ei tl1er 120 meg desogestrel or 650 meg n orethister-
one is under tl'ial.
Other rings are as follows:
I. NuvaRing - 120 meg eto nogestrel + 15 meg E£ 2 daily
release can be re moved during inte rcourse but not for
more than 3 ho urs at a tim e.
2. Nestorone - 150 meg progeste ron e + 15 meg E£ 2, effec-
tive for 1 )'ea r; fai lure rate is 1.2 pe r 100 woman-years.
Advantages of Contraceptive Vaginal Rings
• Self-insertion and removal, good compliance.
• Otl1er advantages of progesLOgen con u·aceptives.
• Quick reversibility.
Disadvantages
• Expe•lSive; Rs 700 per ring per cyde.
• Local irritation is felt b) few, vagin itis 5%.
• Expulsion can occur especially in woman with vagi nal
prolapse.
o S)stemic side effects of progestogens have been noted in
some women.
IUCDs Containing Progestogen. Another route of deliver-
ing hormonal contraceptives which has been successfully
emplo)ed is in the form of I UCD impregnated witl1 proges-
toge•lS. Progest.'\Sel·t and Mirena are two such devices which
have been extensively used. Mirena contains 52 mg LNG in
tl1e vertical ann ofT device and elutes 20 meg daily. The
effect lasts for 5 years.
T he fai lure rate is 0. 1% similar to oral combined pills.
Though primari ly used in AUB, its con u·acep tive benefit
is also appreciated.
The me nsu·ua l irregularity in the first 3 months settles
down to norm al C)'Cies and dysmenorrhoea is also cured.
The incide nce of PI D and ec topic pregnanC)' is red uced.
The inse rtio n is however difficu lt d ue to the thick vertical
stem. Amenorrhoea is reported in abo ut 20% at the end of
I year. Mirena costs Rs 7000.
Skin Patches
Hormonal Patch (Orth o-Evra). Another route of hormonal
contraceptives which has been tested in clinical practice is a
skin patch impregnated in hormone. A Ortl1o Evra
Honnonal patch releases 6.00 mg norelgesu·omin ( GMN)
and 0.75 mg E.E. A patch lasts 7 days. Three patches are
required in each qcle followed b)' !-week patch-free imer-
,oaJ. The patch should be applied within 5 da)S of menses
O\'er tlle buttocks or abdomen but not over tl1e breasts.
269
The failure rate is 1-2.8 per 100 woman-years. Compli-
ance of90% is reported. The breakthro ugh bleeding ( 18%),
skin reaction (20%) and breast discomfort are L11e side
effects. The other S) ln ptoms are headache, nausea and
mastalgia. The site of patd1 should be changed often and is
in obese women.
Altllough fOlUld popular among women in •·ich counuies,
its populal;t) is low in India. Because of sweating, excessi\'e
heat tlle patch may get displaced decreasing its effectiveness.
Percutaneous Gel. Three dai ly of percutaneous gel
of oestradiol witl1 C)clical progestogen is easy LO apply. One
should wait for I hour for the gel to dry up a nd not to be in
contact with otl1er members. It should not be applied over
the b•·easts.
Centchroman (Ormeloxifen)
Centchroman is a nonsteroidal co ntraceptive developed in
India at Centra l Drug Researc h Institute, Lucknow. Cent-
chroman is a synthe ti c no nstero ida l co mraceptive tO be
taken as 60 mg tab let twice a wee k for initial 3 months
followed by a week i)' dose. It is s ta rted on the first day of
menses and taken twi ce week ly for 12 weeks and weekly
thereafter (half- li fe is 170 hours). It does not prevent ovula-
tio n. It prevents implantatio n through e ndo me u·ial changes.
It ex hibits a su·ong an tioestrogenic and a weak oesu·ogenic
action pe•ipherally at the receptor level. The return offertili ty
occ w·s soon after stoppage of the clntg (witl1in 6 months).
Cemchroman is not teratogenic or carcinogenic, exertS
no phannacological effect on other organs. The o nly side
effect noted is prolonged C)Cles and oligomenorrhoea in
8% of cases. This is due to a prolonged proliferative phase.
Pregnane> 1<1te is 1.83 per 100 woman-)eai'S. The drug can
also be used as a postcoital pill, given in 60 mg dose withi n
21 hours of coitus (two tablets repeated 12 hOlii'S later wil11
failure rate of I%). lL has been developed by Central Drug
Research LllStitute, Lucknow, and has been released in lndia
under the name of Stliudi. It W(U introdiiCI'd fwe ofcost in India
wufer famil:y f>larllling with thl' IUIIIU' of 'Oifwya'.
Side Effects
o Headache, nausea, vom iting.
o Gain in weight.
o Does no t protect aga inst ! lt V a nd STD.
o Some delay in re tw·n of fe rti lity (up to 6 mon tl1s).
o Prolonged use ca uses- h)•pe rplas ia of endometrium.
Contraindications
o During 6 mo nths of lacta tion .
o PCOD, hepati c dysfunction, ce rvical d)•splasia, allergy to
the drug.
EMERGENCY CONTRACEPTION (POSTCOITAL
CONTRACEPTION)
Postcoital contraceptive agents are L11e methods used after
LlllSafe coitus which prevent pregnancy by interfering wil11
fertilization or implantation. ThC) interfere wil11 postovula-
wry events which normall) result in pregnancy and are
therefore known as interceptives. Recently, there is lot of
emphasis on emergenc> as it has been seen
that most pregnancies result because of unexpected, unpro-
tected intercourse or as a resu lt of fai lure of
270 SHAW'S TEXTBOOK OF GYNAECOLOGY
Emergency conu·aception is used following rape, unpro-
tected intercourse or accidental rupture of a condom dur-
ing coitus taking place around ovulation. It can also be used
as backup method if woman has forgotten tO take oral pills.
These postcoital methods should be used mainly as 'backup'
methods in these conditions and not as a regular conu-acep-
Live technique. If used frequentl) Emergency Conu-acep-
tion (EC) can cause mensu·ual irregula1ities, EC are also
less effective than regula•· conu-aceptives.
The p•·epa•-ations available include following:
1\l'o tablets of relathely high doses of a combined pill (ovral /
Eug)'non 50), containing I 00 meg EE2 and I mg norethister-
one, or 500 meg LNG, taken within 72 hours of intercourse
followed by two tablets taken 12 hours later (Yuzpe and
Lancee, 1977). Failure rate is 3.2 per 100 woman-years.
Mode of ac/.itm. The ho nn ones may delay ovul ation if taken
soon after intercourse, cause corp us luteolysis and bring
about cervical mucus cha nges a nd e ndometrial atrophy.
1. LNG Tablets
Pros tinar tablet con tains 0.75 mg LNG. One tab let sho uld
be taken within 72 ho urs of un protected interco urse and
another 12 ho urs later. Alternate!)', two tab letS can be taken
as a s in gle dose. The fai lu re rate is I. I %. The tab letS can be
offered up to 120 hours; however, sooner the tab lets taken
after unprotected interco urse more effective they are but itS
efficacy decreases witll tile longer coital-d11.1g interval. LNG
preventS ovulation and causes desynchronization of endo-
metrium through its receptors (luteal phase deficiency).
llle next menses ma> come earlier or delayed.
Side effects are those of progestogens. The honnone is
not te•-atogenic in case pregnane) does occur but risk of
ectopic pregnane> remains.
Advantages
• It has no oestrogen and its associated side effects.
• It can be offered to hypertensive, cardiac and diabetic
woman.
• It can be offe•·ed to a lactating woman.
• It can be given as late as 120 hours after the unp•·otected
intercourse.
• Single-dose the1-apy is a n advantage.
Conu·aindica ted in li ver d isease, co ntains lactate, so
all ergy to ga lactose. The drug is also contraindicated in a
woman with hi sto ry of tllrombop hleb itis and migraine.
2. RU486 (Mifepristone)
RU486 is a steroid witll an affin it)' for progesterone recep-
tors. It does not prevent ferti lization but by b locking the
action of progesterone on tile endomeuium, it causes
sloughing and shedding of decidua and preventS implanta-
tion. It is not teratogenic.
A single dose of 25-50 mg is effective in preven Ling preg-
nancy in 99.1 % cases (failure rate 0.9%). It causes delayed
mensu·uation. Ectopic pregnancy is not avoided. The drug
is expensive compared to L G.
3. Ulipristal
IJlip•istal is a S) ntlletic progesterone honnone receptor
modulator, it attaches to progesterone receptor and
prevents/ delays ovulation and suppresses endometri um,
prevents implantation. A 30 mg tablet should be taken
within 5 days. Two per cent pregnancy rate has been
reported. Side effects are headache and mood changes.
4. Centchroman
Two tablets (60 mg) taken twice in 24 hours within
24 hours of imercourse can p•·evem implantation in 99%
of women.
S. Prostaglandins
Self-administered vaginal suppository containing prosta-
glandin following an unprotected intercourse, b)' virtue
of itS luteol)'tic effect on the ovary and itS increased motil-
ity effect on fallopian tubes and the uterus, preventS im-
p lantation and brings about menstruation. ItS specific
role as emergency co ntraceptive is h owever ye t tO be
establis hed.
6. Copper-T IUCD
lnsened witl1in 5 da)'S of un protected imercourse can
prevent implanta ti o n of a ferti li zed ovum. Advantages of
Copper-T as emergency contraceptio n are as follows:
• It can be inserted as late as 5 clays after th e unprotected
intercourse.
• It is cheap.
• FailLU"e rate is 0.1 %.
• It can remain as on-going conu-aceptive method for
3-5 years.
The conu-aindications and complications of IUCD have
ab·ead)' been mentioned.
IMMUNOLOGICAL METHODS OF CONTRACEPTION
Immunological approach to family planning is still in a
developmental stage. Should immunology prove successful,
family planning effortS will be simplified and will be more
acceptable to tl1e couples. The antigens which are being
experimented upon a•·e as follows:
• 13-hCG s ubunit (300 meg) i.m . 6-weekly X 3 doses evokes
specific an tibodi es and tlle reb)' produces temporary
stelility for I year.
• Zona pellucida p lays a n im portant ro le in fertility. T he
zona pellucida a ntibodies ca n e it11er preve m penetration
of ovum by the spe rm or prevent shedding of zona after
ferti lization so that implantatio n is impossible.
• Antibodies to sperm antigens. These u·ials have not yet
proved s uccessful in human beings.
• Anti-FSI-1 vaccine (inhibin ) is also under trial.
PERMANENT METHODS OF CONTRACEPTION
Surgical Sterilization
The stelilianion operation is undertaken with tlle primary
objective of pre,enting further pregnancy pennanently.
Sterili.tation is suited Lo those couples who have completed
their families and do noL want to bear tile inconvenience or
cost of the other methods of conu-aception, and when tile
other methods are contmindicated.
 CHAPTER 19 - TEMPORARY AND PERMANENT METHODS OF CONTRACEPTION
An ideal method of sterilization sho uld have the follow-
ing characteristics:
• It should be an outpatient procedure.
• 1l1e anaesthesia should be local or short general anaes-
thesia. so that the woman or man can return home in a
few hours.
• The surgical technique should be simple and quick.
• The insu·uments should be inexpensive.
• Minimal scar is desirable.
• The method should be 100% effective.
• Cost effectiYe.
• The complications and sequelae of surgery should be
minimal.
• The technique should be surgically rever·sible in case of
unexpected disaster such as death of children.
MALE STERILIZATION
VASEGOMY
Vasec tomy co nsists of d ivid ing the defe re ns and disrupt·
ing the passage of spe rm s. It is done through a small inci-
sion in th e scro tu m, unde r local a naesth esia. T he sterility is
not immedia te. T he sperms are sto red in th e reproductive
u·act for up to 3 months. The co uple must therefore abstain
from interco urse elu ting this period or use some other
metl1ods of contraception such as condoms. Approximately,
20 ejaculates clear the semen of all spenns. Two semen
analysis reports must con firm the absence of sperms before
tl1e man can be declared sterile. No-scalpel technique has
been now adopted. One single incision is made with a spe-
cial forceps and skin stitch is not required. Clips and plugs
can be applied over the vas instead of cutting. Vasectomy is
cl1eaper tl1an wbectomy (Fig. 19. 17).
Cut ends of vas Closure of vas sheath
with purse-string sutures
Figure 19.17 Vasectomy operation.
271
Reversible inhibition of sperm under guidance (RISUG)
has been experimented by All India Institute of Medical
Sciences and Indian Institute of Technology in India. A
polpner gel is injected into the vas. Reversibility is possible
by flushing the vas with sodium bicarbonate. This technique
is Llllde r trial.
Complications of Vasectomy
• Local pain, skin discolouration, bleeding, haemawma
formation (I %-2%).
• Infection (I %), u-auma to the testicular at·tery causing
gangrene, rat-e.
• Antibody formation and autoimmune disease (40%).
• Failure rate of 0.15 per 100 woman-years at tl1e end
of I year.
• Gt·anul oma for·mation in 0. 1%-3% cases.
• Spontaneous recanali zation.
• Formati on of spermatocele.
• Decreased li bido o r impotency at-e mainl y psychological in
o ri gin and occ ur in men who were no t p rope rly motivated.
• Does no t preve nt iii V, STD.
Advantages
• It is an o utpati ent proced ure.
• Local anaestl1esia is adeq uate.
• It is a minor surgical proced ure and the man can resume
duty after rest of I or 2 days.
• Libido not affected. No evidence of prostate cancer.
REVERSIBLE INHIBITION OF SPERM UNDER
GUIDANCE (RJSUG)
NEWER TECHNIQUES
New nonsclerotic occlusive copol)lner of St) t-ene maleic
anh)dride (SMA) - lowers p H of semen and alters spenn
transportation and mot·phological changes in tl1e spet·ms.
This copolymer is it'tiected in the lumen of vas deferens
under ultrasound guidance with the help of a fine hypoder-
mic needle. Its action begins immediately and action can be
t·eversed subsequently by ir:jcction of anotl1er copolymer
which neutm li:t.es its action.
Chemical sclerosing agents such as 90% ethanol, 3.6%
formaldehyde, silver ni u·ate, hyd roge n peroxide, aceti c acid
can elimi nate tl1e need of surgery, are effec ti ve and easily
administered . However, the co nsequence of imravascular
injec tio n and excessive desu·uctio n of the vas by even a
slight increase of instill ation can be d isasu-o us and tl1 e
proced ure is irreversible.
Occlus ive p lugs and intravasal devices are still in th e
experimental stage.
Plugs
A device called 'Sl-1 UG' consists of two flexible silicon plugs
connected by a n) ion thread which lies outside the vas. 1l1is
thread prevents migration of plugs and allows easy removal
through a small incision.
Conu-aindications LO \'liSectOm) are as follows:
• Local skin infection
• Varicocele, hernia
• Undescended testis
272 SHAW'S TEXTBOOK OF GYNAECOLOOY
FEMALE STERILIZATION (TUBECTOMY, TUBAL
STERIUZATION)
Tubal ligation can be done at any time convenient to the
patient (Fig. 19. 18 0 ). Postpartum steriliation is done
within the first week of delivery when the patient is already
hospitaliLed. lmen-al ste.-iliLation is done when the woman
is not pregnam 0 1· any time after 6 weeks of delivery. Tubec-
tomy can also be combined with caesarean section.
INDICATIONS
Apart from multiparit) a nd the need of pennanent method
of family planning, sterilitation may be advisable in women
with medical diseases. Indications are as follows:
• Multi parity
• Three caesarean de liveries
• Med ica l diseases ma king a s ubseque nt pregnancy high risk.
• Psyc hia tric proble ms
• Breas t ca nce r
Rgure 19.18 Operation for sterili zation. The fallopian tube is drawn
up dissecting forceps in a position where the broad ligament is
relatively bloodless and curved clamps are placed in position on each
side. The tissue enclosed by the two damps is then excised with a
scalpel. Subsequently, the tissue enclosed in the clamps is ligatured.
No effort is made to bury the cut ends of the fallopian tube. Although
the operation Is simple, it gives excellent results and subsequent
adhesions have been shown to cause no trouble. (Source: From:
Shaw's Textbook ol Gynaecobgy, Elsel.ier.)
0 Scan to play Laparoscoplc tubal sterilization
• Eugenic- repeat feta l malformations, haemophilia, Rh
incompatibility, '..Vi lson disease, Tay-Sachs disease and
Ma 1-fan syndrome.
The interval su rgery should preferably be done soon
after menses to avoid the potential risk of pregnancy in the
pOSlQVulaLOry pe1·iod.
CONTRAINDICATION$
I. Woman you nge r than 25 >ears (as directed by the
Governmem of India).
2. Parity less tl1an two c hildre n (as per the Government
rule).
3. Local infection.
METHODS OF STERIUZATION (Figs 19.18- 19.20)
I. Laparo tOm)'
• Po me roy method
• Mad le ne r metl1od
• Irving me th od
• Aldridge me thod
• Cornua l resectio n
• Uch ida me th od
• FimbriecLO my
2. Minil aparotam y
• Pomeroy
• Madle ner
• Aldridge
• Uchida
• FimbriecLOmy
3. Vaginal route
4. Laparoscopy - Silastic ring, bipo lar cautery, Filshie
clip.
5. Hyste roscop) -Chemical agents. Essure
Laparotomy
Laparotomy ste rilitatio n is perfonned during caesarean sec-
Lion and during gy naecological surgery.
Minilaparotomy
The opera tion is performed t11rough a sma ll inc1s1on less
than 2.5 em in Jengt11 (Fig. 19.18 ). Because of its s implicity
and ease of doing operation this procedure is advocated for
ro utine s te ri liza tio n espec ia lI)' in a s ma ll er se t up.
Pomeroy Me thod. The most popu lar tec hnique of tuba l
ligation is t11 e Po me rO)' opera ti o n. T he fa ll op ia n tube is
identifi ed o n eac h s ide, brought o ut tl1ro ug h tl1e inc ision,
the middl e ponion is he ld with a Babcock forceps and a
s ma ll loop of fa ll opia n tube is ti ed at the base with catgut
s uture and t11 e portion between tied points is excised. The
failure rate is 0.4% and it is m ainly due to spontaneous
canali zation. The operation is simple, requires short h ospi-
tal izatio n, does not require sophisticated and expensive
equipment s uch as a laparoscope and can be performed in
a primary health centre by a doctor uained in this proce-
dure. If desired re,ersal of stedliation is possible.
Madlener Operation. A loop of the tube is crushed and li-
gated witl1 a no nabso rbable suture. Failure rate of 7% and
occurrence of ectOpic pregnane> are unacceptable, though
it is a simple procedure to perfonn.
 CHAPTER 19 - TEMPORARY AND PERMANENT METHODS OF CONTRACEPTION
Figure 19.19 Different surgical techniques of sterilization.
0 Scan to play Mini lap Tubal sterilization
3mm
Hulks-Clemens clip
n Vaginal Tubal ligation
2.6cm
Falope ring
Rgure 19.20 Application of Hulks-Clemens c lip and Falope ring.
Irving Method. The mid-ponion of the tube is ligated and
the intervening portion excised. The proximal end is bur-
ied in the m)'Ometrium and the distal end is buri ed in the
broad ligament. It is a reliable method but irreversible and
may require a laparo to my incision.
Aldridge Method. A ho le is made in the ante ti or leaf of the
broad ligament and the fimbria! e nd is bl.llied into this. T he
hi gh failure rate is d ue to the fimbria ! end popping out an d
restoring Ule patency of the LUbe.
Cornual Resection . The co mual portion of the tube is
resected near its uterine aLLac hment. The techn iq ue is com-
plicated and Ule uterine end tends to bleed heavily. This
may also require a laparotomy incision.
Uchida Method. The tubal serosa is stripped off the muscu-
lar layer in Ule mid-segment of u1e tube, which is then ex-
cised. The proximal end is ligated and buried in the broad
ligament. The minimal excision of the tube prese•·ves the
potenlial for wboplast).
Funbriectomy. Excision of fimb•·ia results in pennanent
steriliation and leaves no potential for reversibility.
273
Vaginal tubal ligation is not popular because of higher mor-
bidity and because of relatively more difficulty in performing
Ule procedure. The pouch of Douglas is opened after placing
patient in a liUlOtOlll) position, u1e fallopian LUbe is hooked
out with finger or Babcock and wbectomy perfonned It is
associated with risk of pelvic infection, higher failure rate and
it is more difficult to perform. It is mainly combined with the
Manchester repair operation for prolapse of uterus.
Laparoscopic Sterilimtion
This technique has become the most commonly used tech-
nique of tubal steriliation. Laparoscopicste•·iliLation is carried
out under local or general anaesthesia A small subwnbilical
incision is made and pneumoperitoneum created by insen.ing
a Veress needle and inu·oducing C0 2• C0 2 is safer Ulan air and
nitrous oxide which can cause air embolism and accidental ex-
plosion, respectively. 'v\liul the patiem in the head low position,
the uucar and cannula are inserted through Ule incision and
an operating laparoscope inuuduced after removing Ule uucar.
T he illwnination of Ule pelvic organs for '1sualizatio n is b)' fi.
breoptic light. T he uterus is manipulated from below b)' an as-
sistant so Ulat Ule fallopian tubes are moved to Ute ce mre of the
operating field. Each fallopian tube is picked up near u1e isth-
mic end (2-3 on away) and it clipped/ banded (silas tic bands)
(Filshie, 1-Iulka band, silas tic ring) or cauterization of a segment
of Ute tube done wiLh a bipolar cautery. The gas is allowed to
escape aL Ule end of Ute procedure and the insm.unentS are
removed. A skin stitcll completes ute operation.
The failure rate wiu1 Ulis technique is 0.6 per 100 woman-years.
The earlier cauteriation technique has now been re-
placed by the silastic Falope ring, Hulka clip and Filshie clip,
whicl1 are safer (Fig. I9. 19 0). Mono polar cauterization is
liable to cause accidental intestinal burns and desu·oy a con-
siderable pan of Ule tubal Sll1JCture with a disadvantage if
recanalilation is required aLa later date. The Falope silast.ic
ring destroys 2-3 em of Ule fallopian tube. The 1-lulka and
27 4 SHAW'S TEXTBOOK OF GYNAECOLOGY
Filshie clips desu-oy a smaller segmem (3-4 mm ), LintS pre-
serving the potential for successful reversal of sLe•iliLation if
needed later. The failure rate varies between 0.2% and 1.5%.
Fa lope ring, inu-oduced by Yoon in 1974, is a silas tic band
with 3.6 mm and 1 mm outer and inner ring
respec tive !)\ and is 2.2 mm Lhick. It is impregnated with
balium sulphate for rad iological visua li:t.ati on.
Advantages. Laparoscopic sterili:t.ation has gained popular-
ity all over Ll1e world as it has a number of advantages:
• Subumbilical scar is small and nearly invisible.
• It can be done under local anaesthesia in the OUL-paliem
depa•·tmem.
• It is high I) reversible, with a success rate of70% or more.
Disadvantages.
• The equipment is expensive and maintenance is not easy.
• Experienced personnel are req uired LO perform this op-
erati on.
• Monality of 1-2 per 100,000 and is now very low with
experience.
Complications. Complications are uncommon but when
they do occur, the)• are serious in nature. Seen usually in the
hands of inexpe1ienced personnel:
• Abdominal wall emphysema due to a wrong placemem of
the needle.
• Bleeding from superior epigastric vessel by trocar injul')'.
• ' lea ring of L11e mesosa lpinx and bleeding.
• Uterine perforation.
• A wrong app lication of L11 e ling, e.g. puLLing the ring on
round ligament/mesosalp inx/ ute ro-ova rian ligament,
wi ll cause operati on failure.
• Failure •·ate vades between 0.4% and 2.5%. Although
cautedtation carries a failure of 0.8%, Hulka clip has a
failure rate of 2.3% and Falope ring 0.8%. Most fuilures
occur within 2 )ears of operation. At the end of 10 )ears,
failure is reponed in 1.8% of cases.
• SpomaneottS recanalizalion occurs if caute1ialion is
incomplete.
• Ectopic pregnancy is reported in 0.2%-0.3%.
• Hydrosalpinx formation if the tube is occl uded at two
places so me distance aparL
Contraindications. T he laparoscop ic steri lization is contra-
indicated in following situations:
• In a patient wiLI1 a cardiac or pulmonary disease, head
low position and C02 are conu-aindicated.
• Previous abdominal surgery exposes the patiem to the
l'isk of imeslinal u-auma in case parietal adhesions are
present.
• Puerperal cases. TI1e fallopian LUbes are oedematottS
and vascular and may easily get torn. The uteniS is
soft and can get easily perforated wiLh Ll1e uterine ma-
nipulato •:
• t::xtreme obesity, diaphragmatic or umbi lical hernia. T he
increased risk of interstitial it)jury in these cases.
• In PID, Ll1e fullopian tubes may not be easily visible
amongst the adhesions.
Due to associated morbidity, the Gove.-nmem of lndia
has forbidden laparoscopic ste•·iliLation combined with
MTP or in Ll1e puerperal period.
• Skin infection, anaemia, thrombophlebitis.
Hysteroscopic Sterilization
In this tec hni que during hysteroscopy e ithe r a chem ical
agent or so me plug is introd uced in the corn ual of Ll1e fal-
lopian tube. The technique of using sclerosing agents and
quinacrine has been abandoned because of high fuilure
rate, and other complications such as uterine perforation,
burn injury and infeCLion.
Contraceptive Device (Fig. 19.10). Recent!), a new
device called EssLu·e has become available in developed cotm-
uies, which is inserted in the cornual of the tube dttring
hysteroscopy. The tedmiq ue of 'Essure pe11nanem device' is
a dynamicall)' expanding microinsen e r consisting of a flexi-
b le inner co il made of stainless steel and a dynamic outer coil
made of ni ckel ti tan ium a iiO)' (N iti no l). The device is 1 em
long with inner 0.8 mm diameter. Running along and
through the inner coil is a layer of pol)•eLI1ylene terephthalate
( PET) fibres, ,,11ich initiate a benign local fibrous tissue
growth responsible for the occlusion of the fallopian tube.
The guide wire guides the device imo the fallopian tube.
DUling the insertion, the outer coil is wound down to
keep it in a low-profile posilion. Upon release, the outer coil
expands to 1.5-2 mm from 0.8 mm and anchors lissue
device fim1ly in the fallopian tube. It takes 3 months to
occlude Llle tube, dLUing which oL11er conu·aceptive is
req uired LO protect against pregnane)'· This is an in·evers-
ib le and permanent technique. Hyste rosa lp ingography
3 months la ter sho uld confirm tubal bloc kage.
Ke rin devised this technique. PET fibres are effective
and unlike liquid sclerosing agentS, do not cause chemical
peritonitis.
Buscopan and NSAID are required to prevem tubal
spasm and facilitate proper insertion via h)'Steroscope.
Failure •-ate of 3.5% is reponed.
Optimal placemem of E:ssure device at the proximal fullo-
pian tube aiiO\\'S Ll1e device to span Llle utero-tubal junction.
The device is placed far enough to allow the tubal block, while
a portion of the device trails into L11e uterine cavity (4-8 coils).
Disadvantages
• Hysteroscopy is req uired.
• Cost and expe n.ise required.
• Penn anent meLI10d.
• hCG to confirm blockage.
• 3 months waiting.
• Bilate1-al insertion difficult due to spasm in 15% of cases.
• Tuboplasty for reversal not possible.
• Perfomtion of Ll1e tube
Advantage. No abdominal scar and can be done under lo-
cal anaesthesia.
Complications and Sequelae of Female Sterili:z:ation
• Anaesth etic compli cations.
• Mo rtality of 1 per 100,000 procedures is due to haemor-
rhage, sepsis and embolism, and anaesthetic risks.
 CHAPTER 19 - TEMPORARY AND PERMANENT METHODS OF CONTRACEPTION 275

• Morbidity is due LO postoperat.ive lu ng infection, abdomi- sex ed ucati on wi ll provide benefit., many will req ui re
nal wound sepsis, peri toni Lis. contraceptive guidance and provisio n of a suitable con-
• Trauma to t.he bladder; bowel may occur with a laparo- traception.
scopic technique.
• Thrombophlebit.is and embolism is rare, but may compli- BARRIER METHOD
cate puerperal sterili.tation. It is the best method in )Oung girls. Apan from
• Pelvic adhesions. conu-aceptive method, it can prevent u-ansmission of
• Failure rate of sterili.t:at.ion varies from 0.4% in Pomeroy infections from one partner t.o the other.
technique, 0.3%-0.6% by laparoscopic method t.o 7% by lf the man refuses to use condoms, a man·ied woman
Madlener method. Pregnancy occurs either because can use Today sponge with spennicidal cream. A recemly
of undiagnosed corpus luteal phase pregnancy, faulty married woman may find ba rTier method cwnbersome in
technique or due t.o spontaneous recanali.tat.ion. the initial stages.
• Ectopic pregnancy. Partial sponta neous recanalization The adolescent should receive informed knowledge on
may result. in ectopic pregnancy, and estimated rate is 'unsafe period' when ovulation occurs, and be provided
0.6 per 1000 ster-ilized women. with emergency conu-aception such as LNG, two tabletS.
• AUB followi n g sterilization is seen in 15% of cases but the This is because per·iodic abstinence is difficult. amongst the
exact aetiology is not. known. yo ung co upl es.
• Regret. and depression may ensue especially wh en death
of a chi ld follows s te rilization. Request for wboplasty is IUCD
made whe n a chi ld d ies o r a change of pan.ne r occ urs as Whi le IUC D may no t be a s ui tab le co ntraceptive device
in remarriage. T he success of wboplasty is 70%-80%. in t11 e unm arried and rece ntl y ma rried nulli paro us
Libido is no t usuall y affected. women, it. is a lo ng- te rm coita l-inde pe ndent method
s uited LO )'O un g paro us women, provided no co mra indi-
ca t.ion existS for itS use. lt. is o ne of t.h e best. methods
MIRENA VERSUS TUBECTOMY (Table 19.3)
for spacing childbirth. Progeste ro ne copper device
Late!)'• IVlirena is emerging as a n alternative tO tubectomy is recommended if the woman has heavy periods with
especially in young women who may want to retain ferti li ty dysmenorrhoea.
and avoid a permanent. met.hod.
Mirena may be a bett.er choice in t.he presence offollow- HORMONAL CONTRACEPTIVES
ing condit.ions: COC pills can be safe I) prescribed to adolescen LS. One must
remember tl1e possibilit) of breast. cancer at. a later date if
I. Heav) menstrual bleeding. the young nulliparous woman )Otmger than 24 years of age
2. Dysmenorrhoea. takes COC for more than 4 >ears.
3. Peh·ic endometriosis, adenom)OSis and m)oma. POPs are not. prefer-red O\er COC, because oft.he irregu-
lar bleeding, amenon·hoea, a higher fai lure r-ate and ost.eo-
penia.
CONTRACEPTION FOR ADOLESCENTS Three-monthly or implantS, skin patches
ln lndia, many girls get married at an early age and become and vaginal rings may be acceptable to young man·ied
mother-s. They need counselling regarding spacing and adolescentS, and side effects tolerated. Occasional failure
delaying the bir·th of the next child. Unmar-ried adolescentS may be backed up witJ1 MTP facilities.
are exposed to the r·isk of unwanted pregnancy and unsafe Sterilization should not. be offered LO young couples. The
abortion, as well as the possibili ty of acq uiring AlDS and Government of India has passed a law t11at t11e surgical
sexuall y transmiue<l infectio ns. procedure should not be pcrfo nned in a woman younger
Family plannin g a nd co ntrace ption become impor- than 25 years wi tl1 two or less chi ld re n and the yo ungest
tant. heal th care iss ues amo ngs t. adolescentS. Although chi ld less than 2 yea rs old.
MT P and e merge ncy contracep ti o n sho uld form th e
backup procedmes in t11 ese girls.
Table 19.3 Comparison of Mlrena and TUbectomy
Mlrena Tubectomy PERMANENT STERILIZATION AFTER CHILD BIRTH
• Effective Effective A multiparous woman rn a)' be counselled on sterilization or
• Reversible Surgically reversible - vasect.Om)'· T his is done any time after 2<1 hours of delivery,
success 70% so the woman need not. rewrn t.o the hospital for tubectOmy
Bleeding, dysmenorrhoea less Menstrual Bleeding may later, and this is cost-effective and co nvenient Minilaparot-
increase in 15% omy is a simple and a quick proced ure done under local or
Cheaper than surgery Costly a short general anaesthesia.
No Surgery, anaesthesia Surgery, anaesthesia
complications avoided required
Ectopic pregnancy (0.2/1 000) Risk of ectopic pregnancy CONTRACEPTION FOR A LACTATING WOMAN
slightly increased LAGATING WOMAN
Ovarian function not May be compromised
compromised Regular lactation with one feed at night. delays ovulation
and pregnancy for up to 6 months, provided she remains
276 SHAW'S TEXTBOOK OF GYNAECOLOGY
amenorrhoeic. AfLer 6 months, lac tation has no bearing
on ov ulation and pregnancy ca n occ ur; despite amenor-
rhoea. Thereafter, the woman needs some form of contra-
ceptive precaution.
POP does not suppress lactation or alter the q uantit:y and
qual it) of milk. It can be started after 6 weeks of delivery.
Irregular periods during this period is ta ken as a puerperal
evem and accepted b) the woman. Instead of oral pills,
implants and injection ar·e other altematives.
Oral combined pill in a lactating woman is contraindi-
cated because of following reasons:
• lL reduces the quality and quantity of milk.
• Honnone secreted in the mi lk may be hannfulto the in£u1L
• There is increased l'isk of thromboembolism.
IUC D can be inserted immediately after the delivery.
• Male condoms are safe a nd effecti ve.
CONTRACEPTION FOR A WOMAN
WITH HIV INFECTION
Condoms are th e best in preven tio n of u·ansmission of
infec tion from one partner to the other: Female banier
methods are not as effec tive male condoms, except
Femshield.
The failure rate wiLh co ndom is high, so d ual method of
using hormo nal contraceptives (COC) or lUCD is desirable.
IUCD can be inserted provided the woman has not suffered
from PID and is on medication. The screening for other
STD becomes part of screening procedures before inserting
an IUCD. Surgical procedures are not co ntraindicated in
ti1ese women.
CONTRACEPTION FOR WOMEN OLDER
THAN 35 YEARS
Women older than 35 )ears constitute 20% of the contra-
ceptive users, and selection of the proper conu-aception is
an essential component of family planning counselling.
A woman after th e age of 35 years may become obese,
hypene nsive and diabetic. She is likely to suffer AUB. The
choice depends upon th e sui tabili ty, co nu·aindication and
side effects.
STERILIZATION
When co nside rin g a pe r1 nanent method of sterilization,
one sho uld we igh tile risk of surgical procedure against the
number of years a woman needs con u·aceptive protection.
In a woman neare r th e me nopause with a fewer years of
fertility, surgical proced ure may not be a wise proposition,
and temporary meti10ds will be cost-effec tive as well as safe,
with emergency comraception and MTP as a back-up
meti1od.
LOW-DOSE COC PILLS
The) are safe. if the woman is til in, nonsmoker without any
medical disease up to the age of 45 )ears.
Although POPs may be safer than COC, its adverse effen
on bone density and occu r-rence of osteoporosis must be
borne in mind if ghen o'er a prolonged period. Besides,
they cause irregular b leeding, and the risk of breast cancer
increases.
IUCD may be suitable and effective. If ti1 e woman suffers
from menorrhagia, Mirena ma) be inserted and is effective
for 5 years.
Desogesu·el and gestodene cause thromboembolism and
are conu'aindicated in e lder!) women.
CONTRACEPTION FOR A WOMAN
WITH MEDICAL DISEASE
The risk of pregnanC)' should be weighed against the r·isk of
any conu-aception in a woman with medical disorder. While
prescribing a family planning meti1od, tl!u ronsidf'rtllion and
counselling reltJ/«.1 to lille effix:!J il !U'Cf'M(IIJ'·
lf the risk is negligible, sterilization provides the penna-
n ent method to prevent a pregna ncy. VasectOmy would be
ideal, wi ti1 no risk to til e woman.
IUCD is carefull y co nside red in ca rdi ac a nd d iabetic
women, because of ti1 e possibi li t)' of pelvic infecti on.
COC is co ntraindicated in a hype rtensive, ca rdiac and
diabetic wo men, as well as a woman with cancer,
liver disease and previo us thromboe mbo lism. An epilep tic
wo man and a woman on antiwbe rcular drugs such as rifa-
m>•cin ma)' face a highe r failure rate due tO inte rac tio n
with rifamycin and antiep ileptic drugs excep t sodium val-
proate.
Similarly POP is conu-aindicated in liver diseases,
vascular disorders and breast ca ncer. It is safe in sickle cell
anaemia.
EmergerlC) contraception ( L r tablets) is safe in a
woman with medical disorders.
Conu-aception for a Woman witl1 Ps)d1 iatric Disordel'.
lf a woman is considered unfit to bear children, a nd per-
manem method considered, a wr·itten opinion regarding
psychiatric pr·oblem should be obtained. The written
consent should be obtained from the husband or guardian,
as the ps)chiauic patient may not be mentally aware of tile
nature of ster·iliation.
EmergenC)' contraception is no bar to a woman witi1 a
medical disorder, as onl y two tablets are given in 24 h ours.
WHO CONTRACEPTIVE WHEEL
WHO has introduced a small whee l-like device wh ich can
help doc tor to decide whethe r a particular method of con-
tracep tion is safe for a woman who has so me assoc iated
disease. Recen ti)' WHO has co me out witll an easy to use
disc like device called Contraceptive Wheel. It helps
clinician to choose a safe me tl1od of co nu·aception in th e
presence of a signifi cant medical/surgical condition. Each
contraceptive has been categorized into four categories with
a range where category I means safe to use witi1out an)'
health risk. whereas categor) II indicates use of a method is
more advantageous than risk, category Ill indicates risks are
more ti1an usual. howe,er, method of co ntraception can be
used with caution whereas categor) IV means ti1at use of
conuaceplive method is absolute !) contraindicated in a
give n health condition which women might be suffering.
This contraceptive wheel is user friendly and makes clini-
ciaJl decide the best conu-acepti'e for a woman.
 CHAPTER 19 - TEMPORARY AND PERMANENT METHODS OF CONTRACEPTION
MALE CONTRACEPTION
There have been attempts to find out a safe method of
conu-aception for males other than vasectomy. Till now
there is no proven method of ma le conu-aception because
of several reaso ns such as hi gh count of sperms in
a lo ng period of 72 days for spermatoge nesis and high
incidence of s ide effects.
Fo llowing approac hes are being tested for ma le contra-
ceptio n.
METHODS BASED ON SUPPRESSION
OF SPERMATOGENESIS
GOSSYPOL
Its use as a male comraceptive 11as discovered in China.
Gossypol is a yel low pigment isolated ft'Om couonseed oil. It
is administe red orally 10-20 mg dai ly for 3 moml1s and there-
after 20 mg twice weekly. T he action is direc tl y on the semi-
niferous wbul es inhibiting spermatogenesis witl1o ut altering
FSH a nd LH levels. T he side effects such as weakness, hypo·
kalaem ia and pennanentstetilit)' in 20% of cases limit its use.
TESTOSTERONE ENANTHATE
• enamhate 200 mg injection weekly causes
aLoospermia in 6-12 montllS. bucidate
600 mg 3-mom.hly is also effecti1 e through negative
feedback mechanism without loss of libido.
• Instead of weekly il'tiection, testostemne decanoate 1000 mg
i.m. followed by 500 mg 4-weekly is more convenienL
• Four implants of 200 mg ead1 of testOStetune every
4-6 montl1s witll 300 mg medt'OX)']) t'Ogesterone 3-monthly is
successful in 96% of cases witl1 count less tllan I mi llion/mL.
Side effects - osteopenia, liver and li pid metabo lism
dysfunction, prostate enlargement.
GNRH
111e continuous administration of analogues of gonadotmpin·
releasing honnone (GnRH ) causes a fall in the sperm coum
and spenn motility. The level of testostetune also falls. The
loss of libido and osteopomsis make this regime w1accept·
able over a long period. Besides, it is very expensive and
needs to be given subcutaneo usly.
MEDROXYPROGESTERONE ACETATE
Medroxyp rogesterone acetate 250 mg i.m. with 200 mg
noretl1isterone given as weekly it'tiections is reported to
suppress spermatogenesis witl1 97% success.
DESOGESTREL
It has androgenic property. 75-300 meg daily with subcuta·
neous pellets of testostemne 300 meg causes oligospermia,
11ithout altering tl1e level of HDL.
The hormonal suppression of spermatogenesis causes
loss of li bido and is toxic in hi gh closes. Besides, the
injec tion of hormones is inconvenient 10 ad minister
regul arly. T he acne, weight gain and dec reased HDL are
other side effects. Immunological methods of suppressing
spermatogenesis have not )'et been successful.
277
S) mhetic hormone - 7 alpha-meth) 1-nonestosterone
(M£ T) used as substitute of testosterone-no side
effects.
KEY POINTS
• Fam il )' plannin g and contraception has gained
mom e nwm wo rld overwitl1 an urgent need to con u·ol
the wo rld pop ulation as we ll as to promote woman's
healtl1.
• This has resulted in continuous effort to discover
newer metl10cls and new modes of deli1el') with
optimal effectiveness but with minimal side effects.
• Bat-rier methocls, bOLll male and female, apan fmm
their conu-aceptive effect, ha1e the ach antages of pre-
Yenting u-ansmission of STDs, HIV and reducing the
incidence of cancer of the cervix. A high failure rate
of 10-14 per 100 per woman-year use t'S with barrier
methods ca n be imptuved by a backup method s uch
as usc of eme rge ncy contraception if unpro tec ted
intercourse occurs around ovulation. These advan-
tages along wi tl1 ilie low cost and excellent reversibil-
it) can e nhance tl1e use of tl1is metl1od in preveming
an unwamed pregnancy.
• ewer formulations containing extreme!) small dose
of oesu·ogetlS and an effecti1e progestogen has
reduced t11e failure rate and side effects of oral con-
traceptive pills.
• I UCD is an established method of female contra-
ception in India on account of one-tim e inser-
tion, low cost a nd long efficacy. Progesterone-
impregnated IUC D has a n added advantage of
red ucing me ns u·ual b leedin g, but it is expe ns ive .
T he re mova l rate of 5%-10% on acco unt of s ide ef-
fects is acceptable.
• Newer drug de livery systems are continuous!) on uial,
and tl1eir advamages, disadvantages, effecti1eness and
rC\ ersibilit) are being studied. This has resulted in
availabilit) of implants, vaginal lings and conu-acep-
tives skin patches.
• OCPs offer a number of health benefits in addition to
conu-aception.
• POP are particularly useful when oestrogen is contra-
indicated or its side effects are intolerable. POP is as
effec tive I UC D but less effec ti ve th an COC. It can
be used by the lactating woman, unlike COC.
• Centchroman as an oral con traceptive pill is available
in India. It is cheap and needs to be taken once a
wee!...
• Vasectom> and tubecwmy are tl1e surgical metl1ocls
offered on I) when a pennanem method is desired by
the couple.
• EmergenC)' contraceptive also known as postcoital
contraception is an il1novati1e technique of prevem-
ing conception if t-ape or unprotected intercourse
occurs around ovulation. This method has a 95%-
98% success rate and thus avoids MT P.
• A wide range of contracepti ves allow a wider selec ti on
of cho ice to the couples a nd improves tl1 c acceptabil-
it)' of one or more methods.
278 SHAW'S TEXTBOOK OF GYNAECOLOGY

SUGGESTED READING
SELF-ASSESSMENT Ali>ott Scott, Anna Cla.ier: £,idencc b<o.st-d ''Ontmceptin; choice;;.
Best Pt'dcticc and Clinical Obstetrics and
I. Discuss Lhe advantages and disadvamages of oral Vol 20:5.665-680. Ebc\icr, 2006.
combined con tracepLive pills. Duttcatt Jdirc) S. Shulman Lee P Duncan, Schuman. Year Book of
2. WhaL are 1.he con traindicalions 1.0 oral combined pills? Ob.tetric.. and Women'• Jlc;olth. Page 295,john Wiley
& 20 10.
3. WhaL is 1.he role of minipills in contracepLion? Patta) :\. Studd J: u.c. of the homtone releasing
4. Discuss 1.he complicaLions and conu-aindicalions of intrauterine S).,tclll. Studdj: Progn:» in Ob.tetrics and
inu-auLerine device. Vol13:379-395. Churchill L.hing>tone: Eb<!'ier, 1998.
5. Wt·iLe shorL noLes on:
• H ormonal implanLS
• VasecLomy
• Barrier conu-acepLives
6. Discuss Lhe uses of Mirena and Copper-T.
 Medical Termination
of Pregnancy
Medical Termination of Pregnancy 279 Self-Assessment 284
Key Points 284
MEDICAL TERMINATION OF PREGNANCY
Vo lu ntar)' term ination of pregnane)' before 20 weeks of
pregnancy has been legali:ted in India by a law passed b)' the
Parliamem in the year 1972. This legislation was adopted
aim of reducing incidence of unsafe abortion by an
LlllLrained person. There has always been a need for termi-
nation of pregnancy if it is associated with risk to t11e life of
women, pregnane) resulted becatLSe of sexual abLLSe or
where pregnane) was undesirable or as a result of conLra-
ceptive failure. Before this Act., a pregnant woman sought
help of un Lrained persons to get rid of tulw:uued pregmmcy
lisking her ph) sica! heallh and her life. A number of other
countries in me world also have legaliLed abot·tions as a
safety measure for pregnam woman. Although law is c:tlled
as medical Termination of Pregnancy (MTP), botl1 medic:tl
and occasionally surgical memods are employed for Lenni-
nation of pregnancy. However, many govemmems in the
world over have liberalired 'Abortion Laws' in keeping
"ith changing times, accepting t11e recognition of t11e right
of t11e indi vidual to bear a child at her chosen time
and helping to curb the malpractices accompanying illegal
abortions. ln India, t11e MTP Act was adopted as a health
measure way back in 1972 to avo id death clue to criminal
aborti ons.
DEFINITION
The MTP Act perm its L11e wi lfu l te rmination of pregnanC)'
before t11 e age of fetal viability (20 weeks' gestation) for
well-defined indications. It has to be performed by recog-
nized medical practitioners in a recognized place approved
by the competent authority under the Act.
INCIDENCE
It has been estimated t11at t11e total n umbet· of abort.ions
performed globall) is approximately 46 million annually; of
t11ese, 26 million take place in counu·ies where abortions
are legali.red. ln India, 6. 7 million MTPs take place rumu-
:tlly. Howe-.er, exact incidence remains unknown. ln women
undergoing 40% pregnancies are unpl anned and
25% are unwan ted. Despite L11e law, 40%-50% of abo rtions
are unsafe terminati ons of pregnan cy done by unq ualified
persons under unh)'gien ic conditio ns.
GROUNDS FOR PERFORMING MTP
The MTP Act has permitted termination of pregnancy for
following indications:
MEDICAL GROUNDS
When the continuation of pregnanC) is likely to (i) endrul-
ger me life of t11e pregnant women or (ii) caLLSe grievoLLS
injury to her physical and/ o•· memal healtll, as in cases of
severe h)penension, cardiac disease, diabetes, ps)chiatric
illnesses, genital and breast cancer.
EUGENIC GROUNDS
When ulu-asound shows a malformed embryo or fetus or
there is a substantial r-isk of the child being bom with
serious ph)-sical or mental abnonn alities. For example,
hereditary disordet'S, congenital ma lformation in pre-.,iOtlS
offspring witl1 a hi gh risk of recun·ence in subsequent chil d-
binh/ Rh-isoimmuni:tation, teratogenic drugs and matemal
rubella posing risk of anomalies in the fe tus. Chorion villtlS
biopsy, cordocentesis and sonogra phic evalua Li on of t11 e
fetus have con tri buted significa ntly in identifying t11 e
fetuses a t risk.
HUMANITARIAN GROUNDS
ln cases when t11e pregnanC)' is caused by rape or incest.
SOCIAL GROUNDS
When: (i) in the actual or reasonably foreseeable furure,
her environment (social or economic) might lead to r-isk
of injLLI')' to her mental or ph)-sical health. (ii) pregnancy
resulting from failure of conLraceptive device or memod.
The written consent of the patient on a speci:tlly
presctibed form is necessa•1 before undenaking t11e proce-
dure. The written consem of the legal guardian must be
obtained in case the woman is younger than 18 )eat'S or she
is mentally ill, e-.ren if she is older than 18 )eat'S.
279
280 SHAW'S TEXTBOOK OF GYNAECOLOGY
Indica Lions of MTP are as follows:
• Maternal medical disorders
• Fetal conditions
• Rape. incest
• Failure of con tracepLives
• Social grounds
WHO CAN PERFORM MTP?
Only doctors who have been registered and authorized by
the District Health Authorities for the plll·pose of carrying
out MTP can carry out MTP. Generally for carrying out the
first-trimester MTP, opinion <1nd signatw·e of one doctOr is
St1fficient. However, for the tenn inaLion of pregnan cy
between 12 an d 20 weeks, opinion of two certified doctors
is must.
THE PLACE FOR PERFORMING MTP
T he Act sLipulates that MTP ca n be performed o nly at
(i) a hospital estab lished and maintained b)' the govern ment,
(ii) a p lace recognized and app roved by the government,
t.mder this Act.
• Abortion services a re provided under this Act at these
centres under strict
• The identity of the person is treated as a statutory
personal matter.
• Uluasonic scanning pla)S <1n important role in confinn-
ing uterine pregnanC), estimating gestaLional age, detect-
ing malformed emb•')O and someLimes in perfonning
MTP under ultrasonic guidance.
HOW TO COMPLY WITH THE INDIAN MTP ACT
AND ENSURE QUALITY CARE
• Ensure proper case selection: Document meticulously the
paLient' age, gestaLional maturity and indication for MTP.
• EssenLial investigations pe•·formed such as haemoglobin,
urine routin e, blood group and Rh factOr and sonogra-
phy whenever necessary.
• Opinion of one medical practitio ner for the first-
trimester MT P, and opinions of two med ical practitioners
for the second-trimester MTP.
• MT P to be perform ed b)' a registe red medical practitio-
ner approved for un derta king MT P in a p lace recognized
under the MT P Act.
• Documents to be main ta ined: Form I, Form ll and
admission register:
IMPLICATIONS OF THE MTP ACT
In countries with li beral abortion laws, maternal morbidity
and mortalit) have declined, and women have been
motivated to accept birth conu·oJ measures. DeatllS due to
illegal abortions (500 per 100,000) are mostly due tO haem-
orrhage (20% ). sepsis, embolism (20%-25%), anaemia and
gut inju•1'· Mona lit) and morbidity ino·eases witl1 each week
of gestation, and is fi,efold to tenfold higher in tl1e second
trimester compared to tl1e first-u·imester MTP.
Table 20.1 Methods of the First-Trimester MTP
&-a weeks Medical abortion, menstrual regulation
pregnancy
8-12 weeks Suction evacuation, medical methods
pregnancy
12-14 weeks Extra amniotic drugs, intramuscular
pregnancy prostaglandins, vaginal misoprostol
Repeated abo•·tiollS are not conducive to a woman's
health; hence, MTP should not be considered as a bi•·th
control measure and should not replace prevailing metl10ds
of contraception. Even in tl1e best of circumstances, there is
a small inherent lisk in the procedu re of MT P. This should
serve as a warning that MTP c<1 n neve r be as safe as efficient
contraception. The woman un dergo ing MT P sho uld be
co unselled to accept a safe me thod of conu·acep tion.
When properly counselled, MTP ca n ind irec tly promote
fami ly plann ing and pop ul ati on conu·oJ.
METHODS OF MTP
There are different methods adopted for termination of the
first· and second-uimester pregnancies.
Met11ods of MTP can be broadly class ified as follows (also
refer Table 20.1 ):
Metl1ods of the first-trimester MTP
• Me llStrual regulation
• Dilatation and suction evacuation
• Cervical softening before dilatation and suction evacuation
• Medical metl10<ls
Methods of the second-u·imester tvrrP
• ProstaglandillS ghen vaginally, intraamniotic, exu-a
amniotic or inu-amuscular
• Surgical evacuation
• Extraovular instillation of dn,ags such as et11acridine lactate
• Extrautetine methods
T he above metl1ods are used singly or in co mbina ti o n.
T he oxytOcic drugs stimul ate myomeu·ial ac ti vity and
s horten tl1 e induction-abort.ion interva l in the second
trimeste •: Similar!)', tJ1e use of prostagland ins (gel, supposi-
tory) a few ho urs before the proced ure helps to attain a
grad ual softe ning and a u·aum atic d ilata tion of tl1 e ce rvix,
faci litating furt11er d ilatation a nd evac uation proced ures.
FIRST-TRIMESTER MTP
SURGICAL MElHODS
Menstrual Regulation
MellSU'ltal regulation COilSists of aspiration of the contents of
the ute.-ine caviL) b) mea11S of a disposable plastic cannula
(Kannan·s cannula). It has an attached plastic 50 mL S)Tinge
capable of creating a vacuum of65 em Hg (Fig. 20.1). It has
a simple thumb-operated pressure control valve and a

Figure 20.1 Menstrual regulation syringe with Karman cannula.
piston-locking handle. It is independent of electricity, is por-
table and washable. It is effective when ca•-ried out on preg-
nane>' within 12 days of the lliSt mensu·ual period (LMP). A
paracervicallocal anaesthetic block or preoperative sedative
alone usuall y suffices but sometimes in an apprehensive pa-
ti ent, general anaesthesia may be neces..<;ary. This proced ure
can be performed in an office set-up, o utpati e nt clinic or
day-care cen u·e. Since 1972, this me th od has been exten-
sive ly evalua ted and found to be efficient, safe and easy to
use in te nn inating ea rly pregna ncy. It is a good practice to
examine tl1e products of conception fo llowing the p roce-
dure. The occasional complications enco untered include
fai lu re to evac uate leading to con ti nuation of pregnane>'•
incomplete evacuation, haemorrhage, cervical laceration,
perforation, infection and anaestJ1e tic complications. If
pregnancy was not confirmed by ulu·aso tmd, an ecwpic
pregnancy may be missed.
A failure to evacuate is due to following reasons:
I. Too earl) a pregnane).
2. Ectopic pregnane).
3. Uterus bicomuate, aspiration being can·ied out in a non-
pregnant horn.
Rh anti-D globulin 50 meg i.m. should be given tO an
Rh-negative nonimmuniLed woman with pregnancy less
than 12 weeks.
Medical Abortion
Of late termination of cady pregnancy (less t11an days)
is being carried out with the use of mifepriswne ( RU486)
and misoprostol. T his mctl1ocl avoids need for a surgical
me tl10d suc h as menstrual regulation. In Ind ia termination
of pregnancy up to 49 clays has been perm itted fo r the
use of a med ical me tl1ocl. In a co nfirmed pregnanC)\ the
wo man is in itia l! )' given a t4lb le t of mifep r isw ne co nta in-
ing 200 mg of drug, followed by vagina l adm in is tratio n of
800 meg of misoprosto l. In most cases, abo n.ion is successful
few hours after adm inistration of misoprostol. Most
women experience continuation of bleeding for a period of
7-14 days. A repeat ulu·asound after 14 days is carried o ut tO
d1eck for any retained products or possible continuation of
pregnancy. Some patients may require suction evacuation
for heav) bleeding after medical abortion. Prophylactic
antibiotics are ghen for a period of 48 hours to 5 days.
Rh-negative woman should receive ami-D i11jection. \'\'oriel
over tllis metJ1od has taken over tJ1e surgical evacuation for
tennination of earl) p•·egnanC)'· To avoid complications on
a rare occasion, it will be good idea to ,·isit a doctOr and
avoid self-administration of drugs. In India, regulations
CHAPTER 20 - MEDICALTERMINATION OF PREGNANCY 281
advise regisu·ation of cases in an MTP clinic and dmgs to be
dispensed on the prescription of a certified doctOr.
TERMINATION OF PREGNANCY BETWEEN
8 AND 12 WEEKS
Vacuum Evacuation (Suction Evacuation)
VaCLmm evacuation is the most efficiem method of tenni-
nating pregnanq• up to 12 weeks of gestation. It has
gained rapid acceptance worldwide. The operation can be
generally undertaken under local anaesthetic,
block, coupled witJ1 some sedation if necessary. Apprehen-
sive patients may need general anaestllesia. The procedure
involves examination of the patient in the operation the-
atre observing full aseptic precautions. The gestation size
and the position of the uterus are carefull y assessed. After
administering a paracervical block, the cervix is h eld with
an Allis/vulsell um forceps and dilated by mea ns of Hegar's
or some o tJ1 er metal di lators until adeq uate dilati o n is
ac hieved w perm it in trod uction of the s uction cannula of
the appropriate size (diameter correspo nd ing to the wee ks
of gestati o n) in to tl1e ute rine cavity (Fig. 20.2) . A standard
nega tive sucti on of 650 mm (65 em) of Hg is created a nd
the prod ucts are asp irated. Wh en tJ1e p roced ure is co m-
p le ted, a gra ti ng sensation is fe lt all a rou nd th e uterine
caviL)'• no further tissue is asp irated and the internal os
begins to grip the Karman cann ula wh ich may also reveal
a blood-stained froth. There is no need to follow this up
with a check curettage with a sharp cureue, as tl1is step can
be traLLmatic and lead to complications such as perfora-
tion, synechiae (Asher man S) ndrome), and predispose
to placenta accreta in a fuwre pregnancy. In case me
pregnanq exceeds 8-week gestation siLe, the patient is
nulliparous or there is presence of a uterine scar, gene raJ
anaestJ1esia may be preferred.
ln case of large uterus of 10- to 12-week gestation size, or
nulliparous cervix, p.-iming tJ1e cervix with prostaglandin
gel or suppository, at least 4 hours earlier helps tO soften
the cervix so tl1at it yields more easily and undue force
is avoided during cervical dilatation. This precaution
safeguards against complications such as ce•vical tear,
lacerations and injur-y to the intemal os leading to incompe-
tent ce•·vix; 200-400 meg misoproswl pessary is inserted in
the vagina (prostaglandin E.).
.,'
.:§
20.2 Suction evacuation - aspiration of the products of
conception.
282 SHAW'S TEXTBOOK OF GYNAECOLOGY
Vacuum aspiral.ion as a melhod of MTP has a very low
failure rate (< 1% ). Complical.ions such as incomplete
evantal.ion, infecl.ion, uterine perforal.ion and excessive
bleeding occur in less than 2% of cases. The mortality is less
than 2 per 100,000 procedures. NonimmuniLed Rh-negative
mothers must receive 100 meg of anl.i-0 immunoglobulin
after tmdergoing MTP. Failure to end pregnancy is due to a
ver')' earl) pregnane). unrecogniLed ectopic pregnancy and
pregnane)' in a rudimentary hom. Preoperative uluasow1d
is useful in pre,enting these complications.
MEDICAL ME1HODS
Prostaglandins and RU486 ha,·e been extensively used as
medical methods of MTP in early pregnane)'· Acting singly,
the)' are not as effective as "11en used in combination. The
medical melhod avoids hospitali zation but the prolonged
observation, occasional need of surgical te nn ination (fail-
ure) and the cost of t he drugs are some of th e disadva ntages.
Prostaglandins
Prostaglandi n Injecti ons (Prostin, Ca rboprost-p rostagla nclin
F2cx) 250 meg given i. m. every 3 ho urs up tO a maximum of
10 closes has been found LO be effective in initiating the
process of abortion. It has not been pop ular in the fi rst
u·imester because of an unaccep1.a bly high inc ide nce of
incomplete abortion (20% ) req uiring surgical intervention
to complete the proced ure, and lhe high rate of unp leasant
side effects such as nausea, vomiting, diarrhoea, cramping
abdominal pain, bronchospasm and mild fever at times.
Mifepristone (Mifegest - RU486)
First invented in France, in 1980, RU486 stands for Roussel
Uclaf 486 (laborator1 number).
It is a S)nthetic steroid, a derivative of 19-nortestosterone,
"ith antiprogestogenic eff'ecL It also has antiglucocorticoid
and weak antiandrogenic action. By competing with progester-
one receptors, it reduces the endometrial glandular activity,
accelerates degenerati'e changes and increases su"Omal aCLion,
thereby causing sloughing of endometrium. It thus preventS or
disturbs implantation of the fertilized O\um through luteolysis.
l t also causes utel'ine contractions, softens and slightly
dilates the cervix.
Used singly, it is effective in 83% cases, and ca uses incom-
plete aborti on in 10%-20% cases. Addin g prostaglan din
yields a success t'<lle of95% in pregnancies less than 63 clays
dura ti on, with 4% incom plete abo rtio n and continuation of
pregnancy in 1% cases.
T he pro tocol is as foll ows:
• Written consent for MT P is req ui red.
• Blood gro up Rh, Hb%, urine albumin
• Ulu·asound is done to con firm ute rine pregnancy and
duration, and exclude ectopic pregnancy.
D(ty 1: 200 mg of mifepristone given as a single close- the
woman is observed for half an hour and then allowed to
go home. Anti-0 globulin given tO an Rh-negaLive woman.
Day 3: 800 meg of oral misopr"Ostol (prostaglandin) is
administered unless abortion has occurred. Sublingual
or vaginal misoprostOI is also used but a su·onger· action
of a sublingual r"Oute can cause uter·ine mpture in a
scar·red utet·us. Pulse and BP are observed for 2 hours,
if all is well patient is allowed to go home.
Nowadays, misoprostol (PGEr) vaginal tab let of 400 meg
is insen.ed instead of oral tablel.
D(ty 14: Follow-up to confirm abortion has occurred; if
noL surgical MTP is done.
1l1e bleeding usuall) startS within few hours of taking
mifepr;stone. and abortion occurs in about a week.
Contraindications to mifeprisLOne are as follows:
• l UCO in situ- IUCO should be removed before medical
termination to a'oid the r·isk of perforation.
• Suspected ectopic pregnancy - ultrasound should be
done before termination.
• Hypertension, anaemia, glaucoma, cardiovascular disease,
smoker, asthmatic.
• A woman on anticoagulant (coagulopathy) and glucocor·ti-
coid therapy.
• Allergy, porphyria, sei:t.tu·es (adrenal failure).
• Previo us uterine scar - scar rup tu re ca n occur with
misoprostol.
• Fibroid uterus.
• Lactating wo man - Since the d rugs are sec reted in th e
mil k, leadi ng to cUa n·hoea in infa n1.s. Lactatio n may be
sLOpped te mporaril )'·
• Gesta tion period sho ul d not exceed 63 da)'S (p referably
49 da)'S).
Advantages of misop r"Ostol are as fo llows:
• Easily stored in room temperature
• Shelf life: 3 )Cars
• Cheap
• Easy adminisuation
ot contraindicated in patien LS wiLh asthma.
Complications
• Adrenal failure
• Heaclache, malaise, skin rash, fC\er, vomiting, dianhoea
• Failure to abort, I%
• Misoprostol causes Mobius syndrome in the fetus
(congenital facial palsy, limb defects, bladder exu·ophy,
hydrocephalus). Ther·efore, termination of pr·egnancy is
strongly recommended if medica l termination fails.
• It takes longer time for termination compared tO surgical
term ination and longer follow-up of2 weeks is necessary.
• Surgery is requi red in case of failu re or is incomplete. In
case Lhe woman starts bleeding proftL5ely, eme rge ncy surgi-
cal evacuatio n is required. Therefore, e me rge ncy surgical
bac kup is a must fo r medica l te nn inati on of pregnancy.
• T he subsequent menstntation may be de layed b)' I 0-14 da)'S.
• Sub lingual misop r"Ostol is as effec tive as vaginal pessary,
b uLSicle effects are more severe than wiLh oral tab letS and
vaginal pessaries.
• If vomiting occurs soon after oral misoprostOI, repeat the
dose. Vaginal pessary is Sllfe.
Alternative protocols used are as follows:
• 200 mg of oral mifepristone followed by 800 meg vaginal
misoprostol on the third da).
• 200 mg mifept·istone and I mg tablet of prostaglandin Er
analogue, gemeprost vaginall) - pregnancy failure is
reponed in 0.2%-2.3% cases.
• Methotrexate 50 mg inu-amtLSCular or oral followed
5-7 days later by 800 meg \'llginal misoproswl (repeat
misoprostol 24 hours later, if required).

• Epostane - A progesterone-blocking agent is adminis-
tered in doses of 200 meg every 6 hours for 7 days.
Misoprostol alone for termination of pregnancy between
Sand 12weeks:
For tennination of pregnancies between 8 and 12 weeks,
misoprostol alone has been used extensi,ely. Several dosages
regime have been empiO)ed with a ,-,uiablesuccess •<lle.ln most
cases induction-.'lbortion inter,'lll ma)' last 24 hours or longer
"ith a 1isk of incomplete abortion or excessive bleeding.
Medical versus Surgical Methods for Termination
of Early Pregnancy
While choosing between mnliall a11d surgi.ctd mPtlwds for tennintJJ.ilm
there is nounud1 difference in tenns of safety
and efficacy of two methods. However, surgical method has
inherent risk of complications such as perforation of uterus,
infection and excessive bleeding during the procedure.
SECOND-TRIMESTER MTP
The MTP Act 1972 permits term ination of pregnancies up
to 20 weeks. Opinion of two ce rtified doctOrs is needed and
such a term ination should be carried o ut in a p lace fully
equipped with anaesthesia and an operation theatre to
handle any complication. The second-trimester MTP is as-
sociated with higher complication rates and risk of serious
complications. The incidence of the second-trimester MTP
has dropped with the pass;lge of Lime, from about30% of all
MTPs performed two decades ago LO about 10% in the pres-
ent times and is mostl) performed for fetal malfonnations.
SURGICAL METHODS
Dilatation and Evacuation
ln some western countries, MTP up to 16 weeks is carried
out by a slow and deliberate dilatation of the cervix with the
use of laminada tents, prostaglandin gel or pessary, before
C\'l\cuation of the uterine contents using either \'l\Cuum
aspiration or aspi1-otomy with ovum forceps. Complications
such as ce1vical u-auma, uterine perforation or tear, incom-
plete evacuation, h aemoni1age and infection are more
common with the second-u·imester MTP than the first-
trimester MTP. In India, surgical method for the termination
of the second-trimester MTP is no t commonl y used.
MEDICAL METHODS OF MTP
Medical methods ernpiO)' use of abortifac ient drugs given b)'
vaginal, ex u·amn iotic, inu·a-amn io tic or inu·amuscular ro ute
to accomp lish pregnancy termination.
Extraovular Instillation of Drugs
Several drugs such as ethacricline lactate, hypertonic saline
and prostaglandins have been successfully used in the past,
but the drug of choice has been ethacricline lactate.
Ethaaidine Lactate. Ethacridine lactate is mailable as Em-
credil. The ach'llnt.age is that exu-aovular instillation can be
easil) perfonned in tJ1e second uimester "itJ1 a low faihu·e .-ate.
The p•-ocedure should be undenaken in an operation
theatre. After stead) ing the ante•·ior lip ofthe ce1Yix, a Foley
catheter is introduced u-anscen'ically into the e.xtraovular
CHAPTER 20 - MEDICAL TERMINATION OF PREGNANCY 283
space. The bulb of the Foley catheter is inAated 10-20 ml
of distilled water to seal off the intemal os. Ethacridine
lactate 0.1% pre-prepared solution is instilled into tJ1e
exll<!ovular space in a dose of 10 ml/ week of gestation up
to a maximLUn of 150 ml. The catheter is left in place for
6 hours, whereupon it gets gmduall) expelled spontane-
ously. Altenlativel), tJ1e Fole) catJ1eter bulb is deAated and
the catheter removed. Ute•ine activit) usually begins within
12-18 hours, The mean induction-abo•·tion inten'lll varies
between 21 and 36 hours. About 30% of the abon.ions are
incomplete and require oxytocin infusion and occasionally
blunt curettage to remove tJ1e retained placental tissue.
ln the C\'ent of failu•·e to initiate uterine activity within
24 hour·s, an augmenting oxytocin drip is desirable. ln case
of failure in 72 hours, •-einstillation of ethacridine may be
tried or some other method of MTP should be reson.ed LO.
To increase the success rate witJl etJ1ao·idine lactate,
most gynaecologists prefer starting a drip co ntaining 10-20
units of oxytocin ti ll abortion is co mplete. Altematively,
supplementation witJ1 prostagland ins he lps to hasten t11e
process of abortion. Amongst tJ1e me tJ10ds u·ied, the follow-
ing metJ1ods me rit mention: (i) insti llation of 1 mL of
carboprost or Prostodin injection di luted in 10 mL of dis-
tilled water into tll e exu·aovular space j ust before removing
the Fole)' catJl eter, (ii) instillation of 0.5 mg prostagland in
£ 2 gel (Cerviprime gel, P•-ostodin tablet) 4-6 ho urs before
instillation of £mcredil solution in the extraovular space,
(iii) 1nj. prostaglandin F2a250 meg i.m. every 3 hours, com-
mencing from the Lime of remO\'lll of tJ1e catJ1ete1: In all
such cases. tJ1e induction-abortion inten'lll may be reduced
to 12-18 hours witJ1 a higher success rate of75%-80%.
Intracervical or Extraovular Instillation
of Cerviprime
Comraindications to the use of p•-ostaglandins are c:u·diac
disease, renal disease, h) penension, bronchial asthma aJ\cl
caesarean scar,
Mifepristone and Misoprostal
0•-al mifepristone (200 mg) followed 36-48 hours later by
600 meg of \'llginal misoprostol and tJ1en 400 meg of vaginal
misoprostol every 3 hourly with a maximum of five doses or
200-600 meg of vaginal misoprosLOI eve•)' 12 hourl y for a
maximum of five doses has also been used. A combination of
mifepristone and misoprostol gives a higher success .-ate for
tJ1e second-u·imester MTPs co mpared to misoprosLOI alone.
Postoperatively all women shoul d receive antib iotics,
analgesics and Rh a nti-D globin in an Rh-negative nonim-
munized woman.
Prostaglandins
Before the availabi lity of misoprosto l, Prostaglandin was
widely used. It is available as l•"ti- p•-ostodin I mL ampo ule
(Astra-LDL) containing 0.25 mg of tJ1e dmg, for parente1-al
use. It has been used in doses of 250 meg (I ml) i.m. every
3 hOLLrs. for a maximLUn of 10 doses, Prostaglandins have
also been used instead oflaminaria tents tO soften the
before undertaking dilatation and evacuation.
Combined Methods. These involve the use of seve .-a I meth-
ods in combination to take ach'llntage of their S)llergistic
effects on m)ometrial activity, thereby hasten the abortion
284 SHAW'S TEXTBOOK OF GYNAECOLOGY
process and minimize complications. Amongst the pop t.Llar
combinations in use are: (i) Emcredil plus PG, (ii) PG and
larllinaria tent and (iii) Emcredil and OX)'I.OCi n.
In a nulliparous woman, prior ripeni ng of cervix before
using an> medical met11od increases success rate. This can
be achieved b) local application of prostaglandins or by use
of devices such as laminaria tent.
lATE SEQUElAE OF MTP
Late sequelae of MTP include following:
• Pelvic Inflammatory Disease ( PID)- chroni c pelvic pain.
• Infertility caused by tubal infection and blockage.
• Incompetent os following trauma tO the cervix; iliis
ma)' lead tO pr·etenn birtl1s and recur-rent mid-u·imester
abortions.
• Adheren t placenta in the subseq uent pregna ncy.
• Asherman syndrome.
• Ectopic pregna ncy as a result of PI D.
• Cervical ec topic pregna ncy ca used by u·aum a.
• Intrauterine Growth Resui ction (IUG R).
• Rh-isoimmuniza ti on ifan ti-D has no t been administered
after the MT P to nonimmunized Rh -nega tive moth ers.
• PS)'Cho logical proble ms, if MTP was done witho ut proper
counselling, and tJ1ere is a feeli ng of regret, especially if
infertility follows tJ1e proced ure.
INDIAN EXPERIENCE WllH MTP
• Nearly 15 million MTPs are taking place in India; of
tl1ese. 10 million are performed by 1m recognized provid-
ers. earl) 15.000-20,000 or more women die annually as
a result of complications of unsafe illegal abortions.
• Vacuum aspiration for the first-u·imester MTP has proved
to be effecti'e in 98.6% cases and it can be accomplished
in 9 1.8% cases w1der paracervical block anaesthesia \lith
or without sedation. Slowly, t11ere is a u·end for adopting
medical metJ10<Ls for termination of early pregnancy, L11us
avoiding complications associated \\itll surgical procedure.
• The Indian Council of Medical Research while investigat-
ing tJ1e sequelae of induced abon.ions reported an inci-
dence of minor· complications in 3.13% procedures and
major complications in 0.2 I%.
• Adminisu·ation of tablet of 200-400 meg of misoprostol
inserted into tJ1e posterior fo rnix of tJ1 e vagina 3-4 ho urs
before suction evac uatio n brings abo ut softening of the
cervix and cUiation, thus faci litati ng cervical dilatation
and reducing the Lime of surgery as well as itS accompany-
ing blood loss.
• The second-trimester MTP with e1J1acridine lactate
remains widel) used method becatLSe of itS simplicity, lack
of seriotLS side effectS and low cost. Success rate can be
increased wilh tJ1e addition of prostaglandins to the instil-
lation fluid or setting up OX) tocin clr-ip.
• Tennination of pregnancy in India is pennittecl up to
20 weeks.
KEY POINTS
• MTP service is avai lable in India as a health measure
to avoid criminal abortio n and not as a contraceptive
technique. Its indications are clea rl y defined by
tJ1 e govern men t and sho uld be ab ided by the
gyn aeco logists.
• T he firs t-trim este r MTP b)' sucti on evac uati on is safer
tJ1 an the seco nd-u·irnester terminati on.
• MecUcal me tJ1 od of using mifcp risto ne and misop ros-
to l has proved successful , but the drugs are expe nsive
and requires 2-week follow-up. The surgical method
may still be required in fai led cases.
• The choice betwee n medical and surgical methocls of
termination of pregnane> depends on the d1oice
of tl1e woman and co ntra indica tions of a method.
• Newer prostaglandins ha' e fewer side effects
• Availabilit) of short-acting and lo ng-acting contracep-
tives allows a.he couple 1.0 choose a metl1od of their
need and comenience.
SELf-ASSESSMENT
I. Describe MTP Law prevailing in India.
2. Describe meclical and surgical met11ods of the first-
trimester MTP.
3. Describe commonly used meth ods of tJ1e second-
trimester MT P.
4. Describe complica tions of tJ1e second-trimester MT P.
 BENIGN CONDITIONS IN
GYNAECOLOGY

21 Genital Prolapse 24 Benign Diseases of the Ovary

22 Displacements of the Uterus 25 Benign Diseases of the Vulva
23 Diseases of the Broad ligament, 26 Benign Diseases of the Vagina
Fallopian Tubes and Parametrium

285
 Genital Prolapse

Supports of the Uterus 286 Differential Diagnosis 292

Aetiology of Prolapse Uterus 287 Complications of Pelvic Organ Prolapse 292
of Prolapse 287 Prevention of Prolapse 292
POP-Q System 29 1 Treatment 293
Symptoms of Prolopse 291 Key Points 300
Investigations 292 Self-Assessment 301

Uterine prolapse is a fa irly co mmon conditio n especially

among e lderl)' women. Downwa rd d isplacement of uterus Ischial spine
from iLS normal position is called prolapse of uterus. Uterus and
sacrospinous
is held in iLS norm al positio n by iLS supporLS. Damage to
ligament
muscles and liga mentous suppo rLS of uterus resul LS in pro-
lapse of utents. Beca use of a close relations hip with v-aginal
walls. prolapse of uterus is assoc iated with prolapse of ante-
rior and posterior walls of vagina.

SUPPORTS OF THE UTERUS

Knowledge of supporLS of uterus is helpful in understand-
ing aetiopathogenesis of prolapse of uten.tS. Three levels of
suppo•·LS of utentS ha\ e bee n identified in the pelvis.
DeLan cey described three levels of supporLS of pelvic
o•·gans.
• Level I - Uterosact-al and cardinal ligamenLS support the
utentS and vagi nal vault. The cervix remains at or jttSt
above th e level of ischi al spines.
• Level II - Pelvic fascia and pa racolpos which connect the
vagina to tJ1e white li ne o n the lateral pelvic wall through
tJ1e arcus tendineus fascia pelvis. T his includes the p ubo-
cervical fascia a nteri orly and tJ1 e recLOvaginal fascia and
sep tum posteriorly. Insertion ot
cardinal ligament
• Level Ill - Levator an i muscle suppo ns the lower o ne- Rectum
third of tJ1 e vagina. The levator muscle forms a platform
against which th e pelvic o rgans (uterus and upper
vagina) get compressed d uring su·a ining.
ligaments
• Damage to Level I supports causes uterine descent,
enterocele and va ult descent. Vaginal vault Symphysis
Pubocervical
• Damage to Level 11 suppon.s causes cystocele, rectocele.
fascia
• Damage to Level Ill supporLS causes uretJ1 rocele, gaping Urethra
inu·oitus and deficient perineum. Levator ani -:::::7"-....1...._ 1 Perineal body
For diagrammatic representations of DeLancey's levels (Pubococcygeus)
ofsuppo11. to genital u-act, refer to Figs 2 1.1 and 21.2. Figure 21 .2 Various supports of the uterus.

To \iew the k-cturc note> :.can the >)lllbol or log in I() rour account on \\

286
 CHAPTER 2 I - GENITAL PROLAPSE 287

Clinica lly LUHecogni:t.ed da mages and breaks in these
suppo rts ca n be de tected by ulu·asound and MRl.
AmOLOGY OF PROLAPSE UTERUS
(Table 21 1)
Wea kness o r injut) to no rmal s uppo n s o f ute rus results
in u te rovaginal pro la pse. In most cases, d am age LO
suppons occ urs as a r esul t o f a mis ma naged c hildbin.h.
H oweve r, a conge ni ta l d efect o r weakness of suppo rts
of uterus can resul t in prola pse of uterus a nd vagina.
\>\r. thdrawa l of h o m10n al suppo rt, especially oestrogen ,
foll o wing m e no pa use is an impo rta nt fac to r for the onset
of sympto ms of pr·olapse. Ra rely pelvi c trauma or nerve
dam age to p elvis ca n resu lt in prola pse ute rus. Raised
intraabdo min al press ure, ch ro ni c co ns tipatio n, ch ron ic
obs tn.tctive airway di seases also p lay a role in th e develop·
ment of p elvi c orga n prola pse .
Mismanaged childbirth: Unsupe rvised or wro ng prac-
ti ces d uri ng labour o r pue rpe rium ca n p redi spose a woma n
to s ubseq ue nt develo pme nt of ute rine pro lapse. Prolo nged
bearing down effo rts in tJ1e fi rst s tage of labo ur before the
full d ilatatio n of ce rvix result in und ue s u·e tc hing or tears in
Macke nrodt a nd ute rosac ral ligame nts. Sim ila rly, app lica-
tio n of fo rceps befo re the full dila tio n of cervix res ul ts in
tears in cervix a nd Mac ke nrodt ligame nts with subsequent
risk of ute rine prolapse. Birth o f a big-size baby can also
predispose to prola pse ute rus by dam aging ce rvix and s up-
porting liga me nts. Fo llowing a c hildbinJ1, poor re habilita·
Lio n in puerperitun, earl) resumptio n of physical
li fting hea' ') we ig hts can pred ispose woman LO pro lapse
ute rus.
As discttssed la te r, p•·o la pse of uterus due to a mis man -
aged c hildbi rtll is mostly see n in wo m en in repro ductive
age. T h is t) pe has been called uterovagina l pro lapse a nd
has elonga ti o n of supravaginal po rtion of cervix, vaginal
mucosa is well e pi theli ali Led and associa ted witJ1 good tone
of le,m or muscles.
Me nopause: Me no pause is cha ra ctetized by declining
levels of oesu·ogens. Al l tJ1 e suppo rts of uterus at·e under the
effect of oesu·ogen during reproductive years. Declin ing
le vels of oestroge n after me nopause resul t in loss oftone of
m uscula r s uppo rts a nd relaxa tio n of ligame m o us s upports
of uterus. T hese c ha nges predispose a wo ma n to uterine
pro lapse in the prese nce of preexis ting weakness in
s upports of ute nts .
Prolapse ute rus see n afte r me no pa use is clinically charac-
te rized by a troph y o f vaginal mucosa, the presence of
e nterocele. poor to ne of levatOr muscles and tl1 e a bse nce of
cemx elo ngatio n.
CLASSIFICAnON OF PROLAPSE
(Figs 21 .3 and 21 4)
Ute rine pro la pse has bee n classified in a number of ways.
Howeve r, recently for the plll·pose of a unifo nn repo rting
and compa t·ison of resul ts, a n ew classification has been
proposed by lntem ati o nal Society fo r Swdy of Vulvovaginal
Disorde t-s.
Foll owing sectio n desctibes two comm only used classifica-
tion systems of prolapse, namely Uterovaginal Prolapse System
and Pelvi c Organ Prolapse Qua ntifica tio n Syste m (POP·Q).
Uterovaginal Prolapse System
A Anterior vflginal tv(lll (Fig. 2 1.5 )
Upper two·thi rds---C)'Stocele }
. Cys to ure throcele
Lower o ne- U11rd- Ure tJu ocele
B. Posterior vaginal wall
Upper o ne- tJ1ird - Ente rocele (tJ1e po uc h of Do uglas
he rnia) (Fig. 2 1.())
Lowe r two- tl1irds- Rec tocele
C. Uterine
• Desce nt o f the cerv ix in to the vagina
• Desce nt of the cerv ix up to the in troiws
• Desce nt of the cervix o uts ide tJ1 e illl.ro itLIS
Procidentia - Entire uterus is ouiSide tJ1e introitus (Figs 21.7-21.9).
CYSTOCELE
Prola pse of upper two-thirds of a n terio r vaginal wall is
called C)Stocel e. The bladde r is s u pported by puboce tv ical
fasci a whi ch exte nds laterall y to the arcus tendineus and

Table 21.1 Aetiology of Prolapse

Atonicity • Menopause
Congenital weakness

Birth injuries Prolonged labour

Perineal tear
Pudendal nerve Injury
Operative delivery
MuHiparity
Big baby gh

Other causes Raised intraabdominal pressure Figure 21.3 Pelvic organ prolapse quantification system (POP..Q).
Chronic bronchitis From Rgure 2 1 9. larl Symonds arid Sabaratnarn
Essential Obstetrics and Gynaeoology, 5th Ed., Elsevier, 2013.)
288 SHAW'S TEXTBOOK OF GYNAECOLOGY

Bp
Ap
Ap

+3Aa +6ea +2c -3 Aa -3 Ba ·6c

4 .5gh 1.5pb 6,.. 4.5g. 1 pb a,..

-3Ap -2Bp +3 Ap +5Bp

B Profile A Profile B
Rgure 21.4 Pelvic Ofgan prolapse quantification (POP-Q) system !Of staging pelvic Ofgan prolapse. Aa, Point A anterior; Ap, Point A posterior,
Ba, Point B anteriOf; Bp, Point B posteriOf; C, Cervix or vaginal cuff; D, PosteriOf fOfnix (if cervix is present); gh, Genital hiatus; pb, Perineal body;
tvl, Total vaginal length. (Source: From Figi.Xe 1 11 . VICtOf Nitti: \f.aginal Surgery fOf the Urologist. Saunders: Elsevier, 2012.)

1
I
fuses with the leva tor ani muscle below. T he ureth ra is sup-
ported by the posterior urethral liga me nt whi ch is fixed to
the pubic bone.

(
ln prolapse of tl1ea nte ri orvagina l wa ll, tJ1e upperpartof
the an terior vaginal wa ll descends and in advanced cases it
may prou·ude outside the vagina l orifice. In these cases, tl1e
I vesicle and vagina l fasciae are tl1inn ed o ut and fa il to
\ s upport tl1e b ladder, so that tl1 e bladde r pro lapses with the
_
\

\"........ amerior vaginal wal l. This condiLion is te rmed as cystocele .

Rgure 21.5 Prolapse of the oervix, anterior vaginal wall and blad·
der. The cervix is elongated and hypertrophied. The anterior vaginal
wall and bladder have prolapsed outside the vaginal orifiCe. The cer-
viX is also prolapsed. In this case, the ligamentary supports hold up
the body of the uterus. Note that the almost vertical direction of the
uterosacral ligament from the cervix to the junction of the second and
third sacral vertebrae. Compare this f1Qure with Fig. 21.8.
l n mild cases, the lower portion of the anterior vaginal wa ll
does not prolapse, and the urethra is well supported by the
posterior urethral ligamem. When the urethra along wit11
the lower one-third of tlle anterior wall prolapses, it is
termed uretllrocele, and t11e patient invariably complains of
su·ess incontinence. When t11e C)StOcele protrudes outside
the vulva, owing to friction, the vaginal epithelium becomes
thickened, h)pem-ophied and keratiniLed. Ulceration can
occur over t11e vaginal wall. Senile '<aginitis in menopausal
women shows a min reddened vagina. The breaks in t11e
 CHAPTER 2 1 - GENITAL PROLAPSE 289

Pouch of
Douglas

Rectocele Enterocele
Agure 21.6 The anatomy of prolapse .

Cardinal
Stretched
ligament

·=111
cardinal
ligament

Side wall of
peMs

Pelvic floor

Figure 21.7 Lateral supports of the uterus showing cardinal ligaments.

Vagina

Level of introitus

First Second Tli rd

Normal degree degree degree Procidentia

t I
tupelo
A gu re 21.8 Note the descent of the oervix which is accompanied by stretching of the ligaments and by supravaginal elongation of the cervix.

outside
desantofarrix
into
intones introits
vagina
290 SHAW'S TEXTBOOK Of GYNAECOLOGY

loops of the small intestine in ll1e pouch of Douglas. In most

cases, me ' -aginal por·tion of ll1e cen·ix is h)peru·ophi ed and
in uterine prolapse ofll1e ll1ird degree, the epithelium cover-
ing U1e cervix is often thickened - keratiniLl\tion. It is not
uncommon for trophic ulcers to fonn botl1 on tJ1e cervix and
prolapsed anterior wa ll - ll1ese are called decubitus ulcers.
ln prolapse of tl1 e uterus, the s upravaginal portion of th e
cervix is so me tim es elongated. Supravaginal e longa ti on of
the ce rvix must be distinguished from congenital cervical
e longation, in which the fornices are deep and the elo nga-
tion is restricted only tO that portion of tJ1 e ce rvix which
projects into the vagina (Figs 21.5, 21.8, 21.10 and 2l.ll ).

PROLAPSE OF THE POSTERIOR VAGINAL WAll

Prolapse of middl e ll1ird of poster·ior vaginal " <all is called
rectocele. In rectocele, the rectum protrudes with the pos-
terior vaginal wall. The tissues wh ich nonn all y intervene
between tJ1e posterior vaginal wall and U1e rectum may have
been damaged by obste tric irUUf)\ and the vagina and rec-
tum may become ad hered by sca r tissue. Pro lapse of upper
o ne-tl1ird of posterio r vaginal wall is called e nterocele. This
portion lies in relation to the pouch of Do uglas; it is not
un common for tJ1e upper part of the posterior vagina l wa ll
to prou·ude outside the vulva and loops of Ul e intestine to
be palpable in the prolapsed part. The term 'ente rocele ' is
used to describe this type of prolapse (Fig. 21.()). Enterocele
is herniation of me pouch of Douglas into the rectO\<aginal
septtun. It is often associated with uter·ine prolapse.
Lf a woman with prolapse is examined and asked to
strain, the usua l sequence of events is for· the anterior wa ll
to prou·ude first, followed by the cervix and tJ1 en the poste-
rior vaginal wall.
wall → cervix → posterior
anterior
vaginal vaginal wale

DECUBITUS ULCER
Keratini:t.aLion and pigmentation of U1 e vaginal mucosa
Figure 21.9 (A) Complete procidentia Note that the whole of both
as well as ulcera tion of ll1e prolapsed tissue are caused by
vaginal walls lie outside the vaginal orifice. The whole of the uterus
also lies below this level. Clearly the ligamentary supports of the
uterus must be greatly stretched to allow such a degree of prolapse.
Compare this figure with FIQ. 21.8. (B) Procidentia with cystocele,
enterocele. (Soun::e (B) : From Figure 2. Cyrl C Dill, Uctlenna A Umeh,
Hyglnus U Ezegwul, et al. Uterne Procidentia in an AfriCan Adolescent:
An Uncommon Gynecological Challenge. Journal of Pediatric and Ado-
lescent Gynecology, \k:>l 2(1): 37-39, 2008.)

lateral auac hment cause th e vagina l sulci to disappear and

ll1e lateral portion of the bladder pro lapses.

PROLAPSE OF THE UTERUS

Lf the uterus prolapses, mere is always some associated
descent of the anterior vaginal wall. It is custOmary to de-
scri be three degrees of prolapse of the uterus. In the first
degree, ll1e cervix descends into the vagina; in ll1e second
degree, the cervix descends to U1e level of the inu-oitus; while
in the third degree, the cervix pr-o u·udes outside the vaginal
orifi ce. In procidentia (Fig. 2 1.9A), tl1e whole of uterus pro- Figure 21.10 Prolapse of the uterus at operation. The cervix has
u·udes outside tl1e vagina, bringing witJ1 it both tl1e anterior been drawn down, and the whole of the uterus can be pulled outside
and posterior vaginal walls, and it may be possible to feel the the vaginal orifice.

Figure 21.11 Congenital elongation of cervix.
friction, congestion and circulatory changes in the depen-
dem pan of tJ1e prolapse. Red uction of tJ1e prolapse with
dai ly packing of tampo ns soa ked in glycerine and Acrifla-
vine solution or Be tad ine in t11e vagina he lps in heali ng of
tJ1e ulcer withi n a week or two. Decubitus ulcer needs to be
differen tiated from cancer of tJ1e ce rvix. Apan from cytol-
ogy and biopS)'• the other distinguish ing features are that
tJ1e decubitus ulcer shows a clean edge and heals on reposi-
tion with vaginal packing. In rare cases, carcinoma develops
at t11e site of decubiws ulcer or when a ring pessary is left in
situ for a long period.
ELONGATION OF THE CERVIX
As t11e supravaginal portion of the cervix is well supponed
b)• Mackenrodt ligaments but the vaginal ponion of the
cervix prolapses witlt the 'oagina, tlle supravaginal portion
gets stretched and elongated. This usually happens with the
second-degree and third-<legree prolapse of t11e lllerus. ln
procidentia, the entire uten.ts slides with t11e vagina and
hence the cervix retains its normal length. It is not uncom-
mon for the cervix to elongate to as much as I 0 em in a case
of uterovaginal prolapse. The cetvix may show hyperu·ophy
and congestion. The uterus is invar·iably reli'Ovened.
OBSTRUCTION OF THE URINARY TRACT
A large cystocele ma)' ca use kinking of ure tJ1ra leading to
hype ttrop hy of tJ1e b ladder wa ll and u·abecula tions. T he
kinking of tJ1e dista l ure te rs in procidentia can lead to
h)•droureter and hyd ronep hrosis, if pro lapse is not surgi-
call)' corrected. Urinary Lract infec tion is not un common as
residual urin e remains in tJ1e bladder in a large cystocele.
Incarceration of the prolapse is enco untered in rare
cases when, due to oedema and congestion, t11e prolapse
becomes irreducible. Head low position, ice packing or
packing witl1 magnesium sulphate reduces t11e oedema,
enabling tlte prolapse to be reduced.
POP-Q SYSTEM (Table 21.2, Fig. 21.3)
Quantification of prolapse has latel)• been described by the
lmernational Continence Society, and it is objecti\'e and
CHAPTER 2 I - GENITAL PROLAPSE 291
Table 21.2 Staging of POP
Stage 0 No demonstrable prolapse
Stage 1 All points < -1
Stage 2 Lowest point within 1 em of hymen
(between - 1 and - 1)
Stage 3 Lowest point > 1 em below hymen but not
complete prolapse
Stage 4
---------------------
Complete prolapse with lowest point equal
to TVL-2
site specific. The hymen is taken as a fixed poim (0). Six
reference points ar·e measured, using a scaled spatula, and
tabulated in a grid (Fig. 2 1. 1). The points above the hymen
are described as "minus" and points below as "plus".
SYMPTOMS OF PROLAPSE
T he pa tients moSU)' co mp la in of some tJ1ing descending in
the vagina or of wmethiug protmding outside v(lgina. The
prolapse is aggravated by straining and co ughing, and b)'
heavy work, whereas on rising from tJ1e bed in t11e moming,
the physical signs of prolapse are least. Often the patient
states that t11e prolapse reduces b)' itself when she lies down.
lf t11ere is a large prolapse, the external swelling ma)' cause
inconvenience to her during walking or carrying out her
day-to-day rou Line activities. Even in mild degree, palien ts
are conscious of a sense of weakness and of a lack of support
aroLmd tlle perineum.
Towards the end of the clay, the patiem ma)' complain of
a vague mid-sacral cliscomfon and backache, which are
relieved by resL This symptom is most logically explained as
a strain on uterosacral ligaments. Some women suffer from
a 'bearing-down' feeling above the pubes.
ln most cases of prolapse, there is some degree of vaginal
discharge. The discharge may emanate from a chronically
inflamed lacet"ated cer·vix, but may also be caused by t11e
relaxation of the vaginal orince which allows bacteria to in-
vade the vagina and produce a mi ld degree of vaginitis. A
friction or dec ubitus ulcer is an obviOtL5 cause of discharge
and bleeding. Me ns u·ual cycles are usuall y normal.
One of the importanL S)•mpto ms assoc iated with prolapse
of uterus is urinary co mp la in t in t11 e form of incomplete
evac uation of b ladder or freq uency of micturition; however,
the most frequent is stress incontinence of urine. In this
condition, t11 ere is involuntary escape of little amo unt of
urine d uring an)' act assoc iated witJ1 raised imraabdom inal
pressure such as cough ing, snee:t.ing, change of posture or
lifting heavy weight. This imperfect control of micturition is
caused by lack of support to the sphincter med1anism of t11e
uretJ1ra. Frequency of micturition is also a common symp-
tOm, caused in some, b) chronic cystitis and in ot11ers, by
incomplete empt)ing of tlle bladder. In the presence of
large C)Stocele. patients frequent!) complain tllatthey have
difficulty in micturition, and t11at t11e more they strain, tlle
more difficult it becomes to pass urine. The explanation of
this S)mptom is that when the inu"aabdominal pressure is
raised during stmining, the Ut'ine is pushed down imo t11e
292 SHAW'S TEXTBOOK OF GYNAECOLOGY
cystocele below Lhe level of the internal meatus. Patients
often mention that Lhey are able to pass urine by reposition-
ing prolapse in vagina with the help of a finger. This is
tenned as "splinting". Stress incontinence of urine occ urs
when the neck of Lhe bladder and internal urina ry meatus
descend below the level of the pelvic floor muscles. Urinary
S)1nptoms de,elop when pubocervical fuscia is damaged and
breaks occur at leo. el Ill support.
Rectal S) mptoms are less remarkable, and constipation is
rare (level Ill damage).
Coital difficuflie:. with the third-degree uter·ine prolapse
and procidentia are obvious. A m::yor degree of prolapse
prevents penetration and orgasm due to a lax outleL How-
e-.•er, digital reposition of prolapse before coitus can help
these women in having intercourse.
INVESTIGATIONS
Pati ents with prola pse should be ca refull y exa mined, be-
cause tl1e u·eaun e nt is based o n t11e physical s igns observed.
Altl1ough most patie nts are exam ined in tl1e sup ine
position, exam ination in a sq uattin g position or standing
position will help to assess degree of prolapse. During
examination she is made to co ugh and strain, and the
nature and degree of prolapse noted. In a patient with
symptom of stress incontinence, examination is done with a
partially full The vulva is examined for evidence of
any perineal laceraLion. Inspection will show whetl1er the
vaginal orifice is relaxed. The perineal bod)' and levator
muscles are palpated to detennine the muscle LOne and the
dimensions of t11e hiatus urogenitalis. Stress incontinence
shotLld be looked for b) asking t11e patiem to strain.
Speculum examination determines t11e degree of ULerine
descent and associated prolapse of anterior and posterior
vaginal walls. Cervical C) tolom• ma)' be obtai but it is
importam to remember that in the t11ird-<legree uterine
prolapse and procidentia, a satisfactory smear might not be
obtained as cervix lying outside t11e vagina may be dry. En-
terocele should be looked for carefulI)'· If missed, vault pro-
lapse can occur subsequently. The per vaginal examination
should include measuring t11e length of tl1e cervi.x, position
and mobility of ute rus. Any ad nexal mass present should be
noted. T he general co nditi on of the pa ti ent sho uld be evalu-
ated to decide on her fiu1ess fo r surgery. On the whole, there
is no t much in arriving at a co rrec t d iagnosis.
T he laboratory include: (i) haemogram,
(ii) urine examin ation, urin e culwre, (iii) b lood urea,
(iv) blood sugar; (v) X-ray of t11e chest, (vi) ECG and other
investigations necessary before gynaecological surgery.
IVP is rare ly indicated and may reveal ureteric obstruction
in a major degree of prolapse. UJu·asound and MRI may help
in locali.Ling the defects in Lhe suppo rting stn.acu.u·es.
Transperineal and vaginal ultrasound may reveal defects in
t11e le-.-atorani muscles and lateral supports, whereas u-ansrec-
tal ultrasOtmd is useful to confirm t11e presence of enterocele.
DIFFERENTIAL DIAGNOSIS
• Vulval C)SI and Canner erst can be easily differentiated
from prolapse.
• The of the anterior vaginal wall is usua lly tense with
well-<lefined margins and cannot be reduced on pressure.
• Urethral diverticula are rare, always small a nd are situated
low down in tl1 e anterior vagina I wa II. Uretlwoscopy belps
in the diagnosis.
• Congrmiull ewng(l/ion of tht ctrvix ca n be differentiated
from prolapse as it is the vaginal portion of the cervix that
is elongated and tl1ere is no accompanying \'<lginal wal l
prolapse. The fomices are deep.
• Cervical fibroid polyp:. can be easily identified as the cervix
is high up and a lim of cervix can be felt above the
pedicle of cervical polyp.
• Chronic inversion of uter·us can be recogniLCcl because the
cervix is furtl1er· up, and the uterus cannot be defined.
The uterine sound will con finn t11e diagnosis. Ultrasound
and laparoscopy wi ll identify the fundal depression wi tll
an absence of uteri ne fundus in the pelvis.
• In rare cases, the patient may compla in of vaginal pro-
lapse, but, in fact, a rectal prolapse is evident.
COMPLICATIONS OF PELVIC ORGAN
PROLAPSE
l. Kinking of ure ter witl1 a resu iLa nt re nal damage can occ ur
in procidentia. Duling surgery sometimes, the ureters
can get included in Lhe sutures at t11e vagina l \'<lttlt
2. Urinary tract infection; In a large cystocele witl1 residual
tLrine t11ere can be frequent Urinary Tract Infection (UTI)
leading to upper renal tract infection and renal damage.
3. ln rare cases. cancer of t11e vagina ca n develop at the site
of decubitus ulcer or if a ring pessar) is left. in over a long
per;od.
PREVENTION OF PROLAPSE
Careful attemion dLUing childbirth can do much tO prevem
prolapse.
• Antenatal physiother-apy; relaxation exercises and due
auemion to weight gain and an aemia are im portanL
• Proper supervision and management of t11e second stage
of labo ur:
• An episio to my if indicated as in p ri migravidae, breech
delivery, ins u·um ent cle li veq• should be performed. Re-
cen tly, however, the usefulness and the role of episiotOmy
in prolapse have bee n quesLioned, and complications of
episiotom)' are lis ted.
• Forceps delive r)•/ventouse sho uld be resorted to if there
is del a)' in tl1 e second stage of I
• A perineal tear must be immediately and meticulously
repaired after delivery.
• PosU1atal exercises and physioLherapy are beneficial.
• Early ambulation in postpartum period.
• Provision of adeq uaLe rest for t11e first 6 weeks afLCr deliv-
e ry and tl1e a\-ailabilit) of home help for heavy domestic
duties.
• A reasonable imen-al between pregnancies allows recovery
of muscle tone and ligamentous suppon in pehis. Using a
family planning method so t11at fami ly siLe can be limited
avoicls suain on the ligamenta•)' supports of uterus.
 CHAPTER 2 1 - GENITAL PROLAPSE 293

Curre m indicatio ns fo r use o f pessary a re as follows:

TREATMENT (Table 21 .3)
Surger;• the nwi11 mO<k of treah11ent of pro1t1pse uterus;
lwweuer, bifore to m1y surgical treatment, the most impo r-
llml to coll.!itler i.s lilt appropriate lr«ilment for prolapse in
a JOLmg WOIIUIII follmuillg childbirth. IL is a greaL misrake LO
advise immediaLe ope•-aLive LreaLmenL in such a case. lf Lhe
opem Li o n is pe rfonned "iLhin 6 mom hs of d elivery, t.here is
alwa}'S a p oss ibili ty of recu rre nce of prola pse following Lhe
subsequem childbin h. Besides, t.hese wom en 1-a pidly im-
prove if well-<li rected conser,oa Live m easures are adopt.ed.
Abdominal exercises, maSSllge and pe•·ineal exercises prac-
tised regul arly, will preven t or reduce t.he prolapse. Conser-
vaJive !Jwul<l be following deliver;• fo r initial
4-6
Surgery is advised in women olde r t.han 40 years, unless
iLis co nLraindicated o n acco um of som e medical disorders.
Su rgery fo r prolapse is con traind ica Led d uring p regnan cy.
PESSARY TREATMENT OF PROLAPSE
T he ring pessa ry fo r prolapse is nearl)' a t.hi ng of Lhe past in
elderl)' wo men and very yo ung wo me n desirous of further
childbealin g. With mode rn anaes Lhesia and good preopera-
tive ca re, advanced age is no lo nge r a contraind ication to a
surgical procedure for prolapse.
T he pessary Lreatment of pro lapse has ce rtain followin g
limi tatio ns:
• lLcan ca use vaginitis, ulcera Lio ns in vagina.
• Pessal') needs to be d1anged every 3 mo nths .
• T he wearing of a pessa•) is noL com fon a ble LO some
women and ma> cause d)'spare unia.
• lf Lhe vaginal orifice is paLUious, Lhe pessar y ofLe n geLS
expe ll ed especially in a squaLLing posit.ion as during d ef-
ecaLion or urination.
• A forgouen peSSllry can be Lhe cause of ulcers in vagina,
and in rare cases can produce carcinoma of the ' oagina
and a vesicovagin al fistula .
• A ring peSSllt)' is not helpful for sympw m of stress urinary
incominence.
• In a yo ung woman who wa nts to have subseque m
children ; p rolapse d uring ea rly pregnancy.
• Puerperium.
• Tempo rat) use while LreaLin g infectio n and decubiLLIS
LLicer.
• A woman unfi t for surgeq.
• ln a woman who d eclines su rge•) '·
T he ring pessary is made of a sofL plasti c polyvi nyl
chloride mate•·ial a nd available in differem siLes. A preg-
nant wom an with prolapse m ay n eed a ring pessary limiLed
to the first trimesLer of pregn ancy as subsequeml y Lh e
uterus becom es an inu-a-abdomin al organ and t.he prolapse
spo ntaneotiSiy gets reduced. PeSSllr y t.reaun em may be
again needed during puerpe rium in a wo ma n with a severe
degree of prolapse and di su·cssing symptoms.
OPERATIVE TREATMENT OF PROLAPSE
Surge •)' rem ains tl1e main trea un ent of cure fo r p rolapse.
T he type ofsurget)' de pends upo n her desire to ret.ain uten.ts
for the subseq uent ferti li ty. I lo wever, fo r wo me n older than
40 )'ears, a vaginal hysterec to my witl1 re pair of ante lior and
posterio r vagi nal walls prola pse is t11e desired treatment. In
yo LUl ge r women desirOLIS of retaining uterus, a conservative
SLtrgical procedure such as Manchester o peratio n (Fotller-
gi ll's operatio n) is t.h e surgical procedure of d1o ice.
The aims of surge!') are as fo llows:
• Relieve S)lnptoms
• Restore atlato m>
• Restore sexual function
• Preven t recurre nce
PREOPERATIVE PREPARATION
O estrogen cream applied locall y for senil e vaginilis will help
in improving conditio n of vagi nal mucosa, buL sh ould be
sto pped a few da)'S befo re surge•)'. The pat.iem sho uld receive
a course of ul'inat)' antibi otics if urinary infecti on is presenL.
Dec ubitus ulcer m ay heal by daily inse n.io n of vaginal tampon
soaked in Actiflavine o r 13etad ine solutio n for 2 weeks.

Table 21.3 Management of Genital Prolapse

SURGERY
Null iparous Abdominal sling operations A nwnber ofsurgical proced ures with m inor va ria Lio ns in tech-
Preg nancy Ring pessary up to 16 weeks
niq ues have been desc tibed fo r surgical re pair of prolapse.

Postnatal • Ring pessary and pel vic floor exercises

• Surge•)' fo r anLerio r vaginal wall prola pse- Ante lior
for 3-6 months
Surgery If required thereafter colpo n·hap hy
• Surgery fo r posterio r vagina l wall pro la pse- Poste•io r
Young ooman Conservative vaginal surgery (fertility colpo rrhaphy iolpoperineoraphy
< 40 years sparing surgery) • Surgery for p rola pse of uterus- Manchest.er operatio n
Cystooele, rectocele repair
in yo ung wome n
Manchester repair
• Vaginal h)sterectom) in wo men o lder th an 40 years
Sling operation
• Surgical procedw·es fo r nulliparo tiS pro lapse - Sling
'M:l man older Vaginal hysterectomy and pelvic floor ope •-aLio n
than 40 years repair • Surgical procedure fo•· \>au iLprolapse- Abdominal o r
and multipara
' oaginal surgical procedltl·es
294 SHAW'S TEXTBOOK OF GYNAECOLOGY
ANTERIOR COLPORRHAPHY
Ame•·ior colpon·haphy operation is performed to repair a
C)Stocele and C)'SLOLu·ethrocele. Traction is given on the
cervLx to expose tl1e amerior vaginal wall. An inverted
1:shaped incision is made in the a nterior vagina l wa U, start-
ing with a u·ansverse incision in th e bladde r s ulcus. T hro ugh
its mid point, a vertical incisio n is ex te nded up LO the ure-
thra l ope ning (Fig. 2 1.1 2) . The vagina l walls are reflected
on the e itl1er side to expose the bladder and vesicovaginal
fascia (Fig. 2 1.13). The overlying vesicovaginal fascia is
tightened, and tl1e excess vagi n al wall excised to correct the
laxity. Then tlle vaginal is wall sutured. In women suffering
from su·ess incontinence, in addition a Kelly suture is placed
colporrhaphy. A Transverse incision is
Figure 21.12
given In the bladder sulcus. (8) Mid line vertical Incision is given ex-
tending up to urethral opening. (C) Veslco vaginal space is opened
up. The vesicle fascia is recognized because of t he dil ated veins
which ramify in its layer. The anterior vaginal wall is reflected away
from the bladder on either.
Figure 21.13 The appearance after the dissection of the vaginal
flaps: (1) posterior urethral ligament - the well-defined cranial border
is emphasized. In the illustration, the vesicovaginal space has been
opened up, and the vaginal fascia (2) remains attached to the vaginal
wall. (3) Bladder septum. (4) Vesicocervical ligament.
in the region of bladder neck to correct su·css incominence.
The breaks or defects in the lateral supports require further
suturing of the pubocervical tissue to the a1-ctts tendineus.
This also elevates tlle vaginal wall. In repeat surgery for re-
cu•-rence or failed surgery, a mesh may be supplemented LO
strengthen the support LO the bladder.
POSTERIOR COLPORRHAPHY
AN D COLPOPERINEORRHAPHY
Posterior colporrhap h)' operatio n is done to co n-ecta recto-
cele and re pair a deficient perine um .
The lax vagina over the recwcele is excised, a nd tl1 e
rectovaginal fascia repaired after red ucing the rectocele.
T he approximation of tl1 e medial fibres of the leva LOr ani
h elps to •·estore the calibre of the hiatus urogenitalis, re-
SLOre the perineal body a nd provide an adequate perineum
separating the hiatus urogenitalis from the ana l canal
(Fig. 2 1.11).
It is commo n!) combined with an anterior colporrhaphy,
or vaginal h)Ste•-ectomy. To avoid necurrence and to rein-
force the weak supportive fascia, some use mesh in the
fascial layer. However, dyspat-e unia, erosion o f mesh or
infection req uiring its removal and sinus formation ane the
disadva nw'\ges, in addition to tl1 e high cosL
FOTHERGILrS REPAIR (MANCHESTER OPERATION)
In this oper-ation, the surgeon combines a n anterior col-
porrhaphy with amputation ofthe cervix. The cut ends of
the Mac kenrodt ligaments are sutured in front of the
cervix, and the 1-aw area on the amputated cervix is cov-
ered with '<aginal mucosa. A special technique of cover-
ing ce•vix with vagi nal mucosa has been described and
is called as SLU nndorff sutures. It is followed up with a
colpoperineorrhaphy.
The operation pt-eserves uterus for mensu·ual and child-
bearing functi ons. However, subseq ue nt pregnancies may
be assoc iated wi tl1 a mid-trimester aborti on or preterm
de livery. In some cases, there may be failure of di latati on of
cervix du ring labo ur requiring a caesa ri an section. It is a
suitable procedure for women younger than 40 years who
ane desirous of •·etaining their menstrual and reproductive

Rgure 21.14 (A) Colpop erlneorrhaphy. The posterior vaginal wall is
caught by an allis c lamp and traction provided. (B) The p osterior
vag inal wal l is reflected away from the cervix. (C) A triangular piece of
vag ina has been removed and the free edges of th e wound are drawn
apart. The perineal fascia has been divided and t he levator ani muscles
have been sutured together In the midline.
functions. ln yo unger women, the proced ure can be com-
bined with wbal sterili:t..'lt.ion if fami ly is complete.
To avoid complicat.ions such as stenosis of cervix some
include dilatation of cervix and endomeu·ial curettage as a
preliminary step in Fothergill's repair. This is optional, but
desirable in a woman complaining of menstmal disorder
associated with prolapse.
Cervical amputation ma) lead to incompetent cervical
os, habiwal abort.ions or preterm deliveries. Excessive
fibrosis may lead to cervical stenosis and dystocia during
labour. ln rare cases, it may cause haemaLOmetra. Recur-
rence of p•·olapse may occur following vaginal delivery in
some cases.
CHAPTER 2 1 - GENITAL PROLAPSE 295
To avoid the obstetric complications of Fothergill's
operation, Shirodkar mod ified this operat.ion as follows.
SHIRODKAR'S PROCEDURE
In this procedure, amputation of cervix is avoided. Ante-
rior colpon·haph) is performed as usual, and auachment
of Mackenrodt ligaments to the cervix on each side is
exposed. The vaginal incision is then extended posteri-
orly round the cen·ix. The pouch of Douglas is opened,
merosacral ligaments identified and divided close tO the
cervix. The sLUmps of these ligaments are crossed and
stitched together in front of the cervix. A high closure of
the pe•·itoneum of the pouch of Douglas is carried ou LAs
cervix is not amputated, subsequent pregnancy complica-
tions are avoided. The •-est of the operation is similar tO
Fothergill 's ope.-ation.
O ther conservative su••geries used are as follows:
• Vaginal sacrospinous h)'Steropexy.
• Abdo mi nal/ la pa roscopic sacrohyste ropexy.
T hese can be co mb ined with cystocele, rec tocele repair.
T he advantages are as fo llows:
• Vaginallengtl1 is ma intained.
• Cervix is preserved for sex ual funct.ion.
VAGINAL HYSTERECTOMY WITH PELVIC FLOOR REPAIR
Vaginal hysterectomy with pelvic floor repair is suitable for
women older than 40 )Cars, those who have completed their
families and are no longer keen on retaining their child-
bea•ing and menstrual functions.
The operation alleviates t11e women of her prolapse symp-
tOms, in addition to any associated mensuual problems.
A Kelly stitch is needed while doing ame•·ior colporrhaphy
in case she has associated stress incontinence.
The Steps of Voginal Hysterectomy (Figs 21 15-21 18)
A circular incision is made over the cervix below tl1e bladder
sulcus, and tl1e vaginal mucosa dissected off tl1e cervix all
around. The pouch of Douglas is identified posteriorly and
peritonetml incised and opened. The bladder is now pushed
upwards unti l the uterovesical peritO ne um is visible, and is
similarly incised. T he uterus is now free in the fro m and
behind. T he pecUcles co nta in ing Mac ke nrod t's a nd ute ro-
sacral li ga me ntS are clamped on the e ither side close to
the cervix, cut o n tl1e ute line side and t11e pedicl es trans-
fixed . Next. tl1e uteri ne vessels are idenl.ified, clamped, cut
and ligated. T he uppe r portion of t11e broad ligamem ho ld-
ing the uterus con ta ins round, ovaria n ligaments and th e
fallopian tube. These are similarly dealt wiLh on both sides,
and t11e uterus removed. The peritoneal cavity is closed with
a pLtrse-string suture, using chromic catgut 0. Anterior col-
porrhaphy and posterior colpopelineorrhaphy are per-
formed as required.
The vagina is packed with Betadine or Acliflavine pack
for 24 hours. a Fole) catheter left in place for continuous
drainage of urine for <18 hours. In case Kelly's stitches were
placed for SU 1 the catheter is kept for 5-7 days.
Complications of su•-ge•1'·
1. Haemo•·rhage
2. Sepsis
296 SHAW' S TEXTBOOK OF GYN AEC OLOGY

Figure 2 1.16 Cystocoele repair is being done with buttressing

sutures.

Figure 21.17 (II.) Rectocoele repair. An incision given over posterior

Figure 21.15 (A) The vaginal skin has been excised and pulled vag inal wall (B) Lax vag ina is excised and the rectovaginal fascia
down over the cervix . (B) Mackenrodt's ligaments have been clamped repaired.
and cut, and a suture ligature has been inserted in the left of Mack-
enrodt's ligament. Note that the bladder has been freely mobilized
and pushed well up out of danger. (C) Clamp is being applied over the
cornuo fundal structures.

Figure 21.18 (A) Peritoneal opening closed in vaginal hysterectomy. (B) Pedicles clamped and ligated In vaginal hysterectomy.
3. Urinary tract infection
4. Complications related to anaesthesia
5. Subsequent vault prolapse
6. Dyspareunia due to narrow/ shon vagina
Alternative Methods of Tying Pedicles during Surgery
LigaSure. LigaSure 'essel sealing system is lately used w
secure the pedicles in \'llginal hysterectOmy. The
consists of a bipolar radiofrequency generator, reusable
hand piece and disposable electrodes. The electrodes melt
the collagen and elastin in the vessel \\'llll to form a seal
LOne. Quick surgery with LigaSure is an advantage.
While choosing the \'llginal route for perfonning hyster-
ectomy in a uterus without prolapse, the following points
should be observed.
Vagina l h ysterectomy is co ntraindicated if
• Uterus is very bulky (more than 12-14 weeks).
• The uterus is Faxed b)' abdom ina l adh esions and inflam-
matot)' disease. Abdom ina l ad hesions a re likely to be
prese nt if the woman had previous abdom inal s urgery or
caesarean sec tion.
• Other pelvic patJ1ology exists such as endometriosis and ovar-
ian u.unour. In such cases, proper laparotomy is indicated.
Some experts are also ab le to remove the ovaries by the
'<agi nal route.
lE FORT'S REPAIR
Le Fon's repair is reserved for the vef)• elderly menopausal
woman unfit for major surger). In tlliS procedure, ameJ;or
and posterior \'llginal walls are approximated below the
level of cervix.
Before the procedUt·e, a Pap smear and peh·ic sonography
should be obtained to exclude possible pelvic patllOiogy.
CHAPTER 2 1 - GENITAL PROLAPSE 297
The procedure can be performed under sedation and
local anaesthesia, or epidural anaestJ1esia. The flaps of t11e
vagina from the anterior and posterior \<aginal walls are
excised. tl1e raw areas apposed witJ1 catgut sutures. Thus, a
wide area of adhesion is created in the midline which
prevents the uterus from prolapsing, tJ1e small tunnels on
either side pennitting drainage of discharge.
This operation limits mat·ital functions; hence, it should
not be advisee) in women who are leading an active sexual
life. Some women may develop su-ess incontinence. OtJ1er
comraindications at·e menstruating women and women
witJ1 diseased cervix and uterus.
ABDOMINAL SLING OPERATIONS
A number of abdominal sli ng operations have been de-
scribed for yo ung women suffe rin g from nulliparous pro-
lapse or the second- or third-degree uterine prolapse, wh o
are desirous of retaining tl1 cir chi ldbearing and menstrual
functions. The objective of tJ1 ese ope rations is to b uttress
the weak supports of ute rus (Mac kenrodt's and uterosacral
ligaments) by reinforc ing tJ1 ese witJ1 a nylon mesh or Da-
cron tapes used as slings. The adva ntage of these synthetic
tapes/mesh is that they are strong and non-tissue reactive.
Sling operations are best suited for nulliparous prolapse.
The operations in common use are as fo llows:
• Alxlominal wall cetvicopexy.
• Shirodkar's abdominal sling operation.
• Khanna's alxlominal sling operation.
Abdominal Wall Cervicopexy
The operation entails opening of the abdominal \vall
through a low transverse suprapubic incision deepened
up to the reclus sheath. By means of u-ansverse inci-
sions made in the recllls sheath, two musculofascial slings
298 SHAW'S TEXTBOOK OF GYNAECOLOGY
are elevated from the mid li ne outwards and laterally up to
t11e lateral border of the rectus abdominis muscles on the
either side. The peritoneum is opened in th e midline, and
t11e uterus brough L up in to view. The uterovesical fold is
incised. and the bladder mobilized from L11e from of ilie
ute,;ne isthmus. The medial ends of L11e fascial sling are
now directed retroperitoneall) between the two leaves of
tlle broad ligaments up to the space created in from of ilie
ute•·ine istl1mus; t11e slings are pulled tllrough and an-
chored tllere with stout non absorbable ligawres after ensur-
ing an adequate co•·rection in the position of t11e ute•·us in
tlle pelvis. The uterO\esical fold is next suwred, followed by
closure of the abdomen in larers. Presently, the surgeon
uses a 12-inch-long Me•-silene/nylon tape LO provide the
new artificia l suppons for the uterus. The tape is fixed at itS
midpoint to the utedne isthmus am e•·iorly, and itS late•·al
ends brought out retroperitonea ll y between the two leaves
of the broad liga me nt, so as to eme rge at Ll1e Ia teral border
of t11 e rectus abdom inis muscle o n the eitJ1er side. T he ends
of the tape are now Fixed to the apo neurosis of the external
obliq ue muscle of the abdominal wa ll e itJ1er by weaving it
t11rough the apo neurosis o n the either side from the medial
to t11 e la teral side or by Fixing it to t11e un dersurface of the
aponeurosis wi tJ1 interrupted no nabsorbab le sutures.
Purandare and Mhatre have im proved on tlle original
operation by attach ing the tape poSteriorly on the cervix
close to tl1 e auach me nts of the uterosacral ligaments. The
ends of the tape are t11en brought forward retroperitOneally
as described above, and are attac hed to t11 e external oblique
aponeurosis.
The sling operations can be combined wiL11 a Moschcowiu
repair to treat associated enterocele. Anterior colpon"haphy
and colpoperineon·haph) can be combined to correct addi-
tional genitallaxit) of the vagina.
Many Indian g)naecologists have conu·ibuted signifi-
cantly to the operative repair of genital prolapse. Amongst
tllse, the im ponant modifications wo•·th noting are
Virkud's sling operation, Mangeshkar's laparoscopic
technique and Neeta 'vVarty's laparoscop ic modification
of Shirodkar's oper-ation.
Shirodkar's Abdominal Sling Operation for Uterine
Prolapse
T his operaLion was designed to meet t11e special needs of
t11e case of a nulli paro us prolapse having inherently weak
supports. It is a tec hni call )' a difficu lt operati on to perform
but it is based o n soun d anato mi cal principles and gives
excellen t resul ts. Using Mersile ne t.ape, t11e cervix is fixed to
t11e lu mbosacral fascia by passing t.he tape ex u·aperiwnea lly.
Khanna's Sling Operation
In t11is operation, t11 e Mersile ne tape is fixed tO tlle istllmus
posteriorly, and t11e two free e nds brought o ut retroperito-
neally to emerge out at the lateral margin of t11e recn.IS ab-
dominis muscle on the e ither side. They are anchored to
t11e anterosuperior iliac spine on the e it11er side. 111e sling
supports Mackenrodt.'s ligaments.
ENTEROCELE
Whenever an enterocele is encoumerecl dllling prolapse
ope•-ation, it. should be repaired.
During vaginal hysterectomy, the e nterocele is repaired
after the uteniS is removed. The redundant peritoneum of
t11e pouch of Douglas is dissected, the peritOneal sac excised
and t11e neck of the enterocele is ligated. The e nterocele
apertLLre is closed and strengt11ened by approximating
t11e two uterosacral ligaments and t11e levator ani mLIScles.
Failure to recognit.e and repair the enterocele ca n lead LO
vault prolapse later.
Emerocele can also be •·epaired du•·ing an abdomina l
operation. The cul-de-sac of the pouch of Douglas is obliter-
ated by seveml purse-string suwres starting from below. This
ope1-ation is known as Moschcowiu. repair. One should take
care not to include the ureter in the stitch.
VAULT PROlAPSE
Vau lt prolapse is a clelayed complica tion of abdom inal
and vaginal hyste recto my. It resul ts because of poor
a u ention paid to anc horing th e supporting struc tures to
th e apex of vagina. It also res ul ts fro m fa ilure LO ide ntify
a nd repa ir a n en terocele dur ing hyste rectO my. A tec hni-
cal error in previous Stll·ger)', age, oestroge n defic ie ncy in
a menopausal woman, parity, obesi Ly and c hro nic co ugh
ma>' all comribute to its occ urre nce. Sli ng ope ra tio ns for
u rine stress inconLin e nce leave a defec t in th e posterior
fornix, leading to e nterocele in I 5% of cases. T he
vau lt prolapse follows soo n after the tec hnical error in
SLtrgery, but within 2 years in remaining 50% d ue tO weak-
ness in Ll1e supporting structures. Vault prolapse occurs
equally. commonl) following vaginal a nd abdominal
hysterectomies.
The cu•·ren t incidence of vau lt prolapse is 3-6 per 1000,
but is increasing due to increase in longevity and desire for
sexual life bC) ond menopaLISe that b•·ings t11e woman to L11e
gp1aecologist.
The woman witl1 vau lt prolapse compla ins of coital diffi-
culty and difficulty in walking. Backache, u•·inary and rectal
symptoms may exisL
DEGREES OF VAULT PROlAPSE
First deg•·ee - The vaginal apex is visible at the introitus.
Second degree - The vau lt protru des tl1rough the
in troi Ll.IS.
T hird degree- T he e ntire vagina is o utside th e imroitus.
Vault prolapse is ofte n assoc iated with cystOcele and
enterocele.
PREVENTION
• Enterocele sho uld be rccogni:ted and repaired durin g
the primary surge ry (vaginal/abdom inal h)'Sterecwmy) .
• Attachment of tl1e uteros;\cral and cardinal ligaments tO
the vagina l vau lt during hysterectomy reduces t11e inci-
dence of vau lt prolapse.
TREATMENT (Table 21 .4)
• Right tnmsuagitwl sacro5pinou5 colpopi!X)' in obese and
elderly women not fit for abdom inal surgery was first
described b) Rit.cher in 1968. Bilatera l fixaLion is mrely
required. It is now the preferred surgery in most cases.
The vaginal vau lt is fixed to the sacrospinous ligament,
so tllat in the upright position, the vagina lies in tl\e
 CHAPTER 21 - GENITAL PROLAPSE 299

• Rec urrence of vau lt prolapse

Table 21.4 Vault Prolapse • Fistula
Vault prolapse VAGINAL SACROSPINOUS COLPOPEXY
Young woman Old woman Following opening of the posterior vaginal wall vertically, a
Abdominal sling surgery Vaginal sling surgery window space is created between the vagina and the reCLum
Sacropexy Right transvaginal sacrospinous wwards the t·igln sacrospinous Iigamem. A synthetic sling
Colpopexy colpopexy such as the Mersilene mesh fixes the vault to the sacrospi-
L.aparoscopy Transabdominal (lapa-oscopy) nous ligament with a Miya hook 2 em awa)' from the ischial
Colpopexy sacropexy
spine using a nonabsot·bable suture. DLII·ing surgeq•, cru·e is
Colpocleisis
l e Fort's operation
taken not to it'\iure the recLUm, pudendal vessels a nd nerves
Abdominoperineal surgery at the ischial spine, sciatic nerve and sacral plexus which lie
Ring pessary above the ligament. Ninety per cent success has been
Posterior intravag inal reponed. Previous •·ectal surgery and drainage of pelvic
slingoplasty abscess conu-aindicate this stwgery. Buttock pain ( 15%) fol-
lowing this operation resolves graduall y. It is caused by a
nerve it'\iury. Cystocele may develop at a later date. Recur·
renee of vault prolapse (20%-30%) a nd detrusor overactiv-
ity are reponed (Fig. 2 1.20). l::n te rocele sho uld be repaired
before closing the vagina.
Abdominal sacrocolfJufJexy: In this procedure, the va ult is
fixed to the sacral p romo nto ry by inte rposing a mesh be-
tween apex of vagina and sacral promon tOI")'· T he mesh is
covered with pelvic peritone um to make it reu·operito neal.
T he same proced ure can also be done laparoscop ically. A
careful dissection can avoid inj uries to b ladder, ureters
and presacral vessels. It is best suited for yo unger women,
because coital difficulty following vagi nal surgery is avoided
(Fig. 21.21 ) .

• as a treatment for vault prolapse is used only

in selected 'ef) old women unfit for a major surgical
procedure due to underl)ing medical conditions. This
procedure precludes any sexual activit)' hence is not
suitable in )Ounger women. In this treaunent, vaginal
Vaginal vault mucosa is denuded all around and the cavity is obliter-
Figure 21.19 McCall's culdoplasty. ated with a sedes of purse-string suwres Stat·ting from
the apex downwards. Su·ess incontinence of Lll·ine may
follow this opera Lion.
• opet<ttion is another alternative. It is a kind of
horizontal position and gets compressed aga inst the leva- panial colpocleisis. A small rectangular pot·tion of the
tor ani muscles. McCall culdop lasty comprises fixing the a11terior and posteRior vaginal wall is denuded and
uterosacral and Macke nrodt's ligame ntS lO the vaginal
vault and the peritoneu m of th e pouch of Do uglas. Ure-
teric obstructi on and kinkin g are repon ed in 10% of
cases (Fig. 21.1 9). Vaginal ro ute is safe r for elde rly women.
A cho ice of a n abdo mi na l surgery lO treat va ult prolapse
especiall y in )'Ou ng wome n avo ids dyspareun ia .
Complicati ons of surgery for vault prolapse:
Earl)' complications
• Haemorrhage- primary, reactionary, secondary hae mor-
rhage.
• Sepsis
• Trauma to the bladder, urethra rectum main!)' in repeat
surgery.
• Ut;naJ") infection.
• Thromboembolism
Vault sutured to the
Late sequelae right sacrospinous
ligament
• at·row scarred vagina causing dyspareunia.
• Granulation tissue. Figure 21.20 Sacrospinous fixation.
300 SHAW'S TEXTBOOK Of GYNAECOLOGY
Mesh attached from
the sacral promontory
to the vault as well as
anterior and posterior
vag inal wall
Rgure 21.21 Sacrooolpopexy.
suwred to eac h other with several Vicryl suLUres, thus
obli terating th e vagina in tl1e middle. It is suited for o ld
women no t imerested in sexual function.
• Abdominoperinettl swgery as desc•·ibed b) Zacharin is a dif-
ficult surgery required in complicated cases, especially if
rectal prolapse is also presenL
• Ring pessa•)' is recommended in a woman not fit for
surge•)'·
• Anterior and postel'ior colpo•·rhaphy may be requi•·ed for
cystocele and rectOcele in addition.
Posterior imravagina l sli ngop lasq•; Pe u·os desc ribed this
ope ratio n in 1997. Posterior inu·avaginal sling with a
monofi lamem polypropylene tape (8-m m wide, 40-c m lo ng)
is used to suppon uterosacral ligame nts by o-eating neo-
uterosacralligaments and by relocating the vaulL. All.hough
associated with less morbidity. this surge!') can cause ure-
tel'ic and rectal injury, and postoperative coital difficulties
and pain. Recun·ence of prolapse in 10% of cases is also a
disach<antage. Mesh erosion can also occur.
Alx lominal surgery is preferable in )Oung women witll
vault prolapse as it avoids coital difficulties, and also in
women who develop recurrence foll owing vaginal repair.
POSTOPERATIVE CARE
Postope rative care is important and co mprises fo llowing:
• Paren ta l fluids Lmtil bowel sounds rewm. Early oral
fluids are now advocated.
• Antibiotics, sedatives, metronida.wle i.v. for 24 hours.
• Indwelling catheter for 48 hours.
• Vaginal pack for 24 hours.
• Early ambulation.
RECURRENT PROLAPSE AND PROSTHETICS
About 30% of women who have undergo ne previo us sur-
gery for ge nital prolapse suffer from rec urre nce. They often
need repeat surgical imen·entions. The high failure rate of
p•; mary su rge•)' is a tui buted to poor collagen tissue stren gtl1
of the patient's damaged tissues. Furtller stress and meno-
pausal changes predispose to recurrence.
The introduction of symhetic and biological prosthesis
h as been uti li:t:ed extensively to reduce recurrence in hi gh-
risk cases. Use of synthetic meshes as a plimary surgical tOol
is debatable.
C lassification:
I. Syntlletic materials
A. Mao-o porous, nonabsorbable (Marl ex, Prole ne): The
pore siLe is more than 75 micrometer to allow infiltra-
tion b) macrophages, fibroblasts. new vessels a nd col-
lagen fibres. The long-term problem is mesh erosion,
infection and dyspareunia caused by hard mesh; it
may require its removal surgicall>'·
B. Absorbable polyglaetin (Vicryl): It is free of mesh
compli cations, but long-term results need furLher
evaluatio n.
2. Bio logical
A. mate rial (rec tus fascia, fasc ia lata): Th is
requires two sites of operation, vaginal and in fasc ia
lata, and hence results in a prolonged surgery. The
poor quality of tissues can also cause recurrence of
prolapse a nd wound infection.
B. Xenografts of porcine.
3. 1 ew system
A. A pOl) propylene tape is used in poste1ior intravaginal
sling plasty.
B. Apogee and perigee, used in a sling oper·ation. T he
m esh is secu red tO the arc us tendineus pelvic fascia
thro ugh a u·ansob t:urator approac h.
KEY POINTS
• Pehic organ prolapse is a common proble m encoun-
tered in clinical practice.
• Genital organ descem results from congenital wea k-
ness of the pehic conn ective tissues, acquired tissue
damage following prolonged or difficult childbirtl1
or ,<aginal insu·umemal delive•)'· Conditions causing
•·aised imraabdominal pressure and m enopause with a
resultant oesu·ogen deficiency predispose to prolapse.
• CysLOcele, ure throcele, rectoce le and ute rine desce nt
are rn an ifesu'lti ons of the same patl1ology.
• These women s uffer from S)•mptoms such as protrud-
ing of ce rvix o utside vagina, urin ary S)'lllPLOillS such as
frequenq , incomplete voiding, stress inconti nence,
repeated urinary infections and in rare cases, reten-
tion of urine. Difficulty dLUing defecation, infertility,
coital problems, backache and difficult) in walking
around are also encoumered.
• In )Ounger women desirous of retaining childbea•·ing
fun ctions, conserva tive surgical repair operations
are indicated, whereas in perimenopausal and m eno-
pausal wo me n, vaginal h ysterectom y wiLh repair ofthe
pelvic floor is the operation of choice.
• ln a )'Ounger woman desiro us offw·t11 er child bearing,
Mancheste r operation (Fothergill's operatio n) is tl1e

procedure of choice. Howe1er, amputation of cetvix as a
panofl.his operation may lead to repeated mid-uimester
abon.ions/ preterm delhelies. Vault prolapse is a sequelae
of alxtom inal as well as 1aginal h)SterectOmy ''i1ich re-
quires surgical repait: Both abdominal and vaginal opera-
Lions can be unde11aken to repair vault prolapse. A ring
pcssa•r is applicable only in a woman unfit fo r surgery.
o Recen Lin u·od uction of prosthe ti c materia ls to supple-
ment weakened tissues has resu lted in lo ng-term
benefitS in the management of rec urrent prolapse,
but the cost and complications should be bome in mind.
o A patient witl1 vault prolapse ma) also have otl1er
vaginal defectS. These need additional corrective pro-
cedures along with repair for vaull prolapse.
o 13y fixing the uterosacral and cardinal ligamentS to
t11e vaginal 1>ault at the time of h)Sterectomy, 1>ault
prolapse can be prevented.
o Sacrocolpopexy is considered the gold standard surgi cal
procedw·e for vault prolapse.
SELF -ASSESSMENT
I. Describe t11e normal supportS of the uten.IS.
2. How would you classifY ge nital prolapse?
3. Desc•·ibe me spnptomatology of genital prolapse.
4. Discuss the prophylaxis of genital prolapse.
CHAPTER 2 I - GENITAL PROLAPSE 301
5. Describe the surgical procedw-es for repair of ge nital
prolapse.
6. A 50-)ear-<>ld woman pt-esenLS with third-<legree uterine
prolapse. How will you manage tllis case?
7. A 30-year-<>ld woman, para 2, complains of something
coming out per vagina. DisetLSS tl1e investigations and
management of this case.
8. Disc uss th e management of nu ll iparous prolapse.
9. A 60-year-old woman presentS witJ1 so mething co ming
o ut per vagina following abdom inal hysterectomy 2 years
ago. How wi ll yo u manage tl1e case?
SUGGESTED READING
cr. In : Classif.cation of '"aginal n:lolx.uion. Am J Obstet
Gj11ecol 136(7):957,1980.
CliiTord L, Regan L. In: Recurrent lo;,;,.ln: John Studd.
Progr Obstel Cynaewl Vol 11:387,1994.
Nichol> 0 11. Transvab>inal sacrospinous flXation. Pelvic Surgery
1:10,1981.
Richter K. cvCr$iOn of 1he vagina: Pathogenesis, diagnosis and
tl1erdpy oft he "true· prolapse of the v..ginal stump. Clinkal Ob>teuics
and 25:897,1982 .
Ridley Jll. Emluation of the colpoclei>i> operation: A report of
Amj Obstet Gj-necol 113:1114,1972.
Scigword1 CR. Vaginal \"ault prolap.c with c\CI">ion. Obstet Cynecol
54:255,1979.
StuddJ Progress in Obstetrics and C)11aCCOiog) 17:381. Churchill
Lhing>tonc, Ebe\ier
Sturdec D. Year Book of Obstetrics and Year Book of
Ob>tcuic> and Cp>aewlogy. 61-70,200 I.
 Displacements of the Uterus
Introduction 302 Key Points 306
Retroversion 302 Self-Assessment 306
Inversion of the Uterus 304
INTRODUCTION
1l1e uten.lS is kept in place by a cro&'\-fo rmation offour ligameniS
(pubocervical ligaments, uterosaO<ll ligamentS and a pair of
cardinal or Mackenrodt's or u11nsverse cervical ligamentS, and
by tlte pelvic Aoor muscles and a sheet of connective tissue en-
tlte hollow pelvic viscera them support.
The uterus is normall) maintained in an anteverted,
ameflexed position. However, the uterus is a mobile organ
and iiS position rna> val') depending o n the status of blad-
der, pari!) of the person, the position she is lying down in
and b) the presence of flbroids and other condition in the
uterus. For different r·easons, uterine displacemem may
occur·; tlle displacement may happen sideways but more
commonly backwards, or downwards.
Pelvic inflammatory disease and endometriosis may leave
behind adhesions tl1at may bind tlle uterus to other su·uc-
tures, tltus leading to uterine displacementS - commonly
presenting as a fixed retroversion or a lateral tilting follow-
ing adhesions with adnexal stnrctures. Uterine twnours may
p ush or dm g the uterus into vari ous abnor·ma l positions.
Similarly, tumours in surrounding su·uctures may move the
uterus out of its normal positio n. A fa ulty development of
the su1.rctures supporti ng the ute rus may also cause uterine
disp lacemen L
T here are two common types of uterine displacements
whi ch are often the ca use of physical distress- retroversion
and prolapse.
In retroversion, tJ1 e uterus tips backwards a nd also
possibl)' sags downward. In prolapse, tJ1 e uterus settl es
downward; so me tim es, the d isplacement is so extre me
tltaL th e cervix protrudes o ut from the vu lva, and may
even drag down with it part of the rectum and bladder. ln
o tlt er cases, the entire uterus and vagina prolapse out of
tlt e introiws causing procidentia. Prolapse is more com-
mon after menopause. Pro lapse has been discussed in
chapter 21.
Mostl) displacemem of the uterus has no bearing on the
reproducth·e ftmction or· menstrual functions; however,
in an uncommon situation a uter·ine displacement may
prevem a woman from conceiving; if she does become
302
pregnam under s uch a cond iLio n, it may lead to re te mion
of urine in earl)' pregnan cy and vary rare l)' may e nd in
abortion. Wi th the backward positio n of the uterus, as in
re u·oversion, tlt e ligaments which suppo rt the organ may be
stretched which can resu lt in kinkin g of tJ1e fallopian tubes,
and congestion of t.h e ovaries and tJ1e uterus itSelf. The
same condition can likewise ca use backache, dyspare unia,
dysmenorrhoea, infertilit)', abortio n, menstrual irregulari-
ties, leucorrhoea a nd constipation. Most patients witl1
mobile reu·oversion, however, areS) mpLOmless.
RnROVERSION
The usual position of t.he utenLS is one of ameversion and
anteflexion, in which tlte uterine body is bem forwards at iiS
junction witll tlle cervix. Version refers to the direction of
the cervical canal, wher·eas flexion refers to the inclination
of tlte bod)' of the uterus at tJ1e cervix. The nor·mal utems is
not a static iLS position is altered by the state of the
bladder which, when full, displaces the uterus backwards. ln
most cases of reu·ove r'Sion, tJ1 c uterus is also retroflexed, so
tl1at tJ1 e body of the ut.e rus is Acxed backwards (Fig. 22. 1).
AETIOLOGY
It is difficult to exp lain why the uterus is no rmally
a ntevened and an tefl exed. The r-o und ligame ntS do no t
maintain tJ1 is positio n o n tJt eir own, altho ugh they are used
to correct tlt e reu-ove rsion d uring surge ry. It appears mat
the position of the ute n.lS in re latio n to the cervix is largely
inherent in the uterine myo me u·ium.
MOBILE RElROVERSION
The uterus is reuoverted in 20%-50% of patients, witJ1 no
obvious gynaecological S)lnptoms.
The uterus is usuall) reu-o,ened in case of prolapse, but it
is difficult to sa> if it precedes pr-olapse or if prolapse caLLSes
reu-oversion. Sometimes, t.he displacemem of the uter·us is
caused by twnours such as ant.e ri or wall m)omas and ovarian
C)'SIS in tlle peh·is, which push tJ1e uterus backwards.

Long axis
of the
vagina
Retroflexion Retroversion
Retroversion
Rgure 22.1 Normal and retroverted uterus.
ReU'oversion is commonly noted in women afLer
childbirth. Such displacements often con·ect themselves
sponUineousl y on ce the patiem's muscle tone im proves.
FIXED RETROVERSION
Fixed retroversion means th at the ute rus is bo und down b)'
ad hesions o r tumo urs in the reu·ovcned positio n. Most
fixed retroversions result from pelvic in nammatOt)' diseases
(PID) such as salpingo-oophoritis and pelvic tumot.u·s.
In salpingo-oophoritis, tlte oedematous, tlte distended
fallopian tubes prolapse behind t11e uterus and, partly by
tlteir weight and partly through fonnation of adhesions lO
the surface of ilie uterus, pull back the uterus. ln
the process of healing, adhesions fonn which bind the
utems firmly in its retroverted position. Fixed retroversion
is also ca used by chocolate cysts of the ovary and pelvic
endometriosis.
SYMPTOMS
The sign ificance of retroversion pe r se in clinical practice
has dec li ned during the last few decades. This is due tO the
apprec iatio n of the fuct t11atthe spnptoms earlier auriblllecl
to tJ1is displacement are not to it, ramer tltey are related
to tJte aeuo logical factors causing reu·oversion. Therefore,
as)mptomalic retroversion does not need treatment, and
treaunem of symptomatic fixed retro,ersion is direcLed
towards tJ1e disease that causes it.
DYSMENORRHOEA
Both congestive and spasmodic dysmenorrh oea have been
,wo ngly a Ltributed to mobi le retroversio n. The incidence of
d)'Smcno rrh oea is the sa me in women with the re u·ovened
ute rus as it is in women wiili an an tevertecl uterus. The fixed
re u·ovened uten.LS can cmt.Se dysmenorrhoea.
MENORRHAGIA
Meno rrh agia associated witl1 mobile reu·oversion is eiilier
due to m)Oh)petplasia or abnormal uLet·ine bleeding
(AU B). A manual or surgical cotTection of reu·oversion will
not relieve the menstrual symptoms. In fixed reu·oversion,
menoni1agia is due to pelvic congestion caused by pelvic
patltology.
PRESSURE
A norma l-sized retrove n ed uten ts does not ca use pressure
on the rec tum or o n the bladder.
CHAPTER 22 - DISPLACEMENTS OF THE UTERUS 303
BACKACHE
More likely, the backache is due to an ot·tJ1opaedic cause
and not due to the reu·oven.ed utet·us.
DYSPAREUNIA
Of all the symptoms of rell·oversion, dyspareunia may be one
which is genuine and attribu table to retroversio n. Outing vagi-
nal exam inati on, the bod)' of the retrove rted is te nder
and tlte patient ma)' wince when it is touched. Besides, the
ovary may prolapse in the pouch of Douglas and tllLIS cat.J.Se
dyspare unia d uring coin.LS. Fo Uowing coitus, she may complain
of a dull ac he in tlte pelvis tl1at persists for 12-24 hours. This
mll) lead to ftigidi cy and marital dish;u·mo n).
INFERTILITY
To implicate reu-o,ersion as a cause ofinfet·tility, it is necessary
to perform all ot11er investigations for infertility. In ilie past a
lot of emphasis has been given to retrovet-sion in a woman
with unexplained infenility. Sims-Huh ner test (poStcoital
test) "1tJt abundant motile spenns see n in tJ1e vaginal pool
and cervi cal mucous rules out reu·ove ts ion as a cause of infer-
tilit)'· On tlte conLJ<tt)', fai lu re to detect spenns in tlte cervical
canal indicates tJtat the cervical canal is away from tlte seminal
pool and is not accessible to tlte motile spem1s. In such a case,
retroversion may be the cause of infertilit). A surgical correc-
tion of tJte reli'Oversion may result in conception in sud1 a
rare siwation. Fixed reu-o\'ersion due to salpingo-oophot;Us
causes infertility because of associated tubal blockage.
ABORTION
Reu·ovet-sion as a cause of abortion has bee n greatly exagger-
ated. Fixed re u·oversion would more often lead to infertility
ratJ1 er tJ1a n abo rtion, because of the associa ted wbal block.
RETROVERTED GRAVID VTERUS CAUSING
RETENTION OF URINE
Retroverted uterus especially in a multigmvida may
cause reten Lion of urine ai'O Lmd 12-14 weeks of pregnancy.
This is as a result offailure of tl1e reu·overted to correct
its position tJnLS caLJ.Sing O\'erstretd1ing of anterior \'1\gi naJ wall
and lwnen of ureilim. ln most cases, the utenJS tends to tise
out of pelvis at 12-14 weeks; however, in an acuLely reu-ovet·Led
Ulerus tJ1is may not happen ilius resulting in retention of
urine. The management of such a case comprises placing an
indwelli ng Foley's ca tl1eter for 48 bout'S and allowing urine to
escape slowl)' after tlte initial placeme lll of the catheter. Subse-
quen U)', woman may be asked to lie in an extreme lateml posi-
tion or prone position to prevent rec w-re nce of such an event
DIAGNOSIS
There should be no problem in tl1e diagnosis of tl1e
reu·overted utent.S on bimanual vaginal examination. ln
rare cases, the uterus felt in tlte pouch of Douglas may be
mistaken for an ovarian twnour or a fibroid. The fuct tl1at
the mass in the pouch of Douglas moves with t11e cervix
confirms tl1atthis is tl1e uterine body.
TREATMENT
Lf the re troversion is mobile and the patient is free of symp-
toms, no treatment is required.
304 SHAW'S TEXTBOOK OF GYNAECOLOGY
Rgure 22.2 Digital replacement of a retroverted uterus. The fingers
placed on the abdomen, by pressing the body of the uterus down-
wards, together with help from the Internal fingers which push the
cervix upwards, correct the displacement.
PESSARY TREATMENT
LfLhe patient co mplains of dyspareunia or backache and the
uterus is found to be reu·overted, the uterus is b iman t.tally
replaced (Fig. 22.2) and kept in the anteverted position by
insening a Hodge pessar> into the vagina (Fig. 22.3). The
pessary is made up of plastic.
The pessar> is retained in position for 3 months and then
removed. Lf the S) mptoms persist in spite of the uterus
being in anteversion, one should look for other causes of
the underl)ing S)lnptoms and no operative u·eaunem for
the retroversion should be undertaken. This is known as the
pessary test. Recurrence of S)lnptoms as soon as the pessru·y
is removed su·ongly suggests reu·oversion as the cause the
underlying symptom.
SURGERY
INDICATIONS
I. Fixed reu·oversio n requires surgery for the primary
organic lesion s uch as the pelvic inflammawry mass and
tum our. At the e nd ofLhe surgery, the ute rus is brought
forward by sho n e ning the round liga mentS, as men-
ti oned below, and ma inta ined in an ameverted positio n.
Figure 22.3 A Hodge pessary.
2. Ln patients for whom Lhe pessary test proves that the
symptoms and infertility are caused by reu·oversion.
3. Following wboplasL) and m>omecLOmy operation, uterus
is ventrosuspended to prevent or minimiLe Lhe fonna-
Lion of wbal and pelvic adhesions.
VENTROSUSPENSION
One of the most popular surgical procedures to con-ect the
retroversion is the modified Gilliam's operation in which
the round ligament is first held b)• nonabsorbable sutw·e,
close (I em) to the uteline comua. The encls of this suture
a t-e left long. A long, cuned forceps is now passed between
the antet·ior •·ectus sheath and the muscle at the level oflhe
anterior superior iliac spine. It is now directed close to the
internal abdomina ll'ing into the space between the two lay-
ers of th e broad ligament towards the uterine cornua. The
forceps point is then pushed through the pe ti LOneum of
the broad ligament and the e nds ofthe ligauH-e around th e
round ligament withdrawn along the tract of the forceps.
T hese ends are now anchored LO th e an terior t'eC tus sheath.
T he ro und ligament is thus dra"11 up aga inst the amerior
abdom inal wa ll. T his operation was frequen tly unde rta ke n
in the past with a mistake n im pression tllat it will improve
feni li L)'; however, it is of historical sign ificance in th e
modern times.
PUCATION OF ROUND LIGAMENTS
Shortening of round ligaments b)' plication usi ng a nona!).
sorbable suwre is a simple form ofventrOSttSpension opera-
Lion for fixed retrcl\ersion associated with organic pelvic
disease and fibroids.
BALDY-WEBSTER OPERATION
The round ligaments are passed tl1rough the ame t·ior and
posterior leaves of the broad ligament and are sutured to
the postet·ior surface of the uterus, thus shonening the
round ligaments and ' 'entrOSttSpending the uterus.
INVERSION OF THE UTERUS
In inversion, the uterus is tumed inside out. At first, tl1e
fundus is pushed clown into the cavity of tl1 e uterus leaving
a cup-shaped depression on tl1e pelitoneal surface. As a
result of con u·actions of tl1c uterus, the invagi nati o n is
pushed furtl1 er and furtl1er clown, until finall y the whole
uterus is tum ed ins ide out and hangs in the vagina. If the
peritoneal surface of tl1 e uLen ts is inspec ted, tl1 e fallopian
Lubes, the ovarian and tl1e round ligaments can be seen to
pass down imo a deep ho llow in the position where the
bod)' of the ULe111s should have been. Inve rsion of the uterus
is classified as complete or partial according to the degree
to which the uterus is LUmed inside o ut (Figs 22. I and 22.5) .
AClJTE INVERSION
In most cases an inversion of tl1e utentS occurs as a result of
mismanagement of tl1e third stage of labour. Attempt to pull
the LUnbilicaJ cord before the separation of placenta predis-
poses to acute in,ersion of tl1e uten.tS. Certain practices
during labow·, such as Crede's manoell\Te, are well-known
predisposing factors for acute inversion of the uterus.

Figure 22.4 Inversion of the uterus. (SoU'Ce: W Slephard, HShenassa,
SS Silgh. The Journal of Minimally Invasive Laparosoopic
Management of Uterine Inversion, 2010.)
Figure 22.5 The fallopian tubes. broad ligaments and ovarian
ligaments pass into a cup-shaped depression at the fundus of the
uterus.
ln some cases it may be due to u-action being applied to the
umbilical cord when the placenta is morbidly adherent.,
,,11ereas othei'S are due to sq ueezing a relaxed uterus imme-
cliately after deli very. Neverth eless, most puerperal inversions
are probabl y spontaneous, although the exac t ae tiology is
unknown. It has been suggested that the puerperal contrac-
tions of the body te nd to invaginate the fundus in to the uter-
ine cavity. T he prese nce of muscle defectS in the region of the
uterine fundus may a lso all ow a dimp le LO occ ur and progres-
sive in vagi nation to follow. Puerperal inversion of the uterus
is complete when t11e whole uterus lies outSide the vagina.
The condition is associated a seve re degree of shock,
and the inverted uterus may bleed profusely. Shock may be
neurogenic or he mon·hagic.
PREVENTION
Proper management of the tJ1ird stage of labour can
prevent acute im ersion.
TREATMENT
The treaunem of acute pue1·pe1-al inversio n depends on
how soon after delhery it is recogniLCd. The ideal u·eaunem
CHAPTER 22 - DISPLACEMENTS OF THE UTERUS 305
is an immediate rep lacemenL If t11 e inversion occ urs in the
presence of a doctor or nurse, it sho uld be promptly repos-
ited by exerting a firm and constam pressure o n tl1e
inverted uteri ne fundus. If t11e placenta is attached to t11e
uterus. it should not be removed until after the replacement
of me uterus has been effected. In a ll instances, the shock
shOLLld be treated simultaneouSI) b) u-ansfLLSion witl1 blood
or plasma substiwte. In domiciliar) midwifery, resuscitation
must be continued until woman is shifted to a facility witl1 a
proper a1·rangement for replacement of me ute1us and
management of sh ock.
The best method of perfonning mis has been described
by O'Sullivan. Th e patient is anaesthetiLCd with the least
possible dela)'· One ga llon of warm sterile water is pre-
pared fo1· instillation into the using an in·igating
can, raised 3-4 feet above the level of t11e patient. After
gently pushing the inverted ute rine fundus back imo t11 e
vagina, the nozzl e of th e ca nnula is inserted into
the vagina, and th e vaginal orifice is closed man ually by
the operatOr and a n assista nt. As much as 3 L of fluid may
be needed. T he inve i'Sio n usuall y co rrec ts unde r the hy-
drostati c pressure. If this me thod fai ls, manua l reposition
may be a uemp ted under deep anaesth esia. As a last resort,
the abdomen should be ope ned and, if th e inve rted fun-
dt.LS cannot easil)' and witho ut damage be p ulled back into
position with a simul taneo us pressure from the vagina, the
tight cervical ring may be d ivided fo llowing wh ich the
utenLS is restored to it's orig inal position and tl1en itS cut
edges are repaired. Antibiotic cover sho uld be given.
CHRONIC INVERSION
Chronic inversion of t11e utenLS occurs as a result of me
late presentation of pue1·pe1-al cases in wh ich me diagnosis
was missed at the initial stages of me inversion. Chronic
inversion of the ute•·us can a lso occur along wim e xu·usion
of a submucous fundal fibroid. Clinically, chronic inver-
sion associated with fundal 111)0ma is suspected if the
woman complains inLermillentlower abdominal pain a nd
in·egul ar vaginal bleeding. Over the pe1·iod, the myoma
becomes infected and causes offensive blood-stained dis-
charge. ln a longsta nding nbroma associated wit11 inver-
sion, sarcoma may often exist, whi ch by softening t11 e
uterine wall is responsible for the inve•'Sio n. A diagnosis of
ch roni c inve i'Sion is ofte n d iffic ult to ma ke. A cup-s haped
depression must be ide ntified in the fundus. In co mplete
inversio n, the cervix is drawn up and the vagina l portion
of t11 e cervix will no t be palpable. In partial inve rs io n, t11e
uterine so und can be passed o nly for a s ho rt distance
a long t11 e ute rine cavity, a nd this will he lp to distinguish
the partial inve rsio n from a myo mato us polyp arising from
body of t11e uterLLS. Whe n the tumo ur wh ich protrudes
through t11 e cervix is pulled clown with a vulse llum forceps,
if t11e cervix moves upwards, then it is most s uggestive of
an inverted uterus. If t11e tumo ur is a polyptLS, u-action
brings down the cervix and the tumour may be pulled fur-
mer tl11'ough the external os witl1out the being
d1-awn up. ln chronic imersion, the inverted fundLLS is
like ly LObe ulcemted and infected, a nd may resemble an
infected fibroid pol) p or 11
Ultmsound and laparoscopic examination of t11e
will con finn the diagnosis of ime1'Sion.
306 SHAW'S TEXTBOOK OF GYNAECOLOGY

A First degree B Second degree C Third degree

Figure 22.6 Inversion of the uterus. (A) First degree. (8) Seoond degree . (C) Third degree.

DEGREES OF INVERSION (Fig. 22.6) KEY POINTS

• In first-degree in vet'Sio n, the fw1dus of th e uterus inverts
• The uterus is a mobile o rga n; however, in most cases its
imo th e uterine cavity.
usual position is that of anteversion and anteflexi on.
• In second-degree inversio n, the uterine fundus protrudes
• The ULems is reu·ovetted in about 20%-50% of
through the cervix and lies in the vagina.
women; mobil e reu·ovet'Sion is often as)'mptomatic
• In third-degree inversion, the whole uterus is invened
and requires no treaunenL IL is mot·e likel y in mul-
and prou·udes through the introitus.
tiparous women.
• Fixed retro,ersion is a result of pehic inflammatory
TREATMENT chsease or a result of endomeu·iosis; these women
ma)• complain of chronic backache and deep d rspa-
Before auempting any surgical con·ection of chronic inver-
reunia which ma) conu·ibute to infrequem coiLLIS and
sion, the patient should be u·eated with a ntibiotics and local
inferti IiL).
antiseptic packing.
• Pessaries to correct retro,ersion were in vogue some
years ago. A surgical correction is indicated in women
• If it is desirable to conserve the uterus in yoLmg patients,
witl1. symptomatic retrO\ersion. The operation of
th e can be corrected eitl1er by vaginal or by an
chotec IS \entrosuspens ion. This procedure is earned
abdommal approac h. In the eitl1er instance, t11e impor-
out concomitantl) witl1 laparotomy performed for
tant s tep in the operatio n is tl1e division of the constrict-
other gynaeco logical operations such as myomectomy
ing ring of t.h e cervix after which it is easy to restore the
or tuboplasty.
fundus to its con·ec t position. The transected cervix is
• Acute inve rsion is alwa)'S due to mismanaged third
Lh en re paired by suUJ ring. In vaginal Spine lli's operatio n,
stage of labo ur: If not recognized immediately it may
Lh e cervical ring is cut a nte rior!)' and tl1 e inversion is cor-
result in severe shoc k a nd a t tim es, de mise of the
rec ted fo llowed by repair of tl1e cut edges of cervix. In
patie nt. An immedia te re position of tl1e ute n.ts can
so me cases the rim of ce rvi x may have to be divided pos-
preve m such a se rious co mp lication.
te rio rly (Kus01er's ope ratio n) fo llowed by repos ition of
• Chron ic inversio n of th e uterus is a ra re cli nica l entity.
tl1 e ute rus a nd re pair of the cut edges of cervix. In ab-
dominal repair of chroni c inver'Sion of t11 e uterus after 1L is . like ly to be mista ke n for a s ubmucous poi)'P or
cervt cal ca nce r. A ca reful pelvic examination, pelvic
dilatation of co nstricti on band through wh ich tubes and
ul trasound exa minatio n and laparoscopy wi ll help to
ovaries a re prolapsing an auempt is to restore t11e normal
establish the diagnosis. Treatmem of tl1e condition is
position of the uterus; in difficult cases the rim of cervix
surgical.
may h ave to be divided to r·eposit tl1e inversion followed
b)' repair of incision ( Haultain's oper-ation).
• If it is not desired to conserve the uterus in a multiparous
woman, vagina l or abdomi nal hysterectomy is performed.
• Inversion caused by extrusion of fundal m)orna witl1 SELF-ASSESSMENT
underl)ing sarcomatous changes wi ll mandate radical
hysterectomy followed by radiotl1erapy. l. Desctibe the \'lltieties of displacemem in t11e pelvis o b-
served in din ical pt-actice
In a vaginal m)omectomy under laparo- 2. Describe uterine reu·oversion. When woLtld it require a
scoptc gu tda nce wtll safeguard againstuted ne perforation. surgical correction?
 CHAPTER 22 - DISPLACEMENTS OF THE UTERUS 307

3. Desc•·ibe the role of pessary in the treaunent of the ret- SUGGESTED READING
roverted uterus. Allen WM, Masters WM. Tmumatic laccr.uions or uterine supporr. Am
4. Describe the clinical features of an acute inversion of the ] Obstet Cp>ecol 70:500,1955.
uterus. How would ) ou manage such a case? Rresch A, Seifer DB, LD, et .11. Laparoscopy in I00 women "ith
chronic pel,ic pain. 64:672.1984.
5. Describe the clinical feawt·es of chronic inversion ofthe
lawson JO. Pehic :u>atomy I. Pch;c muscles. Ann R Coli Surg Eng!
uterus and iLS managemenL 54:244-52,1974.
6. Enumerate the various causes of the ULerine inversion. Sternbach RA, Wolf SR, RW. et al. AspcCLs or chronic low back
7. What is the place of the operation of venu·osLJSpen- pain. Psrchosomatic. 14:75,197!1.
sion? Describe the variOLLS surgical operations for Wall DP, R Textbook or Pain. Churchill Lhingswne:
:'\e" York, 1984.
the same. Zdeblick TA. In: The LTCatmem or degencr'.Ui\e lumbar disorders: A
criLical rede" oflitcmtun!. Spine 20(•uppl24):126S..l37S,l995.
 Diseases of the Broad
Ligament, Fallopian Tubes
and Parametrium
Diseases of Broad Ligament 308 Tumours of the Brood Ligament
Broad Ligament Cysls 308 and Parametrium 310
Paraovarian Cysts 308 Key Points 3 10
Tumours of the Fallopian Tubes 309 Self-Assessment 3 11
Conditions the Brood Ligament
and Parametrium 309
DISEASES OF BROAD LIGAMENT
Diseases of broad ligament are mostly benign and are seen
in association wilh other conditions affeCLing ovaries or
uterus. These conditions rna> be in the fonn of cystS,
LLLrnour masses or infections. Following section describes
these conditions which are seen in clinical practice.
BROAD UGAMENT CYSTS
Broad ligament C)'Sts are fairly common. However, they are
small and are of no clinical importance except the para-
ovarian cyst which may attain a la•·ge size and undergo
torsion.
ANATOMICAL CONSIDERATIONS
Vestigial remnantS of the Wolffoan d uct (mesonep hri c duct)
are see n in th e broad liga ment, lying between the fallopian
tube and the hilum of the ovary. T he mesonephric d uct
ex tends from the outer aspect of th e ova•')\ parallel to the
fallopian wbe in an inward and downward direction unti l it
enters tl1 e myometriwn in tJ1 e region of the cervix. Its low·
ermost limit is the region of the hymen. It should be re-
memebered tl1 at wo lfFian d ust is same as mesonephric duct
or gart.ners duel.
Associated with the mesonephric duct and opening into it
are tl1e tubules of the upper pan of the Wolffian body, tl1e
epoophoron or parovarium (sometimes called the organ of
Rosenmi:JIIer). The) are siLUated in the broad ligamem a<lja-
cem to tl1e hilum of t11e ova•)· These mesonephric tubules
are sometimes called Kobelt's wbules. Besides tl1ese, a num-
ber of blind isolated wbular remnants are seen near tl1e
inner border of tl1e Ol'lll)' and are known as paroophoron.
308
The lining of the mesonephric duct a nonc iliated,
low colunmar epitl1e lium. AltJ10ugh the lining of tl1e
mesonephric tubules is low columnar or cuboidal, botl1 cili-
ated and nonciliated cells are present in it.
Cysts may arise in the broad ligamem from eitl1er tl1e
mesoneplwic duct or its tubules. These cystS are usually
small, pedunculated or imraligamemary, lying between
tile layers of tile broad ligament where thC)' may attain a
considerable si.t:e. Mesonephric duct are never lined
ciliated epitl1elium, whereas C)Sts of tile mesonephric
tubules may be. These cystS of mesoneph•·ic o •·igin lie be-
tween the 01oary and the fallopian tube, but are ahl'<l)'S sepa-
rate and easily identified being separate from the ov:uy
PARAOVARIAN CYSTS
Paraovaria n cysts are exu-apcritoneal cysts lying in tl1e broad
ligament adjacent to the ovary, below tJ1e fallopian tube.
The tube is s u·e tched and flaucned over the top of the cyst
which tends to enlarge in a la tera l direc tion so t11 at it may
lie to the side of ovary. Small paraovarian cysts are ex tremely
common and are often found at o peration without their
presence havin g previously been suspec ted. T hey some-
times form a C)'St as large as 15-30 em in diametec The cyst
is usuall)' uni loc ular, and con ta ins clear fl uid. Its wall is
smooth, t11in and translucent. Sometimes, a few loc uli are
present, and papilloma, similar to tJ1e stational)' papillomas
of papillary cystadenomas of the ovary, may be scauered
over tl1e inner surface of tJ1e cyst. Unlike t11e ovarian cyst,
t11e wall of a pru-aovarian C)St frequently comains smootl1
muscle as do tl1e mesonephric tubules. It is tl1erefore
possible to establish tl1e origin of tJ1ese cysts by histological
examination.
Pru-ao,oa•·ian cyst is clinically diagnosed as an Ol'llJian cyst,
and at lapa•·otomy, it can be identified as a broad ligrunem
 CHAPTER 23 - DISEASES OF THE BROAD LIGAMENT, FALLOPIAN TUBES AND PARAMETRIUM
Figure 23.1 A paraovarlan cyst which had undergone torsion
Involving at so the appendages.
cyst wiL11 a no nn alloo king ovary being presenL AILiw ugh an
ova ri an cyst can also bu r1·ow in to the broad ligament but in
such a case, the norma l ovary is not iden tifi able unlike in a
paraovarian C)'St. llisLOiogica l iden tification of L11e muscle in
a cyst establishes the correct diagnosis.
The paraovarian cyst is usually seen in yo ung women. It
displaces the uterus to the opposite side, and may be fixed
in between the two layer-s of the broad ligament. As these
cystS can undergo torsion, they are sometimes misdiagnosed
as twisted ovarian C)SLS ( Fig. 2:U ).
TREATMENT
Surgical removal of the para ovarian cyst becomes necessary
when it attains a large siLe. A delicate incision is made in t11e
peritoneum over the C)St from which it is refleCLed by a
blum dissection. A flnger is then swept ar·oLmd the cyst, be-
tween it and iLS bed until it is sufficiently free to be enucle-
ated. Onl) a few small vessels will need ligation in the cyst
bed. The ureter is found very close to the cyst and may be at
a risk of injury. It is mandatory tl1erefore to idemify it or
u·ace it down from the pelvic brim before any structure is
cut or clamped. Par-aovarian cyst car1 also be removed by
laparoscop)' after initial decompression of the cyst fo llowed
b)' itS removal. In most cases, it is possible to save the ovary
on the same side.
TUMOURS OF THE FALLOPIAN TUBES
Neoplasms of the fallopian tubes are extremely rare and
ofte n malignant. Sec chapter 36.
CONDITIONS AFFECTING THE BROAD
UGAMENT AND PARAMETRIUM
HAEMATOMA
HaemaLOma of the broad ligament and pararnetrium may
result from ectopic gestation which ruptures extraperiwneally
imo L11e broad ligament. A large haematoma may develop
following rupture of tJ1e uterus or cervical laceration
309
during childbirth. Haematoma ma)' follow dilatation of
the cervix, if the cervix geLS split and uterine vessels
get tam. The condition may also develop in cases of
concealed accidental haemorrhage. A broadligamem hae-
mawma tends to spread exu-aperitoneally. It may extend
upwards and cause a swelling abo'e the Poupart's ligamem
and rna>' even spread to the perinephric region. A haema-
wma may sometimes be encoumered following abdominal
and vaginal hysterectOtn) when a vascular· pedicle slips and
retractS into tJ1e cellular tissue. Pain. tachycardia and
haemorrhagic shock ensue. A painful lump is felt in the
lower abdomen. Proph)lactic or therapeutic anticoagu-
lants in the postoperative period Carl also at times produce
a haematama. A small haernatoma usual!)' resolves with
conservative treatment, but a large haematoma requires
laparotOmy, drainage and ligation of tl1 e bleeding vesse l in
broad ligament.
PARAMETRITIS
Parame tritis, first described by Matthews Duncan, is
a celluli tis of the soft tiss ues of tl1e parametrium.
Well-mark ed parametritis al most invariably follows child-
birth or abortion, when the parametrium is infected
from lacerations of the vagina l portion oft11e cervix, the
vaginal vau lt or h-om lacerations of the lower· uterine seg-
ment. Some degree of par-ameu·itis is presem in all acute
infections of the uterus and fallopian tubes and in
advance carcinoma of the cet·vix. The cases which are of
clinical importance are tJ10se complicating childbirth
and abortion. The condition causes S)lllptoms at t11e
beginning of the second week when the patiem com-
plains of pain in the h)pogastrium and back. The
temperawre rises to about 102"F; the pLLise rate is raised
in t11e same proponion. The inflammation of the pelvic
cellular 1issue leads to the de,elopment of a large indu-
rated swelling in the pelvis. In the early stages, tlle uterus
is pushed to t11e opposite side and the indLLrated swelling
of the par-ametrium extends from tl1e uterus to t11e lat-
eral wall of the pelvis, and fixes t11e uterus in the
pelvis. It is im possible to separate the uterus from the
swelli ng, because the parametrium extends to the wa ll of
the uterus. The effus ions in parametrium llla)' spread
backwards along the uterosacral ligaments, and it may
a lso ex te nd upwards a nd poin t above Poupart's liga-
ment. On rare occasions, th e effus ion may point in
th e pe ri ne phric region, in th e isc hiorecta l fossa and
even in th e buuoc k, hav ing trac ked through the greater
sciatic foramen. Suppura ti on in parametric effusion is
uncomm o n. It is rare for fr-ank pus to form, needing
evacuatio n. As the effusion is extraperitoneal, symptoms
of peritoneal irri tation are absent, but rectal symptoms
may ar·ise as the result of inflammation involving the
recwm.
Most parametrial effusions subside with amimicrobial
treatment, but they are followed by scar·ring of t11e
par-ameu·ium and this causes chronic pelvic pain. The
scar-red tissue draws the uterus O\'er to the affected side
and the thick scar tissue is readily palpated on bimanual
examination. rete ric kin king rna) occLu· resulting in
hydronephrosis.
310 SHAW'S TEXTBOOK OF GYNAECOLOGY

Parametritis is often complicated by some degree of • Solid tumours arising from tJ1e bony pelvis, i.e., osteoma,
pelvic t11rombophlebilis wiLh iLS risk of pyaemia, pulmonary chondroma ru1d &c'lrcoma can also be present in reLro-
infarction and extension to the lower exLremities to peritoneal space.
produce a 'white leg'. This clinical syndrome is especially
common if the responsible organism is t11e anaerobic When faced with a retroperitoneal tumour, a t11orough
coccus. Almost all effusions in parametrial space are lateral to preoperaLive invesligalions, i.e., IVP and barium enema,
tlle uterus and vagina, where the parametrium is most plemi- CT and MRl are indicated. Diagnoslic laparoscopy ru1d
ful. However, on rare occasions, an ameroposterior parame- biopsy ru·e helpful. The ulu-asound will indicate its localion.
tritis develops situated between the cervix and the rectal wall Two dangers are encountered du•·ing removal of the reu·o-
posteriori)\ and the bladder and uretllra ame•·iorly. The treaJ.- peritoneal tumour, to ureter and i•1iu•·y to major
ment of parametrilis consists of bed rest, local heat and a full pelvic vessels.
course of tlle appropriate anLibioLic - similar LO t11at de-
scribed in the treatment of acute salpingo-oophorilis. • The ureter may be close to the tumour a nd be cut or
ligated unless it is idenlified at the stan of the surgery.
• Large vessels of tJ1e hypogastric system may obtrude imo
TUMOURS OF THE BROAD UGAMENT the operative fields and tJ1ese must be secured.
AND PARAMETRIUM
In case of inoperable fixed growth, radiotl1erapy is an
alternali ve.
MYOMA T he differen t types of abdo men lumps enco untered in
T he most common tum our found in a broad ligament is gynaeco logy are ill us u·ated in Tab le 23. 1
myoma It may be pli mary (true broad ligament fibroid),
when it alises from tJ1e ute rosacral or round ligame m, and tis-
sues in tJ1e broad ligament, or secondary (false broad ligament
fibroid), when it arises from tJ1e lateral wal l of the uterus or me Table 23.1 Differential Diagnosis of Lumps In the
Lower Abdomen
cervix and grows laterally between tJ1e two layers of me broad
ligamenL In the latter, tJ1e myoma retains iLS attadlmem to t11e Reproductive
LtteniS, and t11e uteline vessels as well as the tu·eter are ptiShed Adolescents Age Menopause
laterally. ln case of a plimary myoma, the uterine vessel is Haematocolpos Pregnancy Pyometra
medial to the fibroid, but tJ1e ureter may lie anywhere in Haematometra Ectopic Endometrial
relation to it tJ1ough usuall) it is beneatJ1 tJ1e tumour. Primary Ovarian tumour pregnancy carcinoma
myoma is also known as tn.1e broad ligamem myoma ru1d uterine ftbroids Full bladder - Ovarian tumour
seconda•1 m)Oma as false broad ligarnem fibroid. (rare) gravid uterus Fallopian tube
Tubercular mass Fibroid or cancer
PeMc kidney ovarian tumour Uterine sarcoma
SARCOMA associated v.ith Chronic retention
Sarcoma in b•·oad ligament is 'ery rare. It presents witl1 clinical pregnancy of urine
Uterine fibroid
features of a m)oma. In tJ1e early stages, surge•y is feasible, but
Pelvic lnflam·
in advanced stages, it can be treated only by radialion. matory Disease
(PI D)
UPOMA • Ovarian t umour

Li poma is rare and ca n be enucleated witl1out much

difficulty durin g su•·gery. ll owever, all preca uti ons sho uld
be exercised to avo id inj u•")' to ure te r and major vessels. KEY POINTS

RETROPERITONEAL TUMOURS
Retroperitoneal tum ours are incl uded here because they
are often mistaken for an ovarian tum our or a broad
ligament tumour, and their exac t naLUre is revea led only at
laparotom)'· These wmours are classified as follows:
• Congenital: Ectopic pelvic kidney should be StiSpected
when a fixed pelvic mass is associated with the absence or
malfonnation of the genital tract. Ulu-asotuld and intra-
venous p) elograph) reveals its u·ue co ndilion.
• Dermoid C)St: Rare I) dermoid cyst can be reu·operiLOneal
in location.
• Ttunours of neurogenic o •·igin: eurofibromas ru1d
tumours arising from the spinal meninges can be presem
in tlle reu·operitoneal space.
• Re mn ants of the Wo lffia n body and the meso nephric
duct are present in the broad liga ment between the
fa llopian tube and the ovary; these can e nlarge and
cause C)'S tic neop lasms. The paraovarian C)'St ca n grow
to a large size. It can unde rgo torsion or rup tu re.
• T he parameu·ium can be the site of a haemaLOma
formation or infec tion causing parametritis.
• The connecthe tissue in the broad ligamem can be
t11e site of a true broad ligame nt fibroid However,
more common is a fibroid aris ing from lateral wall of
uterus extending into broad ligame nt.
• Reu·operitoneal tumours ma) mimic broad ligament
neoplasms.
• The nature of t11e abdominal wmours \>a1ies accord-
ing to tlle age.
 CHAPTER 23 - DISEASES OF THE BROAD LIGAMENT, FALLOPIAN TUBES AND PARAMETRIUM 311

American Collcgc of Ob.>tctridans and Cynccologi$ts. ACOC Practice

SELF ·ASSESSMENT Bulletin. Mou1agcmcnt of adnexal moo.s.st'S. Obstet Cynecol 2007;
110:201.
Ch-en> V. Mitchcll CE, llarmway-Srnith C, e1 al. Diagnosis and rnanage-
I. Describe the different abdo min al tumo urs encottntered mclll of adncxal m:mt.'>. Am Farn 2009; 80:815 .
in g) naecolog>. Crab D. Flock F. Stohr I. ct al.: of >1>)1nptomatic adnexal
2. Wt·ite short notes o n following: mas:.cs b) ultr.O>Ound. m.tgnctic re.onan'-e imaging, and position
a. Haematoma of the bl'Oad ligament cmi»ion tomogr.tph). C)1li"'OI Oncol. Vol 77:454-459, 2000.
Xationallnstitutc> of llealth Coll>Cn>tl> Qc,elopment Conference State-
b. Retropel'itoneal tumoul'S ment. 0\'arian cancer: >crecning, and follow-up. Cynecol
Oncol 199-1: 55:54.
Swdd.J. et al. l'r%rn:;s in Ob.>tctriC> and Cp1aecology 17:306, EJse,·ier,
SUGGESTED READING 2006.
Studd, J. et al. in Ob.>tetriC> and Cyl>aecol<>!,'Y 18:299- 313,
American College of Ob.>tetricians and Cp>ecologists Commiuee on Else,icr. 2008.
Cynccol<>!,riC P.-. .aicc. Comminee Opinion 477: the role of the
obstetrician1.'Ynccologi>t in the early detection of epithelial o'-arian
cancer. Ob.>tct Cynccol 20 II; 117:742.
 Benign Diseases of the Ovary

Nonneoplastic Enlargements of the Ovary 312 Key Points 317

Polycystic Ovarian Syndrome or Diseose Self-Assessment 3 18
PCO, PCOS, PCOD 31 4

O varies can be s ite o f a va ri e ty of d iseases. T hese diseases

includ e f u nc ti o na l C)'SLS, ova ri an e ndome u·iosis, polycys tic Table 24.1 Varieties of Cystic/neoplastic
Enlargements of the Ovaries
ovaries a nd neop lastic diseases. In Lhis c hapte r; fun ctio nal
C)'SLS and po l)'C)'Sti c ova ries a re d esc ribed. 1. Functional cysts • Follicular cysts
Ovaria n e nla rgeme n1.s, C)•Stic o r solid, may occ u r at an y • Lutein cysts
age. F rm c tio na l a nd infl a mma to ry e n la rgemenrs of the • Multiple functional cysts
ovary d evelop almost exc lus ive ly d uring the ch ildbearing Corpus luteal cyst
yea rs. T hey may be asym ptomatic o r p rod uce local disco m· (PCOS)
fort. menstrual d istu rba nces, infe rtility o r in rare cases 2. Inflammatory Salpingo-oophoritis
cause acute S) mp to ms d ue to co m plicatio ns s uc h as hae m· Puerperal , abortal, IUCD related
orrhage. ru ptu re or torsio n .
3. Metaplastic Endometrioma
T he oval') is complex in its embryology, his to logy, ste·
ro idoge nesis a nd has the poten tial to deve lo p malignancy. 4. Neoplastic benign and Benign
T he refore, oval"ian neoplas ms exhi bit a wide v:uiatio n in malignant Borderline tumor
su·uctw·e a nd biologica l be ha,·io u r. t.:nlike the cervix a nd Malignant
uterus, the ovaries are not cl inica lly accessibl e, :u1d the re-
fore, sui table screening m eth ods for detecting ovarian neo-
plasms are n ot avail able. The ovary, a fter the ce rvix, is the
second m ost commo n s ite for d evelopment of gynaecologi·
cal m alig na ncy, with a dism al p rognosis. 73cm ,-27cm
O varia n tum o u rs may occur at a n y age.
FUNCTIONAL CYSTS IN OVARY
Ln ado lescents, the ovari an tum o urs are m ostl y ma lignant O varies ca n be tl1 e site of functi o nal cysts such as folli cular
and a re o f germ cell o ri gin. In pe rimeno pausal and post· cyst. t11eca lutein cyst o r· co rpus lute um cyst. T hese cysts us u-
men opa usal wo me n they te nd to be e pitl1eli al in o rigin. Du r- a ll y form beca use o f no nregressio n o f f unc ti o nal cysts in
ing tl1e ch ildbea ri ng age, t11ese ova ri an e nl argemen ts are ovary.
functi ona l in 70% of cases, neoplasti c (mostly benig n) in 20% 1u define a size must. be at l&.zst 3 b ut
of cases and d ue to O\'tl ri a n in 10% of cases. no t more than 7 e m .

NONNEOPLASTIC ENLARGEMENTS FOLUCULAR CYSTS

OF THE OVARY (Table 24.1 )
Enlarge me nt o f ova ries can be as a resul t o f pe lvic co nges-
tio n as seen in a pe lvic in flamma to ry disease, o varian endo-
me triosis caus ing a c hocolate cyst o r pe rsiste nce and en-
Large me n t of p hysio logical struc wres in t11 e ovary such as
the Graafia n follicle or corpus lu te um. Th e lesio ns due to
in flammator) co nd itions a re discussed in tl1e c hap ter o n a
pe lvic in flammatoq d isease, a nd e ndome triosis affecting
the ovary is d ea lt in Chapte r 27. In this c ha p ter, no nneoplas·
ti c enlargeme n t of the ov;u·ies, a nd poi)C)"SLi c ovari:u1 S)11·
dro me ( PCOS) are described in detail.
Fo llic ula r cysts a re no t u ncom mo n. T hey may be s ing le or
m ul tip le, m ay be b ila te ra l a nd vary in s ize fro m s mall
ble bs to cysts o f large s ize bu t ge ne ra lly d o no t exceed
5.0 e m in dia me te r (Fig. 2 1.1 ). They fo rm as a result o f
fa iiLtre o f a bsorptio n of the fl uid in an in co mple te ly d e-
ve lo pe d fo llicle o r a novula ti o n . They a re us ua lly asymp-
to ma tic unless haemorrhage, ru pw re o r to rs io n supe r-
ve nes, in whic h case S)lnptoms a nd sig ns of an ac u te
a bdo me n d eve lop.
Large :u1d mul tiple cysts may caLLSe pe h,ic pain, d ys p:u·e u·
n ia :u1d irregular bleeding. The e nlarged ovary may be rec-
o g ni a ble cl ini cally or docume n ted o n sonogra phy.

312

Figure 24.1 (A) Corpus luteum cyst. (B) Transvaginal ultrasound showing polycyst ic ovary.
Ovarian neop las ms, infl amma to ry ad nexal e nlargement
and e ndo me u·iosis must be cons ide red in the differentia l
diag nosis.
Most fo llic ula r cysts disappear spontaneously within
4-8 weeks. In t11 e presence of sympto ms s uch as amenor-
rhoea ad ministering o ra l meclroxyprogesterone 10 mg twice
a clay over a period of 5 clays will generally bring o n men-
struation. Norethisterone tablet (Primo lut N) 5 mg Li.d. for
5 da)'S also induces menstmation. O ra l combin ed pills ad-
ministered for 3 montllS he lp resolve the persistent cyst in
most cases.
If (Ill)' cy:.t per..ists for lo11ger tlum 3 numths, or size increases to
> 7 em, the jJOJJibi/it)' of a neopln.stic cyst must be kept in mimi,
ami the patient iiiVI'.IIigMal.
FOLUCULAR HAEMATOMAS (FOLLICULAR CYST WITH
HAEMORRHAGE)
Small follicular haematomas are commo n. To the naked
eye, the ova•-y con tains h aemord1agic cysts. Old cysts appear
to con tain tan-y materia l and a re likely to be mistaken for
endometriosis. Ma ny of t11 ese a re asymptomatic and of no
clinical sig nifi ca nce except for t11e ra re case, wh en the C)'St
ruptures into tl1 e peritoneal cavity ca us in g ac ute abdom en,
and is mistake n fo r a n ec to pic pregnancy.
LUTEIN CYSTS OF THE OVARY
Two l)'pes of lute in cysts a re recognized:
• Granulosa lute in cysts found witllin the corpus lu teum.
• Theca IULei n cysts associated with a trophoblastic disease
and c horio nic gonadotropin therapy.
CORPUS LUTEUM (GRANULOSA LUTEIN) CYSTS
Corpus lu teu m C)Sts are functiona l, no nn eop lastic e n-
largements of the O\'al'). Persistent corpus luteum C)'Sts
may cause local pain, tenderness or dela)ed mensu·uation.
These C)'Sts are often pa lpable clinicall)'· Unless complica-
tiOilS such as torsion or •·upwre lead to an acute abdomen
requiring surgicaltreaunem, most cysts will resolve in due
CHAPTER 24- BENIGN DISEASES OF THE OVARY 313
co urse of tim e. li e nee obse rva ti o n is reco mmended when-
ever this cond iti o n is s uspected. As it resemb les unrup-
tu red ectop ic pregna ncy sonograp h y and se rum quantita-
tive estima tio ns of 13-hCG can he lp to make a correct
diagnosis.
Uluasound reveals a sp ider web-like stm c ture with o r
witllOut a clot. Dopp ler shows increased vascularization with
a hig h blood flow ve locity.
THECA LUTEIN CYSTS
These C)'Sts can sometimes enlarge to several centimeu-es in
diameter. The) are usuall) bi lateral and filled with su-aw-
colottred fluicl Theca lutein cysts are oflen noted in cases of
hydatidifonn moles, cho1iocarcinoma. Induction of ovula-
tion witll gonadotropin (hCG) and clom iphene can also
result in tlle formation of t11eca lutein C) St. The cy:sts spon ta-
neously •·eg•-ess after evacuation of ilie mole, ilierapeutic
curettage and treaunent of choriocarcinoma. In a case under-
going induction of ovulation ,,1t11 gon adotrOpin or clomi-
phene one should avoid giving hCG i-:jection tO prevent fur-
m er enlargement of ova1-y.
Functiona l cysts are distinguished from neoplastic C)'Sts
b y the fact tlwt they uever grow more than 7 tm in size, am uni-
with cltmr fluid wul rf'{,ITf:JS (ifier some t.ime. T he hyper-
s timu la ti on syndro me by c lo miph e ne t11e rapy has been de-
scribed in tl1 e c hapte r on Infe rti lity: Ma le a nd Female.
MULTIPLE FUNCTIONAL CYSTS
Multiple func tio na l cysts are us ua lly ca used by following
concli tio •lS:
• Fo llicle-stimulatin g hormone (FSH )-secretin g pituitary
adenoma.
• O varian h)perstimulation S)ndrome (OHSS)
• PCOS
PITUITARY ADENOMA
ln pituitary adenoma, ovarian C)Sts measure more tllaJl
l em; FSH and oestrogen le,·e ls are raised, but lute inizing
hormone (LH ) le,el is low. Othersig•lSofh)perstimulati on
314 SHAW'S TEXTBOOK OF GYNAECOLOGY
such as hae moconcenu·aLion and coagulation profile are
not present. Amenorrhoea, oligo menorrhoea and infertil-
ity are the clinical feawres. Pituitary adenoma may require
transsphenoidal excision of th e ade noma, but no surgery is
reqtLired for th e ovaria n C)SIS. These eve ntually resolve.
OVARIAN HYPERSTIMULATION SYNDROME
O HSS is omsed main!) b) ad ministration of human chod-
onic gonad otropin injection in a wo man undergoing con-
trol ovarian stimulation with gonadotropin or clomiphene.
The folli cul ar sit.e is usually more than 3 em.
POLYCYSTIC OVARIAN SYNDROME
PCOS is characterit.ed by multiple small cystS less than 1 an;
LH is raised and LH / FSH ratio is This condition is
fairly common affecting 5%- 15% of adolescent girls. It may
also be seen among women in rep roductive age suffering
from inferLility, mens trual irregula rit.i es or hirs utism. Fol-
lowing sec ti on desc ribes in de ta il about aetiopathogenesis,
diagnosis and manage ment of this co nd itio n.
Stein Leventhal
POLYCYSTIC OVARIAN SYNDROME OR
DISEASE PCO, PCOS, PCOD
PCOO is a heterogeneo us, mu ltisyste m endocrinopathy in
women of reprod uctive age with the ovarian expression of
various metabolic diswrb;1nces and a wide spectrum of
clinical feaLUres such as obesity, menstrual abnormalities
and hyperandrogenism. This disease was descdbed by and
named as Stein-Leventhal S) ndro me in 1935. 1o diagnose
PCOS. adrenal and androgen-producing ovarian nunour
shotLld be excl uded.
INCIDENCE
Current incidence of PCOS (5%-15%) is increasing fast
lately due to change in lifeSt) le and stress. It is also becom-
ing a common p•·oblem amongst adolescentS, developing
soon after puberty. Amongst infertile women, about 15%-
20% of infertility cases are due to anovulation caused by
PCOS. Some of the women who develop a cardiovascular
disease, hypertensio n, endomeu·ia l cancer and type 2 diabe-
tes later in life appea r to h ave suffered from PCOS in earlier
years.
AETIOLOGY AND PATHOGENESIS
T he exac t aeLio logy of !'COS re ma ins unknown. A number
of t.h eolies have bee n postul ated in the ge nesis of PCOS.
Some of tJ1e well-known facto rs which may infl uence the
onset of PCOS are lifestyle changes, sedenta•)' life, d iet and
su·ess. ln itia ll)', tJ1e ovaries we re thought tO be the primary
sight which setS tJ1e series of d1anges in the endoa·ine pat-
tem resulting in PCOS. Genetic, fami lial and environmental
factors (autosomal dominant inherited facwrs) were later
added as aetiological facLOrs in the development of PCOS.
The environ men tal facLOrs ma> function in utero or in early
adolescent life, manifesting clinically a few years later as
PCOS. gene mutation has been ident.ified in iliis con-
necLio n. Familial occu•,.e nce has also been reponed where a
sex-linked mode of inheritance has bee n postulated.
AnotJ1er ,•iew held for the de,·elopment o f PCOS is an
enhanced serine phospho•1 lation unification in the
ovary (hyperandrogen) and a red uced ins uli n receptor
activity peripherally (insulin resistance).
is related to PCOS. At leas t 50%-70% of patientS
with PCOS te nd to be obese or overweight. The adipose tis-
sue (fat) is considered an endoc rine a nd immunomoclula-
LOry organ; it secretes leptin, ad ipo nectin and cy1.0kines
which interfere witJ1 the ill.SU/ill pathways in tlle
liver and muscles resulting in i11.su/in n'Sistrmce, and hyperin-
sulhwemia. Increased binh weight in obese and PCOS moth·
ers can also cause PCOS in their adolesce m daughte rs.
Raised LH secretion by insulin ca n cause infertility or
misca•·riage through improper oocyte matura tion.
Obesity is characterit.ed as the condition "11en bod)' mass in·
dex > 30 kg/ m2 and waist line > 88 em; waist/hip ratio > 0.85.
Endogenous !3-endorphin also stimulates insuli n release
and ma y contribute to insulin resistance.
Hyperandrogenism and resultin g anovulation were ini-
ti al!)' tho ught LO arise plimaril y in th e ova ries. It has now
being proved that insuli n resista nce with resul tan t h yperin-
s ulinaemi a in itiates PCOS in 50%-70% cases, tJw ugh hypo-
thalamic-pilltita•r-ova ri an ax is, ad renal glands also play a
ro le in the genesis of PCOS to so me ex te nt.
OVARIAN STEROIDOGEN ESIS IN PCOS
Insuli n ind uces Ll-1 to cause theca-cell hyperp lasia and se-
crete androgens, testostero ne and epi-androstenedione
which are converted to oesu·ogen in the gran ulosa cells.
£pi-androstenedione is co nve rted in tJ1 e pe ripheral fat to
oestrone. This leads to lise in tJ1e oesu·ogen and inhibin
level. These in turn cause high Ll l surge.
While oesu·one level increases, oesu-adio l level remains
nonnal with tJ1e result Ulatthe oestro ne/ oestradio l ratio lises.
Hyperandroge nism lowe rs tJ1 e level of hepa tic sex hor-
mone-binding globulin (SI IBG), as a res ult levels of free
testosterone in se•·um rises leading to hirsutism. AJUlrogen
also wpprlllle:. the grmutlt of 1111' domill(lllt folliclt' wul pTl!Vt!nt.s
of smaller whiclt lln' non1lflll)' dP.stined to
pmr in the lme foUicu/(lr pluJJe.
PCOS may set in early adolescent life, but clinically
manifest in the rep•·oductive age with long-tenn complica-
tions such as diabetes, hypenension , hyperlipidaemia and a
cardiovascular disease; this cluster of disorders is known as
the ' X syndrome' or 'metabolic syndrome'.
Endocrinological changes in PCOS are as follows:
l. Oestro ne/£2 level rises.
2. LH level is ra ised over I0 IU/ m L.
FSH level re ma ins no rma l, but FSH/ LH ra ti o falls.
3. SHBG levels fa ll d ue to hypcra nd rogenism.
4. Tes tosterone and ep i-androstened ione levels rise.
5. Fasti ng b lood glucose/ fasting insuli n < 4.5 suggestS insu-
lin resistance.
6. Triglyceride level > 150 mg/ dlrhyperl ipidaemia High
Density Lipoprote ins (HOL) < 50 mg/ d L.
Testosterone > 2 ngl mL, free T > 2.2 pg/ mL (Normal
level 0.2-0.8 ng/ mL)
onnal androstenedione.
Raised Oeh)droepiandrosterone Acetate Sulfate (OHEA-S)
level
7. Pro lactin is mildly raised in 15% of cases.
8. Fasting insulin le,·els are 1-aised (> IOmlU / L in 50-70%
cases of PCOS).
 CHAPTER 24 - BENIGN DISEASES OF THE OVARY 315

of tl1ese girls. Me nstruatio n for t.he initia l few years may be

Rgure 24.2 Bi lateral enlarged ovaries w ith a smooth and thickened
capsule. (Source: From Figure 22.3A . R. Jeffrey Chang: Polycystic
Oiary Syndrome and Hyperandrogenlc States. Jero me F Strauss a nd
Robert L Barbieri: In: Yen & Jaffe's Reproductive Endocrinology: Physiol-
ogy, Pathophysiology, and Clinical Management, 7th Ed ition . Saunders:
B sevier, 2014.)
9. Th)•roid f1m ctio n LeSlS may be abnormal (h ypothyroid-
ism) .
10. Urin ary co rtisol < 50 mcg/ 24 hours.
PATHOLOGY
Mac roscopicall), bo th ovaries are e nlarged. The ovary shows
a thick white caps ule of wnica albuginea. The ovarian sur-
face ma) be lo bulated but the pe rito neal surface is free of
adhesions.
Multiple cysts ( 12 o •· more) o f 2-9 mm siLe are loca ted
pe •·iphera lly along the surface of the ov:u·y gi,•ing it a ' neck-
lace' appearan ce o n ul traSound. These are persistemalt'etic
follicl es. Theca-ce ll h) pe •·plasia and stromal hyperplasia a c-
count for the increase in the siLe of the ovary which
a mounts to than 10 em' in volume. The laparoscopic
view of th e pol)'C)Stic ovari an disease is shown in Fig. 21.2.
CUNICAL FEATURES (Table 24.2}
The pathoge nesis appca•'S to be initiated either in utero or
in earl y adolesce nt life. Earl y adrenarche in the form of
earl y pube rta l ha ir and ca rl)• menarche is observed in some
no rmal, but as clinical fea tures of PCOS develop the cycles
beco me o ligomenorrheic (87%) o r they deve lop a short
pe riod of a me no rrhoea (26%) fo llowed by pro longed or
heavy pe riods (a co mmo n complaint in a majo ri ty of cases) .
Drsme no•·rhoea is abse nt.
ln the reproducti' e )Cars, infertili t) is see n in a numbe•·
o f these women. This is du e to anovulatOI')' q cles. lf a
woma n with PCOS conceives, she d evelo ps ca rbohrdra te
intolerance , diabetes and h) pen ension. Pregna ncy loss oc-
curs in 20o/o -30% cases due to aborti ons.
Hypera nch-ogenism a ppears in the form of acne (30%)
and hirsutism. Facial hair appea rs over the upper lip, chin,
breasts and thighs . Baldness is sometim es noted, but virilism
does not develop.
Histol')' of lifestyle, diet and smoking and exogenous
hormon e adminisu-a ti on sho uld be enquired. Family his-
tory of diabetes and hypertensio n should also be asked.
EXAMINATION OF A GIRL WITH PCOS
Look for
• Obesit)', especially waistJinc . Waist LO hip ratio > 0.85 is
abnormal; 50% of wo me n are obese.
• Bod)' mass index betwee n 25 and 30 - overweight; and
above 30 - obesit)'·
• Thyro id e nlargeme nL.
• Hirsutism and ac ne .
• Hype rinsulinae mia which ma) manifest as acantJ1 osis ni-
gricans (5%) ove r tJ1e nape of tJ1e nec k, axilla a nd below
the breasts; 75% of obese PCOS women have h)'Pe rinsu-
linae mia.
• Blo od pressure in obese wo men .
Peh·ic findings are usually nonnal, and it is not easy to
palpate the enlarged ova.-ies.
DIAGI'OSTIC CRITERIA FOR MAKING A !lAGI'K)SIS OF PCOS
For the di agnosis of PCOS, th e Rou erdam u iteria (2003)
a•·e genera lly followed. It states that at least two of three
crite.-ia should be p•·esent. These c•·iteri a are as follows:
• Oligo/ ame norrhoea, anovulati on , infertili ty
• Hi rsutism/ acn e
• Ultrasound findings (sec sec ti o n ' Investigations')

Table 24.2 Clinical Features of PCOS

Clinical Features Hormonal Sequelae

• • Diabetes (15%)

:
• Young woman level
• Central obesity • t LH levels • cardiovascular Disease (CVO)
BMI > 30 kglcm2 t FSHILH ratio Llpidaemlas
Waist line > 88 em fAndrogens Hypertension
Oligomenorrhoea. amenorrhoea t
Testosterone, epi- androstenedlone, dehydro- Endometrial cancer
Infertility (20%) epiandrosterone Breast cancer
Hirsutism 17-a·hydroxyprogesterone > 300 ng/dl Premature ovarian failure following
Acanthosis nigricans due to Insulin resis- Testosterone > 2 nglml surgery
tance; thick pigmented skin over the nape Prolactin t
of neck, i nner thigh and axilla Sex hormone-binding globulin (SHBG) l
Most androgen come from OVflrl l E:!oestrooe (E 1) ratio
t fasting insul in > 10 miU/l F. glucose/insulin ratio < 4.5
316 SHAW'S TEXTBOOK OF GYNAECOLOGY
DIFFERENTIAL DIAGNOSIS
Although the diagnosis is easy in most cases. congenital or
adult adrenal hypetplasia, Cushing disease and ovarian mas-
cui in i£ing tumottrs should be considered in differemial diag-
nosis especially, if a woman isex u·emelyobese or had features
of virilism. With irregular C)•cles in yo ung girls, hormonal as-
says wi ll idemify a hypo thalam ic-pitu ita t)•-ovarian dysfunc-
tion. Thyroid function testS may be called in for a few cases.
INVESTIGATIONS
Ultrasound is diagnostic of PCOS.
early follicular phase
• It confil"lns the enlarged ov:uies, their sit.e and increased
su·oma. Ov:u·ian volwne will be mot·e tl1an 10
• It shows 12 or more small follicles each of2-9 mm in size
placed peripherally.
• It helps to rule o ut ovarian ttunouc
• It can also show endomeu·ial hyperp lasia, if present.
In a case wi tl1 suspicious adrena l tum our/adrenal hyper-
plasia, abdominal scan, estimation of 17-0H hydroxy-
progesterone level will help in d iagnosis of these conditions.
'lb make a diagnosis of PCOS, ultrasou nd should preferably
be perfonned in tl1e early follicular phase. An increased
blood flow is sometimes revealed on Doppler uluasow1d
Ulu-asound is also used to watch the response of medication
and to decide when to stop lhe drug therapy. Sometimes,
onl) one ov:uy may show features of PCOS. These ovarian
d1anges cannot be relied upon if a woman is on combined
oral pi lis, as tl1ese pills change tl1e ovarian morphology.
• Hormonal stud)' mentioned ea rlier is not performed ro u-
ti ne l)', bm specific hormonal swdics are undertaken in a
woman as and when requ ired. All ho rm onal studies are
not needed as a ro utine.
• Thyroid function testS in an obese woman.
• Laparoscop)' is reserved for a t11erapeutic purpose. ln
most cases diagnosis can be confirmed on uluasound.
Laparoscopy reveals enl:u·ged bilateral ovarian cystS.
TREATMENT
The aims of u·eaunem are as follows:
• To cure a woman with menstrual disorders
• To treat hirsutism
• To treat inferti lity
• To preve nt long-term effec ts in t11e form of X syndrome
in later life.
The lrtYJiment sfwttkt be tailomlto thrreqttiremeu/. oftlte umnan.
• loss. Weight loss of more than 5% of previous
weight alone is beneficial in mild hirsutism; it restores the
honnonal milieu considerabl)'· \\'e ight loss increases the
secretion of tl1e SHBG, reduces insulin level and testos-
terone level.
• Lifestyle changes. Cigarette smoking should be stopped.
It lowers level and raises DHEA and androgen level.
• Hormones to regulate mensu·uation are as follows:
• Oral combined pills (OC)
• OC containing cyproterone acetate or drospirenone
• Spironolactone and OCs
• Ketoconazole 200 mg dai ly reduces testosterone secretion.
Oesu·ogen suppresses androgens and adrenal hol"lnones
(DHEA). It raises tl1e secretion of SHBG in the liver, which
binds witl1 testosterone, tllLLS reducing free testosterone. It
also suppresses LH. It is best given as low-dose combined pills,
having progestogen witl1 lesser androgenic effecL Fourtl1 gen-
eration of combined pills wh ich comains30 meg and 2-3 mg
drosp ircnone (progestogen witl1 an ti-androgenic acti on) are
best for PCOS (Yasm in, J anya, Tarana). IL helps to reduce
acne and further development of hirsutism. It preventS water
retention and reduces weight; it maintains a lipid profile.
• Progestogen may be required to induce menstruation in
an amenorrhoeic woman prior to initiating a ho.-n1onal
C)clical tl1erapy.
• Oral Conu-aceptive Pills (O CP) con r.ain ing C) proterone is
prescribed, if the wom:u1 has hirsutism (see Chapter 9).
• EAorinthine cream topicall)' prevents hair growtl1.
Ami-androgens used are described in detai l in
chapter o n llormone T herapy in Gynaecolog)'· Acne can be
managed by a clindamycin loti on I % or e rythromycin gel
2%, if pustules form. For severe acne, isou·etinoin is used,
but it is ter-atogenic and pregnancy should be avoided whi le
on this medication. The drugs take IIWnlhl before imjntrue-
mmt in Mnttli.!m il noltxi.
Dexamethasone (0.5 mg) at bedtime reduces androgen
production, and is used in some infer·tile women if DHEA-S
is raised abo'e 5 ng/ mL
l nfertilit)'. For managing infertility in a PCOS wom:u1 Cib-
mip11Pnl' is the firlllirw of ln!tllment. It induces ovulation in 80%
and <10%-50% conceive. A 25%-40% abortion rate has
been reported in a PCOS woman who conceives after ovula-
ti on ind uction, it may be due 1.0 a corpus luteal p hase
defecL The re is an increased ris k of ovarian hyperstimu la-
tion in a woman with PCOS when ovulation is induced.
Clomiphene with dex:unethasone improves ferti lity rate. ln
a resistant case, tamoxifen 20-40 mg daily for 5 days or
letroLOie (2.5 mg daily for 5 clays or 20 mg single dose on
day 3) can be trie<l F:tilure after the abo'e therapy calls for
FSH, LH or GnRH :u1alogues tl1erapy. A woman wilh insulin
resistance requires. in addition, metformin.
These women also have raised level of hornOC)Steine in
which case N-acetyl-cysteine (NAC) 1.2 g may be added to
clomiphene therapy. NAC is a mucolytic drug and an insu-
lin sensitizer.
Meifonnin Me tformin treatS t11 e root ca use of PCOS, rec-
tifies e ndocrine and metabolic fun ctions and im proves fer-
ti li t)' rate. It is used as an insulin sensiti zer. It reduces insuli n
level, delays glucose absorption and production of glucose
in liver (liver neoglycolysis). It also improves peripheral
utilitation of glucose; Liver :u1d renal function testS should
be perfonned prior to metfonnin administration.
Besides reducing t11e level of insulin, metfonnin also re-
duces the le,el of total and free testosterone and increases
the SHBG. Ovulation occurs in 70%-80%, and pregnancy
in 30%-40%. It does not catLSe hypoglycaemia and does not
red uce weight. It is contraind icated in a hepatic and rena l
disease, and catLSes gastrointestinal diswrbances and lactic
acidosis. The refore, starting with 500 mg da il )', the close is
grad uall )' increased to 500 mg tluee tim es a day. Metformin
should not be adm inistered for more t11 an 6 months. lf
metformin is contraindicated, acarbose 300 mg daily can be
 CHAPTER 24- BENIGN DISEASES OF THE OVARY 317

used. OCLequiLide pe ptide ho rmo ne secreted by hypothala-
mus which inhibits the growth ho rmone and insulin has
also bee n used to Lrea tth ese cases. It enhances ovulation in
d o miph ene-resistan t infertility.
Latel). to improve the pregnancy rate in PCOS, instead
of metfo •·min. so me ID naeco logisLS have smned us ing
Nacet) l qste ine with micronuu·ien ts. This reduces the ho-
mocysteine Je, el. The mi cronu trie nLS include
minerals, chromium, selenium, inositol and foli c acid (Ova-
ca re, one ta blet twi ce da ily) .
It u importan t to infonn tltl' potimt tlwt PCOD can recur.
Disadvantages of surger y are foDows:
• SL1rgery invo lves a naest11 esia a nd la parosco py.
• Adh esio ns ma> fo nn posto perative ly.
• Pre ma ture ovaria n failu re due to destn•ctio n of ovarian
tissue if cautel') is used. Fo r this reaso n, many now prefer
a simple puncwre o f the cysts.
0,
Surge ry is not a prefen·ed u·ea un ent for management o f
PCOS as it may result in a d ecrease in ov:u·ian reserve :md
adhesions might fonn around ovaries.

SURGERY
Surgery is rese1ved for th ose in whom

• Medical th empy fails

• Hype•'Stimulati on occu •'S Perform ultrasound
• Inferti le women Abdoml nalfTVS
• Previous pregnancy losses

Surgery comp rises laparoscopic chilling or p uncture of

not more tl1an four C)'SLS in eac h ova ry eithe r b)' laser or b)' • Clear cyst >4cm
unipolar elec u·oca ute ry (Fig. 2t1.3). • Size <4cm • Multilocular
Surge•')' resto res endocrine milie u and improves ferti li ty • Unilocular cyst • Thick septae
for a period o f 6-12 mo nths. Pe lvic adhesions ca used b)' • Associated ascites
surgery may reduce fe rti lity rate . Hydroflotation reduces
adhesion formation.
Advantages of surgery are as follows: Likely to be benign Perform serum Ga-125
functional cyst
• Tubal testin g with chro motu bation can be performed (Follicular/Lutein)
simu Itaneousl).
• Otlle r causes of infe rtili t), i.e. endo metriosis looked for.
• One- time treatment. Repeat ultrasound
• lntense and pro longed monitoring not required. after 8 wks
• Cost-effective compared to In-,·iu·o Fe rtiliLati on (LVF) . Benign Suspect ovarian
• Reduces androgen and LH pro ducti on cystadenoma malignancy
• Following surgery, single o' ulation occurs with drugs, and
hyperstimulation and multiple pregnancy are avoided.
• Ovulation occurs in 80%- 90% and pregnanq• in 60%-70%. PREVENTION
Witl1 tl1 e kn owl ed ge that PCOS has long-tenn adve1'Se
effectS (threefold) on tl1 c health of t11 e woman, such as
development of di abetes, h ypertensi on, a cardiovascular
disease and hype rlipidae mi a, e ndom etrial cancer, it is now
s uggested that PCOS sho uld be adequately u·eated at th e
earliest. These wom e n should be observed for these
a ilments in late r life . Obcs iL)' in ado lescenLs needs to be
avo ided and correc ted. LifeSL)•le changes sho uld be reco m-
mended.

Rg ure 24.3 Laparoscopic ovarian drilling. (Sou'oe: From FtQU'e 2.
SU'esh Kint In: Polycystic ovary diagnosis and manage.
ment of related hfertil«y practice points. Obstetrics, Gynaecology ard
Reprodu::tiw Medcine. \A)! 22(t 2): 347--353, 2012.)
KEY POINTS
• Polycystic ovary is a mtdtiS)Ste m endocrine disorder
with feawres of oligomenorrhoea, anovulation, obe-
sity and hirsutism. It is a disease of young women.
• PCOS originates fro m insulin resistance; hyperinsu-
linaemia and o besit) are linked.
• PCOS calLSes o ligome norrh oea, hirsutism and infer-
tilit) .
• Ultrasound is th e go ld standard imesligalion in the
diagnosis o fPCO . Ho nnona l Sllld) is pe rfo nned only
if required.
318 SHAW'S TEXTBOOK OF GYNAECOLOGY
• Decrease in weight and change of lifestyle improves
the condition co nsiderabl).
• Surgeq is perfo rmed if medical therapy fails and to
impro'e ferl.ilit) rate.
• Follow-up sho uld be e nsu red to avoid late sequel such
as diabetes. h)penension , a cardiovascular disease
and h)perlipidaemia.
• Raised £ 1 le,el, Ll I le, el and a ndroge ns with low or
nonnal FSH charactet-iLe this S) ndrome .
• Clomiphene remains the first line of treatmem for
infertility in PCOS. Resistant cases require lapaw-
scopic puncwre or gonadotropins and metfonnin.
SELF-ASSESSMENT
I. Describe th e clinical feawres of PCOS.
2. Disc uss the ma nage me nt of PCOS.
3. Disc uss long-term seq ue lae of PCOS.
SUGGESTED READING
ACOC Commiuc-c on Practice 13ullctin s-Cyn ccolof,'Y· ACOC Practice
Bulletin 1o. 108: Polycystic ov.ory >yndrome. Obstct Cynccol 2009;
114:936.
American College of Ob.>tetricians and GynecologistS O:nnrniLLee on
Gynecologic Practice. Coonmitttoe Opinion No. 477: the role of the
ob.>tetrician-gynecologbt in the early detection of epithelial ovarian
cancer. Ob.>tct Cynecol 20 II: 117:742.
American College of Ob.>tctrician.> and ACOC Practice
Bulletin. Management of adnexal ma>>t'.>. Obstet 2007;
110:201.
Bonnar J. Recent Ad.-ance.> in Ob.>tctric.> ;u1d Cpuoet"OI<>gj Vol 19:121,
1995.
Bonnar J. Recent Ad\ance.> in Ob.>tctriC> and C,naecology 21: Ill,
2001.
Fauser BC. Tartalris BC. Rebar R\\', et al. Con .en>& IS on women 's health
aspectS of poi).C)'>tic oval") .>yndrome (PCOS): the Amsterdam
ESIIRE/ ASR.\1-Spon;,on:d Srd PCOS Consen>&IS Workshop Croup.
Fcrtil Steril 2012: 97:28.
Goodman NF. Cobin Rll. Fuucn,eit \\', et al. American association of
clinical american college of endocrinol<>j.,')', and
andrQ!,<en excess and pco> ;,ocicty di.case state clinical Guide
to the best practic<-'> in the C\'!luation and treatment of polycystic
I. Endocr Pr.tct2015; 21:1291.
Rou<erdarn ESIIRE/ ASRM-Sponsorcd PCOS Consensus Workshop
Croup. Re vis.c-d 2003 con>cn>IIS on dias.:nostic criteria and long-term
health risks related 10 polycy.>tic ov.try .>yndrome. Fertil Steril 2004;
81:19.
Studd J. ProbttL..S in Ob.>tetrics and Cyn accoloj.,'Y 11:851, 1994.
Studd J. ProbttL..S in Ob.>tetrics and Cyn accoloj.,'Y Vol 16:227, 2005
 Benign Diseases of the Vulva
Introduction 319 Vulval Dystrophies 322
Benign Diseases of the Vulva 319 Cysts and Neoplasms 325
lnAamrnotory lesions 319 Key Points 325
Ukers 321 Self-Assessment 325
Atrophy 322
INTRODUCTION
A \'3.-iety of developmenLal, trophic, innammaLOry, allergic
and neoplastic diseases can occur in the vulvar skin and iLS
appendages. 1l1e common n•lvar diseases affecting Lhe
vulva are as follows:
t. and dennis. Common dermatological disorders,
a lle rgies, infections, naevi, d)'Siroph ies, ulcers and new
growll1s.
2. Sltin r•fJfJendages. Folliculitis, sebaceous cysLS, hid radeno-
mas, Bartholin's cyst or abscess and Paget disease.
3. lldj(ICtml stmctures. Li pomas, fibromas, haemangiomas,
vadcosities, carcinomas, sarcomas and endometriosis.
4. DevelopmmJaL Vulvovaginal C)Sts, imperforate hymen,
vulval anus and intersex problems.
5. Homw11aL Vulval au·ophy in menopausal women.
• Despite ll1e fact that vulvar diseases are not tmcommon,
and the \ulva is easily accessible to clinical examination,
ll1ere is oft.en a delay in ng at diagnosis dLte to delay in
seeking medical advice out of a sense of modesty wh ich
prevails and pre,·e ms the patielll from seeking early advice.
• T he symptoms most commonly produced by vulvar
lesions are excoria ti on, swelli ng, ulceration or altered
pigmentation wh ich may be accompan ied b)' itching,
pain or bleeding. An accurate diagnosis can usually
be made by inspection, palpation, smear and culture
examination and biopsy.
BENIGN DISEASES OF THE VULVA
Benign conditions of the vulva may be classified as follows:
• lnjllmmwtory• lesions. (a) Skin diseases, (b) sex uall)'
tcd diseases, (c) contact vulviLis and (d) vu lvar infections
associated wi ll1 vaginitis.
• Ulcer.,. (a) Simple acute ulcers, (b) (c) 1raumatic
ulcers and (d) malignant ulcers.
•
• D)Strophies.
• Crsts and neoplasms.
INFLAMMATORY LESIONS
SKIN INFECTIONS
INTERTRIGO AND FOLUCULITIS
I ntenri go and fo lliculitis are common I)• seen in obese
women, using tight garments whi ch prevent evaporation
of the moisture from tllese parts leading to chaffing fol-
lowed by bacte•·ial and fungal infection. Pyogenic bacte-
ria, sLaphylococcus can cause folliculitis. The treaunem
involves weight reduclion, use of loose undergarmenLS,
ad,·ice •·egarding personal hygiene, tLSe of a bland soap
and an unmedicated protective d1LSting powder. Anlimi-
crobial ointments may be tLSed iniliall) to control second-
ary bacterial infection. Occasionally, oral antibiotics may
be needed. Local app lication of 0.5% hydrocortisone
o inunentthree to four times dail)' he lps LO re lieve itching
in intertrigo.
TINEA CRURIS
Tinea cruris or ringworm of the thigh, vulva and groin is
not infrequent!)' encountered in the tropics. The causative
organism is TriclwfJh)'I011 rubru11L It tends to be chronic and
frequently •·elapses after u·eaunenL The characteristic
e11 tJ1 ematOlLS circumscdbed areas are found in the skin
flexures of ll1e ll1ighs and outer aspect of the labia. A fine
papular rash is LLSually seen sharply demarcated from Lhe
adjacent healthy skin. Patients experience intense itching;
scratchin g leads to superimposed infec tion. Treatment
co nsists of metic ulo us hygiene, t11e use of freq uently
chan ged light underclothes, dustin g will1 a fungicidal
powder or app lica ti on of a fungicida l o illlment co nLaining
benzoic and salicylic acids. Oral ad ministra ti on of griseo-
fulvi n is also high ly effective.
319
320 SHAW'S TEXTBOOK OF GYNAECOLOGY

THREADWORMS
ven11icuktm may seco nclalily infect the vulva from
t11e anorectal area, particularly in d1 ildren. The diagnosis is
easily established on sLOol exa minalio n. The treaunem is
with anthelmintic drugs such as pipem2ine o r mebendazole.
VULVOVAGINITIS
Vulvovaginitis in children may be nonspecific due LOa for-
eign body accidentally inu·oduced in the vagina or due to
threadwonn infeCLion. Gonococcal and fw1gal infection
may rarely be due to sexual abuse or contamination. Ban.ho-
linitis is mostl y gonococcal but other cocci may also be
responsible, and pr·e sent with a painful and tender swelling
over the labia m<jjora (Fig. 25. 1). Recurrent ba•·Ll10linitis is
not uncomm on. Bartl1olinitis needs antibiotics.
BARTHOLIN'S ABSCESS
Bartl10lin's gland is mainl)' infec ted by gonococci, though
otl1er nonspecific orga nisms may be involved. T he woman
presents with a painfu l vul val swell ing and p urulen t discharge.
T he swell ing is inflamed and painful. It requires d rainage
under anaestl1esia. T he pus sho uld be culwred and approp li-
ate an tibiotics instituted. After dra inage, Ll1e area heals by
gran ulation. It has a propensity fo r frequent rec urrences.
PSORIASIS Figure 25.2 Psoriasis of the vulva. Note the extent of the lesion
extending laterally to the Inner thighs and posteriorly to Involve the
Psoriasis (Fig. 25.2) affects th e vu lva l skin causing plaques of
perianal skin and cleft. (Sowce: Danielle Mazza \Nomen's in
scaly well-defined patches. The silvery scale can be easily General PractK:e. Genital tract disorders. Churchil Uvngstone, 2011 .)
scraped off to reveal a red papular underlying surface. The
aeliology is not known but the condilion responds satisfac- and causes lymphatic oedema of the legs and e lephantiasis of
tOrily to u·eaunent with local ste roids. Psoriasis is also seen the legs and vulva. It is prevalent in u·opical co untries.
characteristicall) on the e lbows and knees. A search fo•·
lesio ns at these sites helps in establishing the diagnosis. CONTACT VULVITIS
FILARIASIS Co ntact vuhitis ofte n represents a local reaction to under-
garments made from S)lllhetic mate•ials, to soaps and
This is caused by th e \\QJ·m Il'udtt'l'l'ria bmu:rofti which is spread detergents, to chemi cals (deodora nts) and occasionally to
by mosquitoes. The parasite reproduces in the lymphatics medica ments and indusuial pollutants. Examination reveals
oedema and reddening of the vulvar skin and vestibule
without accompanying vaginitis. The acute S)'mptoms can
be controlled by administering oral antihistamines, applica-
tion of local steroidal oinuncnts or o·eams, using couon
underwear, advocating Ll1 e usc of bland soaps and scnlpu-
lously avoiding offending drugs.
PRURITUS VULVA
Pruritus vulva is an itchi ng sensation witl1 an intense desire
to scratch Ll1e vu lva. Vulvar is no t Ll1 e sa me as pru-
Incision ritus, but it is a painful cond ition assoc iated with burning
sensation. Pro longed or severe pruli tus ca n even w all)' lead
to vulva l irritation Ll1ro ugh sc ratch ing and abrasions.
Causes of Pruritus Vulvae
There are several causes, though o ften it may be difficult tO
elucidate the cause, and the treatment becomes empirical.
Some of t11e kn own aetio logical factors in pruritus v1.1lva are
as fo llows:
• Vaginal due to Triclwmonll.s vaginali.s o r fungal
mo nilial infectio n acco unts for 80% of all cases of pruri-
tus vulva. T he vagi nal discharge ma)' be slight but causes
Rgure 25.1 Barthollns gland cyst. (Socrce: Wharton, LA. Gynaecol- ime nse pru.-itus within the intro itus as well as on the
ogy with a Section on Hlna/e Urology, 2nd ed. Philac:lephia: WB vulva. Purulent discha rge on the other ha nd, produces
Saunders, 1947.) irritation rather t11an pnu·iws.

• Genera/disease. For example, cl iabe tes,j aund ice, uraemia,
cirrhosis, haemochromaLOsis.
• NutritionaL Iron deficiency anaemia, vitamin A and 8 12
deficienc). ach lorh)clria.
• Gmeraliutl or localiLecl dermatitis, such as psoriasis,
ecLema.
• Allergy to drugs, contact dermatitis, allergy to soap, deter-
gents, antiseptics, phenol, dusting powder, deodorants,
wea.·ing tight S)nthetic undergannems, imperfecLiy
1insed underclothes.
• Cervical conditions such as cervicitis; erosion produces
excessi'e mucoid secretion which causes vulval itching.
• Vul:valjxmJJitic infectiOIM such as pecliculosis, scabies.
• Vul:val tliltXIltl such as condyloma acum inata, gran ulomas,
Behcet syndrome, Paget disease and vulval cancer.
• Anr1l. T l11·eadwom1 infestation.
• Uriufi')'. Baci ll ulia, acidic urin e, inco ntin en ce and glycos-
tuia, bladder fiswla.
• Allerg)' to co ndoms or d iap hragms, spe rm icidal agen ts.
• Pl)'Chologi.cal. Psyc ho ne urosis cl ue LO su·ess. T he sc ratchin g
hab it may develop fo llowing sex ua l fms u·atio n, feeli ng of
gui lt, ovennaswrbatio n o r o the r sex ual p rac tices.
• Otnmic vul:vt1l of vulva l skin such as le ukop lakia,
lichen sclerosis, kra urosis vulva and Paget disease.
• Rad iation vu lvitis.
• Cli nicall)'• the woman develops an ite hing sensatio n an d
begins to scratch the vu lva. Persistent and prolonged
scratching can lead to abrasions, inflammation and irrita-
tion with soreness. The patient may lose sleep because of
itching and becomes irritable.
Treatment
The cause of pruriws should be investigated systematically
a11d treated with amihistamines and sedation may allay L11e
S) mptoms. H) clroconisone ointment/ steroid o inunem
locally or £UJ'ax oinunem often helps. Oesu·ogen crea.n is
useful in kraurosis vulva due to menopausal changes.
Fungal infection is treated with n)statin cream or one ofthe
imid;uole group of antifungal drugs such as m iconazole,
econaLole, clou·imaLOle, terconazole or oral a11 tifungal
drugs such as fluconarole/ keLOconazole or itracon azole.
Oral metronidarole is specific for Tridtom01UIS infection. If
tl1e skin is h ard and te nds to crack, a crea m made of zin c
oxide ( 10 parts) and olive oil (60 parts) or cod liver oil
helps LO softe n the skin . Injecti o n of absolute alcohol subcu-
taneo usly 0.5-1 mL breaks the sc ratch hab it, but if given
very s upe rfi cia ll y o r in deep tiss ues or in excessive amo un t,
it may cause s lo ughing of the tissues. Ba ll's o pera tio n, now
rare!)' pe•fo nned, co m prises d ivisio n of cuta neo us nerves
b)' a circ ular inc ision aroun d the vu lva. T he effec t lasts
for 3-6 months. Latel)'• interfPrrm is used as an o in tm e nt
(hu man leucocyte interferon) with 90% regress io n in sym p-
toms; Applying <1000 uniLs/ g o in unent fo ur times a day for
5 weeks is recommended. Systemic inu·am usc ular interferon
2,000,000 units daily for I0 days has yielded 90% cure rate.
Fever. m)algia, headad1e are Lhe side effects with t11e sys-
temic use of illterferoll.
ULCERS
Traumatic ulcers are easily recogniLed by t11eir appearance,
comused edges and history of hun. 1i·eaunem comprises
CHAPTER 25 - BENIGN DISEASES OF THE VULVA 321
local app licaLions of antib iolic o inunem to prevent infec-
tion and administration of oral analgesics to relieve pain.
• Tuberculous ulcers appear as Lhin serpiginous ulcers with
LLndennined edges and a Lhin )ellowish discharge at t11e
base. Biops) from the eclge reveals L11e typical, tubercu-
lous granulomatous lesions showing the presence of
LaJ1ghans t) pe of giant cells.
• Venereal diseases such asS) phi lis, chancroid and granu-
loma inguinale present with ulcers on the ' 'ulva.
• Vulval cancers present as nonhealing ulcers witll raisecl
evertecl edges or as growths which breakdown and
ulcerate.
• Vulva l ulcer·s are classified as fol lows:
• Primary disease
Fungal infection, streptococcal infection , syphilis,
T B.
• Cha ncroid, Be hcet disease, t raum ali c ulcer,
a moebiasis, lymp hogra nulo ma ve nere um, granu-
lo ma in g uin ale.
• De •matiti s
• Liche n sclerosus, lichen planus, C ro hn d isease,
a llergy to d n•gs.
• Viral infec tion, herpes simplex (Fig. 25.3 )
Imm uno logical.
Vulvar intraep iLhe lial neoplasia (VLN), Paget
disease, malignant ulce•:
CUNICAL FEATURES
Mrutulcen art' pai11jul except 11Utlig'tumtulcers. P111ritus if presem
suggests infecti'e condition. General and systemic examina-
tion will reveal general or p•ima•) skin lesion. Serological
tests, culture and biops) confirm the nature of the ulcer.
BEHCET DISEASE
Behcet disease is associated with oral and ocular ulcers. lt is
a chronic inflammatory multis)Stem disorder of unknown
aetiology, so the u·eatment is nonspecific. Co•·ticosteroid
cream helps.
Figure 25.3 Herpes simplex of vulva
322 SHAW'S TEXTBOOK OF GYNAECOLOGY
ATROPHY
Atrophy occurs ac; a r10nnal consequence of deo·eased oestro-
gen levels after menopause. The labia become flatter and the
skin hangs loose!) due to loss of subcutaneous fat. The epithe-
liwn is pale. smooth and thin. The introitLIS narrows do\\11.
Au-ophic changes can be prevented by timelyadminisu-ation of
oesu·ogens in the form of local creams or at times by systemic
adminisu-ation. Howe-.er, once the tissues undergo au·oph)\
these changes cannot be r"e\ ersed by the use of hormones.
Women who undergo menopause after r-adiation ther-ap)• or
following surgical casu·mion appear to be more pr-one to this
change. The condition is akin to lichen sclerosus.
VULVAL PAIN SYNDROME
Lynch introduced th is term in 199 Iro describe women
unp rovoked 'chro ni c vulval d iscomfo r1. of b urning, stinging
and irritation' in the abse nce of any visible ab no rmali ty in
tl1e vulva, or raw area aroun d the vulva.
• Several causes have bee n imp licated and it is at times
difficu lt to e lucidate and treat t11e cause. Urinary oxa late
excretion and deficient im mune S)'Stem are the probable
causes. The u·eatment remains empirical. Some of the
known causes are as fo llows:
• Skin infection - Human papilloma virus and ftmgal
infection, herpes simplex infection.
• Organic disease
• Autoimmune disease
• Iatrogenic- Topical agents, deodorants
• Irr·itants and allerro
• Tense le-.<ator ani muscles
• Ps)chological
• Ur·inar·y oxalate causing vulval bur·ning
• Hor·monal - Low oesu·ogen le-.·els in body and use of
oral conu-acepti,es
• Pelvic floor muscle tension
• Vuh<al vestibulitis.
• The woman \\ith chronic vulval pain is usua lly 20-
40 yea r-s of age.
VESTIBULITIS
Vestibulitis ca uses pai n o n touch, local tenderness on pres-
sure and ery tl1e ma in the vestibu lar regio n. A woman
of chi ldbearing age ma>• co mp la in superficial dyspare unia.
Intensity of pain va ries fi·o m mild to severe d isco mfort.
DYSAESTHEllC VULYODYNIA
D)•saestltetic vu lvodyn ia is a cuLaneo us dysaesthesia which
causes nonlocalited vu lval pain, un provoked constant
netLrologic pain in t11e vu lva and pe rianal region. A btu·ning
ache similar to post11erpetic pain occurs trsually in
perimenopausal and posunenopausal woman; tlterefore,
history of dyspareunia is rarely reponed. A woman is often
psychologicall) disturbed and anxious. This affects nonnal
activit). ,,<a) king. social life and sexual fw1ction.
MANAGEMENT
• Eliminate and treatLhe under!) ing cause.
• Thirty per cent ha'e remission in a time.
• Medical -Topical lignocaine I %-2% may he lp, so also
stet-oid creams.
• Interferon gel cures only 20% of the cases. Amiuipt:yline,
uicyclic anLidepressam for neuralgic pain in a dose of
10 mg dail) is ghen, graduall) increasing to 60 mg daily as
reqttired. The drug causes ell") moutl1, weiglugain and has
a sedative effect. The woman should not conceive or
breastfeed while on tltese drugs. Other drugs are Tegretol
(car-bamuepine), in severe cases, gabapentin 300 mg
orally. ln a SC\'ere case, a \\Oman ma)• need vestibulectomy.
It consists of excision of the horseshoe-shaped vestibule
and inner labial fold and covering the raw area witl1
\<aginal mucosa dissected fr-om the posterior wginal \\<all.
WLVAL DYSTROPHIES
Now known as nonneoplastic epithelial disorders, vulvar
dystrop hi es represe nt a s pcc u·um of atrop hi c a nd hyper-
trop hi c lesions caused by a variety of co nditi o ns resulting
in c irc umscribed or d iffuse 'white lesions'. T hese lesio ns
a lso often s how diffe rin g microsco pic pa tte rns varying
from mi ld d)'Splas ia to fran k ma lignancy in d ifferent parts
of t11 e same lesion. Mu ltip le b iopsies are the refo re neces-
sary, and the to lu idine b lue test helps in iden tifying areas
of maximum epithelia l hyperac tivity that are most sui tab le
for biopsy. A variety of causes are implicated in tlte devel-
opment of vuh<a l dystrophies, such as trauma of scratch-
ing, allergy. folic acid and Br2 deficiency, chronic infec-
tion, metabolic disorders such as diabetes and tllyroid,
immtmosuppression and autoimmune diseases such as
systemic luptrs eq thematosus (SLE).
• Cun·ently used histological classification of \'uh<ar dysu·o-
phy Cfa ble 25.1) is based on the recommendations of the
International Society for the Study of Vuh<ar Diseases.
The histological classification is more meaningful in the
management tltan relying on the gr-oss mor·phology
which may not be helpful in the diagnosis.
HYPERPLASTIC DYSTROPHY (SQUAMOUS CELL
HYPERPLASIA), PREVIOUSLY KNOWN AS
LEUKOPLAKIA
Chroni c irritation or chronic vulvovaginal infection ofte n leads
to benign epitl1elial tl1icke ning and hyperkeratOsis. Some of
these wo men suffer fmm auto immune such as diabe-
tes, t11yroiditis, ac hlorh)•cl tia. During the acute phase, tl1e le-
sions ma)' appear red and moist d ue to seconclar)• infection. As
epitl1elial tl1ickening develops, vulval skin appears as raised
wh ite lesion which may be circumsc ribed or diffuse; it looks
rubbery. It may involve any par1. of the vulva, perianal area,
perineum or skin of t11e adjacent thighs. These lesions have
also been designated as lichen simplex cl1ronicus or neuroder-
matitis. Patients suffer fr-om pruritis, discllarge and
dysparew1ia (Fig. 2.'i. l). The woman is often premenopausal.
The lesion begins as white pOI)gonal papules whicl1 coalesce to
fonn plaques giving tl1e appear-ance of being ' splashed with
white wasb'- fissures ma> develop due to so-atclling.
• Microscopic examination r·e-.·eals in·egular clown growtl1
of the rete pegs deep into the dennis. The cells of the
 CHAPTER 25 - BENIGN DISEASES OF THE VULVA 323

Table 25.1 Vulvar Dystrophies

Type of Dyst rophy Hyperplastic Lesions Lichen Sclerosis Mixed Dystrophy

Gross appearance White/ greyish white, focal Small bluish-white papules that Combination of both
or diffuse coalesce into white papules

Symptoms Pruritus Pruritus, dyspareunia, dysuria Combination of both

Feel on palpation Firm , cartilage like Thin, parchment-like Combination of both

Histology Thickened keratin with Moderate hyperkeratosis with
proliferative epithelium - epithelial thinning. Loss of rete
Acanthosis hyaliniZation in dermis

Pathophysiology Reactive phenomenon Unknown

from irritation

Method of diagnosis Biopsy Biopsy

Treatment Fluorinated corticosteroids Testosterone cream

Rgure 25.4 Leucoplakla of the vulva showing scratch marks and

ulcerations. (Socrce: Novak Eml Md Novak Edmund, G}flaeco/ogic Figure 25.5 Hypertrophic leucoplakla of vulva showing irregular
and Obstetric Pathology, 4th ed., Phladelphia and London: WB down growth of papillae, abnormal basal cel ls and superficial kerati -
Saunders, 1958.) nization.

basal laye1'S show ac tive mitosis, th e prickle cell layer is
increased in th ickness, a nd the re is a heavy acc umul ation
of keratin on the surfu ce. The dermis reveals infiltration
with inflamm atory cells (Fig. 25.5). About 10%-30% of
these cases deve lop ma ligna nt change. Initial treatment
with oestrogens is worthwhi le . Oral adm inistratio n of
0.625 mg of conj ugated eq uine oes u·ogen (Pre marin)
helps to contro l vu lva l pruritus. Bland local medicaments
such as Cala mine lo tio n, cro t.amine or zinc oxide paste
are soothing. In case of sus pected superadded inflanuna-
tion , ste ro id oinunent containi ng I % hydrocortisone,
betame tJ1 aso ne, fluocino lo ne with or without antimicro-
bial age nts such as neo myc in, Soframycin {antibiotic),
mico nazo le or chiniofon (antifungal) are useful. A pre-
scliption fo r a mild sedative a t bedtime ensures adequate
rest, helps recover) a nd preve nts pa tients from scratch-
ing. Two pe r cen t lignocaine o inune m a lso re lieves pain.
Clobetasol 0.05% o ·eam is most useful.
• ln case ma ligna ncy is susp ected , multi pie biopsies
from suspicious areas a re manda to ry. Lesser degrees
of d ysplasia 1·equi re observation , but in more
advanced lesions, surgical excision is indicated to
relieve prurillls as well as to re move the potential
s ite of malignanC)'· Colposcopic inspec tio n using
ace ti c ac id and to luid ine b lue is desirab le . One
percent aq ueo us to luidin e b lue is app li ed and was hed
off after 1 minute with 1% aceti c ac id. Blue areas
are biopsied.
LICHEN SCLEROSUS (ATROPHIC DYSTROPHY)
With ageing, endoge no us oestroge n dec reases and atrophic
changes in the vulvar skin and subde nnal tissues appear
some years afte r advanced atro ph) o f the vaginal mucous
membran e. There is co ntracture o f tJ1 e vaginal introitus,
and ilie vagina l mucous me mbrane beco mes thin and is
easily traumali t.ed (Fig'> 23.() and 25.7).
• Goolama l e t a l. showed tha t this lesio n is linked
to a utoimmune diseases in 40% o f cases a nd is seen
324 SHAW'S TEXTBOOK OF GYNAECOLOGY
Figure 25.6 Lichen sclerosus et atrophicus of the vulva (SOU"ce: Juan
Rosai. Rosai and Ad<errm1's Sugical Pathologf. Female reproducti\19
!>)'stern. Mosby, 2011 .)
Figure 25.7 Lichen sclerosis . Histology shows hyperkeratosis, but
the epidermis is thinner than normal. The most striking feature of
lichen sclerosis Is the presence of a hyaline zone In the superficial
dermis . This is the result of oedema and degeneration of the collagen
and elastic fibres of the dermis. (Source: Hacker NF, Gambone
JC, Hebel CJ, Hacker and Moore's Essentials of Obstetrics and
Gynecology, 5th ed. Philadelphia: Elsevier, 201 0.)
in diabetes, th)roid disorders, SLE syndrome and
pernicious anaemia. Antith) ro id antibodies are often
detected.
• It is usuall> a disease of e lde r! )' women older than
65 >ears of age; genetic and familial tendency is also
noted. During the acute phase, the lesion may appear
dusky im ohing the vulva, perineum and per·ianal area
in an hour-glass pattern (figure-of-eight). The skin is
papery thin and wrinkled. As the disease progresses,
the labia minora blend into the labia majora thus
causing a narrow introitus. Although the lesion is
essen tiall) atrophic in lo ngsta nding lesions areas
of dysplasia and malignanq ma> occur in I %-5%
of cases. Longstanding Lichen scle rosus is a well-
recognit.ed predisposing factor for developmem of
carcinoma ,•ulva. All suspicious areas must be biopsied.
The chief S) mptoms are intense prur·itus, d ys uria,
d yspareunia and local discomfort. Biopsy reveals
hyperkeratosis, thinning of the epidermal epithelium,
flattening of the rete pegs and hyalinit.ation of the
tissue beneath the epidermis. Treatment with bland
creams is recommended. The condition responds well
to local application of steroids, such as oestrogen
cream and testoster·one propionate.
• Two per cent testosterone oinu11ent in a whi te petrole um
jell y resolves pruritus in 6-8 weeks. Andractim gel (5 g)
dose can be grad ually reduced beca use of the risk of
virilization and acne. About 80% response is reported.
Testosterone by converti ng to d ih yd roteswste rone brings
abo ut favo urable skin changes.
• Excision of the areas to re lieve pr uriLUs is often
fo llowed b)' recurre nce of th e lesion aro und the
excised margins. Hypertrophic changes may fo llow,
for which biopsy is advis.'lb le. Lichen sclerosus is
now treated with 0.05% clobe tasol (Dennovate)
ointment for 8-12 weeks followed by Trimovate
(clobetasone plus n)Statin and oxytetracycline) to
maintain S)lnptomatic relief.
• Oesu·ogen and testosterone creams are useful in older
women. Vitamin A is useful, and reti no id analogues have
been administered. Twenty to thil'l)' milligrams aciu·etin
given for I montJ1s is effecti'e in 60%-70% of cases. It
can cause ell") ness of skin, e>e irritation, hair loss and
mya lgia. Its teratogenic effect prevents its use during
pregnancy, and you ng women should use contraceptives
to prevent pregnancy. lntralesional intPr.frrrm is successful
in some cases.
• It must be emphasit.ed that before medical treatment,
multiple or selective biopsy is mandatory to rule out ma-
lignancy or preinvasive lesion, as 5%-10% ofthese lesions
show concomitant malignancy or develop these changes
in d ue course of tim e. Pap smea r is also desirable to
check on tJ1e cervical histology.
• S·urgery is rarely empluyed lmd is not. t ll.mble. Fresh lesio n may
appear in tJ1e vicin iq• of the excised area. Ski nn ing vulvec-
tOmy, cryoablati on and laser ab lation and vulvecwmy in
o lder women have been employed.
• The treatmenL th e refore, is d irected LOwards symp-
tomatic re lief, preve nLi ng ca nce r by reg ul ar fo llow- up
and improving the appearance of the vul val skin. This
indicates the ne ed for prolonged and continuous
follow-up.
• Mixed variet) shows histological changes of hypertro-
phied as well as atrophic d)Stroph) at different sites in ilie
same lesion. The treatment is also based on predomi-
nance of t)pe of lesion seen.
• De nervation ofvulva b) ' Me ring' procedure with a curved
incision around the vuh'<lup to tJ1e subcutaneous tissue is
sometimes recommended.
 CHAPTER 25 - BENIGN DISEASES OF THE VULVA 325

CYSTS AND NEOPLASMS

VULVAL CYSTS
SEBACEOUS CYST
Sebaceous cyst resul ts from b loc kage of the duct of the
sebaceous gland and contains c heeS)' ma terial. IL is com-
monly seen between the lab ia a nd lab ia minora and
ca n get infec ted.

BARTHOLIN'S CYST
Banholin's C)SL is formed when its duct is blocked either
by infla mmation or by inspissated secretion. It appears as
a swelling on Lhe inner side of thejunCLion of Lhe ame,;or
two-thirds wilh the pos terio r o ne-third of Lhe labium
maju s. A small cyst remains asymptomalic, but a larger one
bulges across t11e vaginal inu·oiws and ca uses dyspareunia,
disco mfort- it may get in fected, thus needing e xcision or
ma rs upi a li zation. T he Iauer is easy to perform, causes
less b leeding and retains th e fun c ti o n of t11 e g land. T he
in cisio n runs along the long ax is of tJ1 e lab ia majora away
from t11 e introitus to avoid a painful scar and d yspareunia.
The cavity is scraped, h aemostasis secu•·ed and the edge
SUllll"ed to t11e ski n. The cavity shrinks and heals by gra nu-
lation tissue.
CYST OF THE CANAL OF NUCK
C)St of the canal of Nuck is a re mna m of the processus
vaginal is beneath t11e amerior pan o f the labia minora.
VULVAL NEOPLASMS
FIBROMA AND UPOMA
a nd li poma are occasio nall)' seen in vulva. They pres-
ent as pedtmctuated benign swelli ng that ca n be easil y excised.
HIDRADENOMA
Hi dradenoma arises in t11e apocrine glands, mrely exceeding
I em in siL.e . H is tologically, it shows C)"Stic spaces e nclosing a
papilla!') adenomawus mass. In rare cases. it may undergo
malignam change, Lherefore req uirin g excision.
PIGMENTED MOLE OR NAEVI
Pigmen ted mo le or naevi are no t un co mm o n over the vu lva
a nd may develop into melanoma. A g rowing mole s ho uld be
exc ised a nd s ubj ected to hi stOlogy.
ENDOMETRIOSIS
Endo m etriosis of vulva is a purplish swelling seen over the
labia maj ora or episiotomy scar over the perineum. It grows
during m ensu·uation and becomes painful but recedes
in betwee n menstruation. IL requ ires excisio n. IL does not
respond to drugs.
ELEPHANTIASIS OF VULVA (Fig. 25.8)
Elephamiasis of vu lva is a filarial disease of t11 e u·opics and
is ca used b)' Wttcltertritl It causes e lep hantiasis vu lva
a nd ing uinal lymphadenitis. By tJ1 e time c hro nic lymphaLic
obsu·uc tion occ urs, fila 1iae are not de tected. Lf diethylcar-
bama:t.ine fails to cure tJ1e conditi o n, s urgical excision is
n eeded. Tube•·culosis is a rare ca use of elephantiasis vulva.
Figure 25.8 Bephantiasls of vulva.
KEY POINTS
• Vulva is a common site of sexuall y u·ans mitted diseases
such as syphilis, he1pes, condyloma acuminata.
• PnH·itLLS vuh<a has several aetiological factors which
need e'<aluation. Some are idiopathic a nd •·espond to
e mpiricaltreaunenL
• Vuh<al d)strophies represent a specu·um of au·ophic
a nd h) penrophic lesio ns which ma) be locali.ted or
diffuse. About 10%-30% develop malignancy, and
ma lig nancy may exist in the sa me lesio n. It is there-
fore im portant to rule o ut cancer by to luidine blue
test, colposcopy and biopS)'·
• Vu lvodynia is a painful vu lva l co ndition witho ut an
obvio us clinical lesion. It is diffic ult to elucidate the
cause. Symptomatic reliefwitll drugs is t11 e first line of
treaun e nt.
SELF-ASSESSMENT
I. Describe the benign lesions of the vulva e ncoumered in
clinical practice.
2. How would )'Ou manage a case of vulva l pruritus?
3. How wou ld yo u manage a complain t ofvulvod ynia?
4. What a re tl1 e types of vu lva l d ystroph ies? Disc uss their
mana gem e n 1.
SUGGESTED READING
of 'uh-ar
ACOC l'r.tcticc Bulletin 93: dia!,'110>;S and
skin di>orders. Ob.tet Gynecol 2008; Ill : 1243.
Br.tcro CL. Carli P. Somni L, et al. ;md hhtological effects
oflopicaltreauncms of\'Uh-al lichen sclero.u;: A clinical C\'aluation.
J Rep rod 38:37--40, 1993.
Elchalal U. Gilead L. Vardy DA, et al. Treaunent of lid1en >dcro.us in
1hc elderly: An u pdatt:. Obsetet Sun· 50:155-62, 1998.
Faber Sand FL, Albicri V, et al. Prc\'a lcnce and type di>tribution of
hum i:Ul papillomavirus in squamous <.:ell cardn om a and int r.tcpic he lial
neoplasia oft he vulva. lmj Cancer 2017; 141 :1161.
llood AF, Lumadue]. In: Beni!,'11 vulvar Ocrmatologic Clinics
10:371-385, 1992.
Lawson J O. In: J>cJvic anawmy I , Pelvic floor mu scles. Ann R Coli Surg
Eng 154:244-252. 1974.
 Benign Diseases of the Vagina
Biology of the Vagina 326 Cysts and Neoplasms of the Vagina 335
Pathological Vaginal Infections 329 Key Points 335
lnAommotions of the Vagina 332 Self-Assessment 335
Ukerotions of the Vogina 334
T he vagina is usuall)' a site of benign conditions s uch as in·
fections, ulceration and other changes related to age of the
patient; howeve r; rare!)' the vagina can be a site of malig·
nanC)'· Nawre has provided a number of protections in the
form of high acidic pH, thick sq uamous cell epithe lit.un in
rl1e vagina which prevents occun·ence of common diseases,
whenever these normal defences of vagina are altered rl1ere
is an increased risk of diseases of the vagina.
BIOLOGY OF THE VAGINA
In a heallhy adult woman of childbear·ing age, rl1e vaginal
secretions consist of white coagulated mater·ial comprising
squamous cells, DOderlein's bacilli and coagulated secre-
tion. Doderlein's bacilli are large Gram-positive bacteria
which are sugar fermenting. This ability to convenglycogen
into lactic acid is responsible for rJ1e high acidity (pH) of
rl1e normal healrJ1 y adult vagina. The vaginal contentS are
mostly del'ived from the squa mous cells of rl1e vaginal mu-
cosa. Some contributio n co mes from endometrial and cervi·
cal seO'etion. ln a health)' woman, ce rvical secretions are
small in amount and rl1 ere is li LLie secreti on from the endo·
me u·ium of rl1 e body ofLhe ute rus eve n during rl1 e secretOI')'
phase of the me nsuua l cycle. ParJ1 ological conditions s uch
as erosions and ec tropio n of the ce rvix cause increased
mucus secreti o n and tJ1 c patient compla ins of mucous
discharge at tJ1 e vaginal orifice.
The superficia l cornified cells of tJ1e vaginal mucosa pro·
duce glycogen under oesu'Ogen stimulation and are con·
tinuously desquamated. Subsequently, as a resul t of the
breaking down of tJ1e cells, glycogen is liberated and ulti·
mately converted into laCLic acid. In the newborn, before
rl1e appearance of DOderlein 's bacilli, glycogen is bro ken
down into lactic acid and tJ1ere is some e''idence that the
pr'Ocess is brought about b) enL)me action. After me ap-
pearance of DOderlein 's bacilli, rl1e production of rl1e lactic
acid is augmented b) tJ1e action of bacilli on glycogen.
The amowll of nonnal \'l'lginal secretion varies wirl1 age, in
healm and in disease. During pregnancy, it ino·eases and it is
326
maximal in the early puerperium and in women following an
abortion. lt varies at d ifferent times in the mensu·ual cycle
increasing at ovulation and j ust before mensu·uation. ln
healrl1, it is dependent on tJ1e \'l'ISCular srme of the genitalia,
and rl1is itself is largely oesu·ogen dependent Congestive con·
ditions of rl1e genitalia and acljacent pelvic organs increase
vaginal transudation such as in prolapse wirl1 hypertrophied
cervix and cervicitis and in retro,ersion of rJ1e rHems wirl1 a
congested and m)Oh)perplastic uterus. The peh'ic congestion
of dll'onic constipation also aggra\'l'ltes \'l'lginal discharge.
l. The nonnal moisU1ess of the "agina is sufficient to lubri·
cate the \'l'lgina and labia minora wimout staining or
moistening the underclothes except at onrlation, in im·
mediate premensuual phase, during pregnancy and
under me stimulus of sexual excitation.
2. Wim a moderate increase in \'l'lginal secretion, rl1e un·
derclothes ar·e undeniably soiled and require changing
and washing frequently.
3. An excessive amow1t of,'l'lginal secretion requires rl1e wear·
ing of some exu·a abso rbe nt pad, diaper or internal tampon
and is genuinely pa thological. It is to be su·essed, however,
rl1at rl1is excessive discharge is not necessa rily pa rl1ological.
T he components of vagina l secreti on are fmm the
following:
• The sweat and sebaceo us gla nds of the vulva and rl1e spe-
cialized racemose glands of Bartho lin 's. T he characteris-
tic odour of vaginal secretion is pt'Ovided by the apocrine
glands of rl1e vu lva.
• The transudate of the vaginal epitJ1elium and rl1e desqua·
mated cells of the cornified layer. This is strongly acidic.
• The mucous secretions of tJ1e endocen'ical glands which
is alkaline.
• The endometrial glandular secretion.
All these play a \'l'll') ing pan at different times of the
menstrual C)cle, the last t\\0 being most active just before
menstruation.

Rgure 26.1 Parabasal and basal cells (postpartum smear). Para-
basal cells (large arrow) are oval and typically have dense cytoplasm.
Basal cells (small arrow) are similar but have less cytoplasm. Many
cells have abundant pale-yellow staining glycogen, a characteristic
b ut nonspecific feature of squamous cells of pregnancy and the post-
partum period. (Source: From Figure 1 5. EdmundS Gibas and Barbara
S Ducatman. Cytology: Diagnostic Principles and Clinical Correlates,
4th ed. Saunders: Elsevier, 2014.)
STRUCTURE OF VAGINAl EPITHEliUM
The squamous cells of vagina are divided imo three layers:
superficial, intermediate and deep. The deep layer consistS
of two t) pes of cells, basal and parabasal. The basal cells
are the less mature, smaller and more basophilic cell. It is
a small round cell with a basophilic cytoplasm and a rela-
tively large cen u-al nucleus which is unifonn in shape and
siLe. Vaginal smears where this cell predominates are typi-
cal of low oestrogen content, for example, menopausal,
lactating or postpamun smears (Fig. 26.1 ). The pat-a basal
cell is similar to the basal cell but slightly more mature.
The intennediate cell type is represented by a cell imerme-
diate between the basal and the superficial or fully corni-
fied cell. It is tlu·ee times larger than the basal cell and el-
li psoid or quaddlatel-al in sh ape. The cytoplasm stains
light and th e nucleus is smaller and has less deep staining
Ulan in the basal cell. The nucle us is vesicular. T he pres-
ence of parabasal cells in a vaginal smear ind icates a low
but not absent oesu·ogenic influence as seen in normal
menopause. Its presence in la rge numbers is also charac-
teristic of rapid desq ua mation of the vagina l epitheliu m
which ma)' res ult from vagi na t infec lion or basal cell hyper-
p lasia. T he sup erfi cial cells a re of two t)•pes: precornified
and cornified. The precornified cell is larger than the in-
termediate cell, being a hexago nal or octagonal flat wafer.
Its main point of distinction from t11e fu lly cornified cell is
t11at its cytoplasm is still fairly basophilic. Its nucleus is
small and p)knotic. The cornified or fully ma[Ure cell rep-
resentS the Final phase of complete oestrogenic mawrity. It
has a pink eosinophilic C) to plasm, 1he largest cytoplasm of
an> vaginal cell (Fig. 2().2). The nucleus is pyknotic. The
maximum level of cornification is usually seen in the late
prolife1-ative phase of a nonnall)' menstmaling womatl
when oestrogen production is maximum near the Lime of
ovulation.
CHAPTER 26 - BENIGN DISEASES OF THE VAGINA 327
a a
a
]!
.2
'!:
b
::>
(J)
b l
.!!! c
E c
(J c
...
•
£
d d
.ri
d
rf
.,
co e
Figure 262 The layers of vaginal epithelium of the well- oestrogenized
adult. The superliclal layer contains surlace cells that are cornified
(squamous) with eosinophilic cytoplasm and pyknotic nuclei (a) as well
as large intraepithelial cells that are also karyopyknotic but basophilic
{b). The intermediate zone oontalns basophilic cells that have less cy-
toplasm and intermediate-size nuclei (c). Parabasal and basal cells
have successively smaller amounts of basophilic cytoplasm and more
vesicular nuclei {d, e). (Source . From Rgl.le 15-29. Mark A Sparing:
Pediatric Erdocrirology, 4th Ed. Saunders: Bsevier, 2014.)
PHYSIOlOGICAl CHANGES IN THE VAGINAl
EPITHEUUM
It is possible to demonsu-ate C)clical \'31·iations in the \<aginal
epithelium during u1e mensu·ual cycle by cytological exami-
nation. This technique has become so well authenticated
that a competent C)•tologist can diagnose t11e date of tl1e
menstrual calendar from an examination of the \<aginal
smea1· wiu1 nearly u1e same accuracy as can be accessed
f1·om the swdy of u1e e ndometrium. The comification in-
dex (the percentage of the cornified cells) is one sim ple
method of assessing oesu·ogen activity. The vaginal cywlogy
during u1 e differe nt phases of menstrual cycle is as follows:
1. Menstruation. Endorneu·ial deb ris, red and wh ite blood
co1puscles and histiocytes are present. T he vaginal
sq uames are immature in that they have basoph ilic cyto-
p lasm; Ule)' are adherent or co nglomerate and their nu-
clei are larger u1 an u10se of mature cells.
2. Early proliferative phase. Po lymorphs are few and the
squ:unes tend to be discrete and more mature, their cy-
toplasm more acidophilic and their nuclei more P>'k·
no tic and smaller; the cornification index rises.
3. Late proliferative phase. As the oesarogen activity reaches
itS maximum. u1e squames become uniform and mature,
atld the nuclei are small and P> knotic. The cells :u·e
sepat-ate. and tlle cornification index is the highesL
4. Early secretory pbase. The squames become clumped
togetller in clusters. They are less mature, tlle crtoplasm
is now largely basophilic, and t11e nuclei are bigger, less
328 SHAW'S TEXTBOOK OF GYNAECOLOGY
dark-staining and vesicular. The cells are no longer flat
but appear to be folded with a crinkled or o·wnpled ap-
pearance. Some are pointed and characteristically spear
shaped. The cornificatio n index falls.
5. Late secre tory phase. Intermediate precomified cells
predominate. There is lack of com ification. Cytoplasm is
basophilic- the cells are o ·umpled and folded. The nu-
clei are large, pale staining a nd vesicular. Pyknosis and
concentration of nuclear su bsta nce are absenL Poly-
mot·phs are on the increase. The background is mud.'}'
(diny).
The C)clical ch anges in the vaginal epithelium show that
the activity is at its maximum during the week before the
onset of mensu·uati on. Br0\\11 staining of the vagina, when
t11e walls are painted with Lugol's iodine, gives a rough indi-
cation of tl1e gi)'Cogen co nte nt of t11e cells li ning tl1e vaginal
epitl1elium, and thereby the oestrogenic tiu-e of t11e pati ent's
blood. T he maximum glycogen co nt.e nt in t11 e vaginal epi-
tlleliu m is found in the vagina l forni ces, whe re it is prese nt
to th e ex tent of 2.5-3.0 mg%, and it is at its lowest in the
lower tl1ird, whe re its va lue is 0.6-0.9 mg%.
CYTOLOGY OF THE VAGINA
Cornification of the vagina is well marked in the vagina of
t11e newborn because of th e high oestrogen level wh ich has
been transferred from the mot11er. After about 10 days, the
vaginal epithelium beco mes thinner and remains in tl1is
state until the approach of puberty. At puberty, the func-
tional la)er increases in t11 ickn ess. In t11e first half of a
normal pregnanc), t11e co rnifi cation index is low and
shotLid not exceed 10%. In the presence of progesterone
deficienc) tl1 ere is a t·ise in the comification index, and if
the index tises over 25%, the patiem is likely to abort. ln
late pregnancy, the cornification index falls even lower and
at tet·m, it may fall below 10%. Aft.er menopause, altl10ugh
the ovat·ies haYe ceased to function, some degree of comi-
fication is usually present, the oestrogens probably being
derived ft·om tl1 e adt·en al cortex and from conversion of
androstenedione (fi·om ovary) to oestrone in the pet·iph-
eral adipose tissue.
After menopause, th e vagina l epitheli um atrophi es with
witl1drawal of the oestrogen supporL T he epithelium be-
comes tl1in and parc hmem-like and is prone to infection
(sen ile vaginitis). T he vagina l s mea r shows ma inly the basal
basop hi lic rounded cells with la rge nucl ei. T he bac k-
ground shows le ucocy ti c infi ltrati on . T he s uperfi cial
sq uames are absent and th e inte rmed ia te cells are few and
far between.
VAGINAL ACIDilY
The vaginal acidity is due to lactic acid, which may be pres-
ent in a variable amount The pH value is 5.7 in the new-
hom and reaches 6-8 in children , and falls tO 4 at puberty.
Ottring pregnane), the pi ! value is usually 4. After meno-
pattSe. tl1e p H rises to 7. The normal pH in healthy women
dwing the childbeal'ing period is about 4.5.
It is important to understand that DOderlein's bacillttS is
the only organism which will grow at a pH of 4-4.5. As the
acidity of the vagina falls and t11e pH tises, nonresident
pathogens are able to thti\e.
NATURAL DEFENCE MECHANISM OF THE VAGINA
The skin of the vagina is a tough stratified sq uamot.LS epitlle-
lium devoid of glands. It presents a smootJ1 unbroken sur-
face to the aLLack of pat11ogenic organisms. There are no
crypts where organisms co uld multiply unlike in tl1e endo-
cervix. The p H is low and the high acidity mitigates against
bacLetial growth. The thickness of the epitJ1elium and the
hostile p H depe nd upo n oestroge n, and therefore, it is only
in extreme young girls, befot·e puberty, and in senescence,
i.e. after menopause, tl1at bactetial inroacls are likely. There
are following cen.ain phases when the p H is raised:
• During menstruation, when th e cervi cal and the endome-
trial which is alkaline, tends to neutralize tl1e
vaginal acidity.
• After abortion and childbirth , wh en the alka li ne lochia
h as a similar elfecl.
• An excessive cervical discharge, such as occ urs in endo-
cervicitis, has the same effect.
Apa tt fro m these excep ti ons, the vagina is na turally self-
s Lerilizing under the ac ti on of DOde rle in's bacilli.
FLORA OF THE FEMALE GENITAL TRACT
In healtl1y women, the fa llopian Lubes, tl1e cavity of the
utentS and the upper third of the cervical canal are free of
microorganisms. The lower third of t11 e cervical canal always
comains microorganisms, as does the vagina.
a. Lactobacilli (Doderlein's bacilli)- mainly responsible for
the production of h)drogen peroxide whid1 is toxic to
anaerobes. The> also protect against bactet·ia and candida.
b. Facultative organisms (low, nonpathoge nic numbers)
( 1) Diphthei'Oids
(2) Coagulase negati' e staph) lococci
(3) Streptococci (gt·oups Band D)
( 4) &cherichilt coli
(5)
(6)
c. Anaerobic organisms (poor concentration)
( I) Peptosu·eptococci
(2) Bactemidll.l
(3) Ft.tsobacteriwn species
In healtl1y wome n, Dode rl e in's bacillus is tl1e o nly o rgan-
ism found in Lhe upper two-tl1ircls of the vagina; b ut in tl1 e
neighbourhood of tl1e vulva, both sap rop h)'tic and parasitic
organisms can be de monstrated. Docle rle in's bacilli have
been fo t.Uld in tl1e vagina of the newbom witl1in 9 hours
after de livery, a lthough the usual Lime for them to appear is
15 hours. The vagina of the newborn is probably inoculated
dttring parwrition.
Otuing tl1e pueq)erium, ac idity of the vagina is reduced
and foreign organisms such as colifonn bacilli and otJ1er
patl1ogens can grow.
Vaginal discharge increases aro und 0\1.tlation, during
pregnancy and intercourse. Antibiotics and bat-rier contra-
ceptives also make vaginal secretion mo re alkaline.
Outing the climacteric a nd after menopause, the num-
ber of DOderlein 's bacillus is reduced and sometimes, tl1is

organism cannot be demonstrated in the vagina. The im-
portance of Dode rle in's b.1cill us is that its presence is associ-
ated witJ1 tl1 e production o f lactic ac id contained in tl1e va-
gina and tl1 is acid it) inhibits tJ1e growth of o tJ1er organisms.
Ln multiparous women, when the vaginal orifice is patulous
as a result of childbirth, foreign organisms may be found in
tJ1e lower part of tJ1e vagina which by producing a low-grade
vaginitis give rise to discharge.
lEUCORRHOEA
The tenn leucorrlwea should be resu·icted to tl1ose conditions
wh en m e nonn al vagin al secretions are increased in amounL
Ln such patients, tJ1ere will be n o excessofleucocytes present
"hen tl1 e disch ar-ge is examined under tl1e microscope, and
tl1e dischar-ge is macroscopicall y and microscopically non pu-
n.denL Purulent disciHu•ges due to specific infections such
as gonorrhoea, u·icl1omoniasis and mo niliasis. Ulcerated
growtJ1s of th e ce rvix and the vagina and d isch arges caused
by urinary fiswlae arc of a d ifferent type and sho uld be ex-
cluded from tl1e term ' leucorr·hoea'. Some cl inicians use the
term to describe an)' whi te or yellowish-white d isc harge fro m
tJ1e vagina. An increase in t11e norma l vaginal secretions is
ph)•siological at p ube rty, d uring pregnane)', at ovulation and,
in some women, during t11 e pre me nsu·ual phase of the men-
su·ual cycle. During pregnancy, the nonnal discharge is in-
a ·eased in ;unotu1L because of ina·eased vascu larity of the
female ge nital tract. During the latte r part of the menstrual
cycle, tl1 e h)'Peru·oph ied premensu·ual glands of tl1e endo-
metri tun secrete muco us whid1 is discharged through the
ce rvix into the vagina. The leuco ni1oea of pubeny is proba-
bly caused b) the increased vascu larit)' of tl1e ute n.IS, cervix
and vagina at that time. It is of shon duration and needs no
u·eatme nL This secretion contains proteins, polysaccharides,
;unino acids, en0mes and immunoglobulins.
onpathogenic leuconi1oea, merefore, ca n be classified
into: (i) cervical and (i i) vaginal.
EXCESSIVE CERVICAL SECRETIONS
(CERVICAL LEUCORRHOEA)
Mucous discharge fr·om t11e endocervical glands increases in
such conditions as chroni c cerv icitis, cervical erosion, mu-
cot.IS polypi and ecu·opion. When t11e mucous secretions of
tl1e cervix are produced in excess, it u ndergoes little ch ange
in the vagina and appea rs as m ucoid discharge at the vulva.
EXCESSIVE VAGINAL SECRETIONS
(NONPATHOGENIC VAGINAL LEUCORRHOEA)
T his form of leucorrhoea is seen when t11e disc harge origi·
nates in tl1e vagina itse lf as a transudation tl1rough the vagi·
nal walls. Nom1ally lac tic ac id o f the healtl1y vagina is formed
from tl1e glycogen co nta ined in tl1 e kerati nized cells of the
vaginal mucosa and the vagi nal portion of tl1e cervix. These
cells are co nsta nLly being desquamated when tl1eir glycogen
liberated is fermented b) DOde rlein's bacilli, whid1 produces
lactic acid This process is under tl1e con u·ol of oestrogen, the
level of which determines tl1e pH of L11e vagina.
Local co nditions in pelvis with an increase in blood flow
to me pelvic organs as see n in pregnancy, acq uired reu·over-
sio n and prolapsed congested ovar·ies, duonic in-
flammator)• disease (PID ) and chro ni c constipation are
causes of an increased ' -aginal secretions.
CHAPTER 26 - BENIGN DISEASES OF THE VAGINA 329
Leucorrhoea must be distinguished from specific vagini-
tis by perfom1ing bacteriological examination and care
mLISt be taken to differentiate between L11e cervical dis-
charge of chronic cerv icitis and excessive '-aginal sec retion.
A specLLium exami nation of the '<agina usually helps to de-
cide Llle source of leucorrhoea. If cervical, an excessive
mucoid discharge will be obvious at the extem a l os.
PATHOLOGICAL VAGINAL INFECTIONS
• Gonococcal
• Trichomonal 15%-20%
• Monilial 20%-25%
• Chlamydia)
• Bacterial vaginosis 50%
Except bacte ria l vaginosis, the o tl1 er infec tions are mostly
sex uall y u·ansmitted and t11 erefore desc ribed in chap ter o n
Sexually Transm iued Diseases.
VAGINITIS
Vaginitis causes significant inflamma tOr)' response seen in
the vaginal wall. There is evidence o f increase in WBCs in
the vagina l fluid. This is co mm o nly seen in infections
caLISed by trichomo niasis, and herpes, STDs
including I-I IV infections.
General Features
I. Symptoms - Pruritus, burning in vagina
a. MalodourOLIS discharge a nd dyspareunia.
2. Physical findings:
a. Congestion of vaginal walls, microhaemon·hages, tl1e
presence of abnor·mal ' -agina l discharge - It may be
copious in amowll and frequently foul smelling.
b. Ln crease in \<aginal pH.
c. Tenderness/ discomfort during pelvic examination.
3. Investigations
a. Hanging drop ex;unination - Reveals the presence of
motil e Triclwmonm in a case of Trichmrwno.s
vaginitis.
b. KOH treated preparation of vaginal discharge - This
reveals tl1e presence ofpseudomycelia and spores in a
case of Candida vagi ni tis.
c. Whi ff test - T he Fish)' odour on add ing a d rop of 10%
KO H to the vagina l secretion is s uggestive of tJ1e pres-
ence of bacteri al vaginosis.
d. Gram's stain - This may reveal presence of Gram-
negative inu·acell ular and extracellular d ip lococci
suggestive of gonococci. The presence of Clue cells is
suggestive of bacterial vaginosis.
e. Culture:
Clwcolitte Agar- Gorux!X·ci
medium or Nicker$()nS medium- Cttrulidtl
SjJer:U:tl enrichetlmetlium- Triclwnwntls
i11Jectio11
CANDIDAL VAGINITIS
Cmulillt1 is me next common cause of,-aginitis.lt is
not a sexually transmiued infection. It is commonly seen
330 SHAW'S TEXTBOOK OF GYNAECOLOGY
whenever there is increase in conten t of glycogen in vagina
in conditions such as pregnancy, diabetics, woman taking
oral pills or in the immunocompromised woman. Often in-
fection ma> occur following a course of oral antibiotics for
some conditions.
I. Risk factors altering the immtme response include
a. PregnanC)
b. Medications - Oral contraceptives, antibiotics, corti-
costeroids, cancer chemotherapy
c. H£\1 and other STDs
d. Diabetes mellitus
2. Poor p ersonal hygiene
3. Run down condition of health in general
I . Clinical
Complaints of pruriws, buming, dysuria
Evidence of vulvar eryth ema , oedema, scratch marks
• Disc harge: whitish, fla ky or curd-li ke
• Vaginal p i I 4.5
lnvestigatiorn
• A KOH wet motmt prepa rati o n of the vaginal disc harge
he lps to dissolve a ll cell ular debris, leaving behind the
resistant hyp hae and spores of candida thus making
diagnosis easy.
• Culture: Though not routinely advocated, vaginal dis-
charge can be cultured on Sabouraud's agar - The
presence of discrete creamy rounded colonies appears
in 48-72 hours, giving a typical yeast-like odour.
• ickerson's Medium is a special medium, on whid1
candida colonies appear in 48-72 hours as brown-black
discrete round colonies.
Treatment
Preventive measures- These include the following:
a. lmprO\'e personal h)giene
b. Discontinue offending medications
c. Control diabetes
The treatment of candida vaginitis comprises of use of
antifungal creams or pessaries for a duration of 7-14 days.
Some of the commonly used amifungal pessa•·ies contain
clotrima:wle, miconazole, terconazole or butOconazole.
Oral antifu ngal agents - Rarely oral antifungal agents
may have to be used especiall)' in yo ung unm arried girls or
in women who have frequent rec urrences with vaginal anti-
funga l agents. Fluconazole ca n be given as a s ingle oral dose
of 150 mg. ltraconazo le and newe r amifungal age nts wh ich
are aCLive aga inst cand ida ca n be given orall y.
TRICHOMONAS VAGINITIS
Diagnosis: This is based o n cli nical suspicion fo llowed by
con firma tOt")' tests to es tab lish the diagnosis.
( 1) Clinical Findings: These in dude
Vulvar erytlumw (md oedema
Jrotll:y yelwwislt-grren foul smellirl(J disclwrge
Punctate l&imu of cervix (strtnubeTT)' ceroix)
Vagitwl pH > 4.5
(2) Hanging drop test: Reveals presence of actively mo-
tile pear·shaped flagellate organisms.
(3) Culture: Requires use of special media, these are not
•·outinely used.
Treatment
Being a protozoal infection Triclumwnos vaginitis response
well to Metronida:wle or one of the drugs belonging to
Imidazole group. Metronida:t.ole is give n in a dose of
400 mg three times ada) for a period of5 days. Altema-
tivel)'• same drug can be given in a single dose of 2 gm.
Both the partners need to be given treatment at the
same time to pre,ent t·isk of recurrence. Tinidazole 2 g
as a single dose or secnidaLole in a single dose of 2 g has
also been used for the treatment of Trichomlllws vagini-
tis. There may be a biuer metallic taste in case patient or
husband is alcoholic. Single dose therapy ensures better
compliance.
VAGINOSIS (BACTERIAL)
Vaginosis (also known earlier as nonspecific vaginitis/
Ganlnerd./11 vaginitis and anaero-
bic vaginitis) is associated with min imal inflammatO t) '
response; th e vaginal fl ui d revea ls few leucocytes.
Bac teri al vaginosis is te rm ed utl{,rinosis rath er than
vaginitis, because it is assoc ia ted with alte ratio n in th e
normal vaginal flora ra the r than cl ue to an)' specific infec-
tion. Th ere is a considerable decrease in th e n umber of
lac tobacilli in th e vaginal d isc ha rge with 100-fold increase
in growth of other anaerobic bacteria. Lactobac illi red uce
p H and release hydrogen peroxide toxic to other bacte-
ria, so reduction in their number a llows o ther bacteria,
i.e. aerobic and anaerobic bacteria, to grow. These are
vagina/is, G. vagitwlis, MobiluncLIS and M.
lwminis. MobilutiCLI.I is a Cram-positive rod-shaped bacte-
rium with a characteristic corkscrew spinning anaerobe.
Bacte t;al vaginosis is therefore a pol)microbial condition
(Fig. 26.3).
It is not sexually ll'ansmitted and has a v:uiable incuba-
tion period About 50% women are as)lnptomatic carriers
of infection, but majotity complain 'oaginal discharge with-
out itching.
The charactetistics of \>aginal discharge in bactet·ial 'oagi-
nosis are as follows (Amsel's criteria):
• White, milky, nonviscous disd1a1-ge adherent to the vagi-
nal wall.
• p H of the discharge is more than 4.5. (p H 5-7).
• Fishy odour when mixed with 10% KOH is due to
a mino-metaboli tes from vario us o rga nisms (a mine or
whiff test).
• Presence of clue cells - the epithe lia l cells have a fuzzy
border due Lo ad here nce of bacteria (Fig. 26.4A and B) .
• Increased numbe r of G. vagina/is and o th er microorgan-
isms and reduced number of lactobac illi and le ucocytes.
The woman has minima l vu lval irrita tion. The diagno-
sis is based on wet smear and c ulture. The smear reveals
clean background with few inflammatory cells and other
organisms. but scant) lactobacilli. Many epi thelial cells
presem a granular C) to plasm caused by small Cram-
negative bacilli adhel'ing on their surface, the so-called
clue cells. Free floating clumps of are seen.
Cram stain is 90% sensitive and 83% specific. D A probe
for G. vagina/is is now avai lable. Cas liquid chromatOgra-
phy is useful.
 CHAPTER 26 - BENIGN DISEASES OF THE VAGINA 331

DOderlein's
bacilli

Figure 26.3 (A) Normal mature vaginal cells wit h D&lerlein's lactobacilli. (B) Clue cells with very few DOderleln's bacilli.

Bacterial ca n ca use PID, chorioamnion itis,

premature n.tplllre of memb r,lne (PROM) and pretenn
labour.
TREATMENT
The 7-day course of metronidazole 400 mg twice daily is
effective in 85% of cases, whereas a single dose of 2 g cures
only 45% of cases. Ampicillin 500 mg or cephalospori n
500 mg b.i.d. for 7 da)S is also effect..ive. Tetracycline 500 mg
four Limes ada). dox> C) cline I00 mg twice a day and sulpha-
fumLole for 10-1<1 da)S are the alternative antibiotics in
nonpregnant women.
Clindamycin 2% cream locall)' is effective in 85% of
cases. Oral clindam)•cin 300 mg dai ly for 7 days is also effec-
tive. OrnidaLOie 500 mg vaginal tablet daily for 7 days is a lso
effective, use of vaginal tablets a'·oid the first-pass effect in
li ver seen with oral route.
Lacteal is a protein-free acidifying lactate gel which neu-
trali zes the vaginal pH (lactic acid 5% W/V, 0. 1% glyco-
A gen)- 5 mL is applied dai ly for 7 days. Rec urrence rate is
30%.
Meu·onidaz.ole does no t red uce th e number of lactOba-
cilli un like clindamycin and ma>' be co nside red supe rior tO
the laue t: Metron idazo le to u·eat bacteri al vaginosis may be
avoided in first uim este t:
PROBIOTICS
Ecoflora
Ecoflora capsule contains Lal'tobacillus rhmmuJSus GR-1 and
reuteri Rc-14. These are probiotic age nts, effec-
tive against Gram-negative pathogens a nd resistamto sper-
, micides. Th ey also have anti-inflammatory ac tivity. They
secrete collagen-binding proteins that prevent pathogen

..'
adhesions. The ecoflora adheres to the epithelial cells,
·" prevent adhesion of other pathogens and produce 1-120 2 ,
thus maintaining p i-1 in the vagina. One to two capsules
daily for 30 days are followed by one capsule daily for an-
Figure 26.4 Bacterial vaginosis. (A) Vaginal smear showing DOder· other 30 da) s. The drug is, howe,·er, contraindicated during
lein's bacilli. (B) Clue cells suggestive of bacterial vaginosis. pregnancy.
332 SHAW'S TEXTBOOK OF GYNAECOLOGY

MISCELLANEOUS CAUSES OF EXCESSIVE VAGINAL The infection is more common fo llowing menstmation or
DISCHARGE following in te reo u rse.

a. Excessive physiological discharge DIAGNOSIS

(1) Comm on causes
Sexual excitement Diagnosis is established b) smear and cuiLUre of vaginal
Cervical erosion discharge.
Ovulation lime
Ps) chological factors TREATMENT
(2) Management Treaunem \oa1·ies according to the infecting organism and is
Clinical evaluation to exclude pathology general as well as local.
Counselling and education
Electrocalllery of erosion cervix GENERAL
b. Other infections All measures a1·e designed to improve tJ1e gener·al healtl1 of
( 1) Common microorganisms suspected include the patient.
Chlamydia
Gonorrhoea LOCAL
Herpes T he correction of the vaginal p i I to 4.5 by a water<lispersible,
Foreign body buffered vaginal jell y whi ch ca n be inserted in gi·ad uated
Chemical irritation amoun ts witl1 a special disposab le app lica tor (Fig. 26.5) .
Senile vagin itis A locall y app lied bacte ri cida l crea m such as uiple sulpha
c. Management options (sulphathiazole 3.42%, N-a cetyl s ulphan ilam ide 2.86%
Advice abo ut personal hygiene. and N-benzo)rl sul p han ilam idc 3.70%, excipiem to 100%)
Avo id use of il,.itants such as do uches, vaginal comracep- (Fig. 26.6) or an tibiotic pess;\ries when Lhe organism and
lives (chem ical creams, foam tabletS) if they are the sensitivit)' are known.
cause.
Remove foreign body- retained condom, tampon, pes-
saries)
Chlamydia - treat with tetracycline/ doxycycline/ eryth-
romycin.
Gono1·rhoea - treat with penicillin/ ceftriaxone/ cipro-
floxacin. cefiXime.
Herpes -treat with aC)clOvir and allied de1ivalives.

INFLAMMATION OF THE VAGINA Rgure 26.5 pH corrected using a special disposable applicator.

ln this imponantgroup of disorders, a v:uiety of mixed patho-

gens are recoverable on smear and culture, i.e. SuJpltyioc()CcuS,
both haemolytic and anaerobic, and E. coli.

AETIOLOGY
Chemicals, drugs, douches, pessa ri es, tampons, trauma,
foreign bodies such as rubbe r 1ing contraceptives
and even vaginal and ce rvical ope ra lio ns a re all causative.
Alterati on in tl1 e pH towards alkalinity always favours non-
specific infec ti on; he nce, it is co mmon in the puerperium.
Often present infection witJ1 trichomoniasis is important,
because the isolation of the seconda•)' organism may mask
the presence of tJ1 e Trichonwna1, wh ich is really responsible
for the discharge. He nce, it is important to use selective
culture media in all cases where response to u·eatment is
disappointing.

SYMPTOMS AND SIGNS

A red. swollen, tender vagina with irritation, buming :md
often dysul'ia with frequency of micw•·ition is present. The
vaginitis is mild or seve•·e and acute or cl1ronic, and the Figure 26.6 Applicator Inserted in the vagina and the cream
colour, consistency and amount of discharge are variable. injected (local application).

The elimination of infection in the gen ital u·act such as
chronic endocervicitis by diathermy cauterization and con-
uation. A woman with nonspecific vaginitis can be conve-
niently treated without extensive laboratory investigations
wiLh I-da) therap) using the kiLS containing combination
of Auconat.ole 150 mg, at.ithromycin I g and secnidazole.
lnsLead ofat.iLilrOm)cin, dOx)C)cline can be used for 10-
14 da)S. Same wa> ceflxime can be used for gonorrhoea
and chlam)dia, and I g of secnidat.ole with 45% cure rate.
A<h'<lntage of using such a combination is tl1at it avoids
detail diagnostic work up. This is repeated a week later if
required.
OESTROGEN DEFICIENCY-RELATED VAGINITIS
Oestrogen deficiency vagi nitis is seen as vulvovaginitis in
children and as se nil e vagini ti5 in postmenopausal women.
In both these age groups, the vaginal epitl1elium is thin and
ill-protec ted aga inst infection; glycoge n content is low.
Doderlein 's baci ll us is thin ly populated and the vaginal
pH is high er than norm al, approac hin g or exceeding 7.4.
Cytology reveals predom inantl y basal and parabasa l cells.
VULVOVAGINITIS IN CHILDREN
The commonly affected age gro up is in the first 5 years of
life, but other prepubertal girls can be affected. The infect-
ing organism may be any pyogenic cocc us or E. coli, Tricho-
"wrutJ and Mo11ilia are uncommon except in a case
of sexual abuse. Infection is u-ansmitted from aduiLS or
anotl1er child b) hands, Loilet, utensils or doilies. Tlwead-
wonns which scratching are a fairly common
caltsative factor in this age group. In children, always tllink
about a possibilit) of a foreign bod) inserted in tl1e vagina,
tlle \'<lriety of which baffles enumeration, must not be
forgotten. This p.-imithe Freudian urge accountS for many
otherwise inexplicable \'<lginal discharge in )Oung children.
Occasionally, vulvovaginitis in children may be due to sexual
abuse.
SYMPTOMS AND SIGNS
A reddened, oedematous vul va bathed in a profuse puru-
lent discharge, wi th soreness and irritation. The child is
fidgety an d consta ntJ y ha ndli ng or scra tching L11e external
genitalia. Labial ad hesio ns may so metimes form.
DIAGNOSIS
Examination rmde r anaestJ1esia is probably tJ1e most effec tive
method of excluding a foreign bOd)', obtaining an adeq uate
smear an d inspec tin g the upper vagina.
TREATMENT
Local and systemic antibiotics will provide prompt relief
from Ll1e symptorns.
Etl1inyloesuadiol 0.01 mg increases tJ1e \'<lginal epitl1elial
resistance and improves tJ1e \'<lginal acidity and is often all
tJ1at is needed to affect a cure.
• Specific antibiotics sud1 as ampici II in or cephalospori ns are
effective to which tl1e infecting organism is sensitive. This is
best given systemically and not locally.
• o local treatment is desi•-able in young girls.
CHAPTER 26 - BENIGN DISEASES OF THE VAGINA 333
• Isolation from otl1er children to prevent cross-infectio n is
desirable.
• If not adequately treated and speedily eradicated, tl1e
infection can become dnonic and resistant.
SENILE VAGINITIS
ln many aspeciS, senile \'<lginitis is comparable to vulvO\'<Igi-
nitis in children. As a result of oesu·ogen deficiency, tl1e
\'<lginal epitllelium becomes thin and au·ophic, tlle glycogen
content and acidity of tl1e \'<!gina are lowered and the ever
present mixed pathogens obtain a footing.
AETIOLOGY
Apart from women with natu•-al menopause, prolonged lac-
tation or premature menopause, women who h ave under-
gone oophorectomy are prone to develop senil e vaginitis.
SYMPTOMS AND SIGNS
Dry vagina, dyspa re rmia and a puru le nt, often slight!)' b lood
tinged, discharge are evidcnL The vagina is inAamed and
te nder and the mucosa is excoriated. Urinary symptoms in
th e form of ina·eased frequency and d)•Suria are common.
On exam ination, tl1e uretlH·aJ meatLL5 is pouti ng and shows a
low-gmde du"'nic urethritis often misdiagnosed as a urethtal
canmde. There is patchy gmnular vaginitis, tJ1e spoiS of
whid1 are red and bleed eaSil) when swabbed. These 1-aw and
inflamed areas ma) become adherent and cause an oblitera-
tion of tJ1e canal in the region of tJ1e fornices or vaulL The
infection ma) spread upwards to involve tl1e endomeu;lUn
and p•"'duce a senile endomeu·itis, and later a pyomeu-a.
DIAGNOSIS
The clinical features outlined abo'e are easy to inte•·pret,
but cenain reservations are of great importance.
• Senile vaginitis does produce a blood-stained discharge,
but this does not exclude the coi ncident can cer of tJ1e
endometrium or endoce•v ix.
• Senile vagin itis and senile endometritis may coexist.
It is tJ1 erefore obli ga to ry to exa mine women with post-
menopausal b leeding under anaesthesia and perform a di-
agnosti c cure ttage to exclude ca nce r of tJ1 e endometriu m,
endocervix and a p)•ome u·a.
TREATMENT
Oesu·ogen therapy is given to improve the resistance of tlle
vaginal epithelium, raise the glycoge n con tent and lower the
vaginal pH. Etl1inyloesuadiol 0.0 I mg daily for 3 weeks
should SlLffice.
Local treaunent b) pessaf) / Oinunent containing oestrO-
gen can be emplo)ed.
As an altemati'e to pessaries whid1 may be difficult for
tJ1e patient to insen, a vaginal a ·eam containing tl1e same in-
gredieniS may be instilled by patient witll tl1e help of special
applicator illusuated in Fig. 2G.5 and 26.6. This treaunent is
usuallyeffecti'e and can be repeated iftlle S)lnptoms recur.
334 SHAW'S TEXTBOOK OF GYNAECOLOGY
SECONDARY VAGINITIS
All varieties of vaginitis in whid1 the primary cause is not
vaginal are included in this section.
• Foreign body. ll1e presence of a vaginal pessary to manage
prolapse or retroversion invariably causes vaginit.is. Con-
traceptives and vaginal tampons operate in a similar way,
especially if forgotten and left inside for a long period.
• InfectiVI!: conditiom of till' ceroix. Vaginitis is fi·equem.ly
seconda•·y to chronic infection of the cenrix, usually an
endocervicitis, the effecthe eradication of which is suffi-
cient to clear up the vaginal infection. Childbirth injuries
of the genital U""act, such as cervical tear are other causes
• tl reterovagi.•wluri.11ory fistulae tJilll rectwaginal
fotulrM. These are causes of secondary vaginal infection,
and cause pet'Sistent discharge.
GROWTH ON CERVIX
A grow th on cervix espccia ll )' ca rcinoma cervix or a cervi-
cal polyp is a lways infected and may ca use seco ndary
vaginitis.
VAGINITIS MEDICAMENTOSA
lt is a special q•pe of vagin itis usua ll)' caused by chemicals,
douches, arsenic pessaries and occasionally contraceptives.
RARE FORMS OF VAGINITIS
EMPHYSEMATOUS VAGINITIS
ln this extremel) rare condition, the vaginal walls are dis-
tended with gas-eon taining vesicles. The subepithelial Lis-
sues are indurated and oedematous, and the clinical pic[Ure
suggests a malignant infiltration. There is, however, no ul-
ceration. The main S)mptom apan from a swollen vagina is
profuse 'oaginal discharge. The aetiology is unknown except
that the patients are usually pregnanL Treatment is expect-
am as the condition resolves spontaneously. Less-severe \'<1-
rieties of this emph)sema ha,·e been desctibed in whim the
gas-containing vesicles are found on a routine inspection of
the \'<\gina, and these cause minimal symptoms.
TREATMENT
ln case of vagina l disc harge in whi ch there is some local
cause, such as a re tained pessary, th e cause must be re-
moved. l n vaginitis d ue to prolapse and seco nd at) ' vag initis
caused by tl1e fisw lae, it is us uall y waste of effo rts to treat
vag initis witho ut dea li ng wit.ll the prima•)' cause. Specific
infec tions of tl1 e vagina are treated b)' approp riate antibi-
otics as soon as the ca usa tive organism has been identified.
There are various methods of treating vaginal discharge.
Vaginal Irrigations
Vaginal irrigation is rarely employed nowadays. ln cases of
prolapse, Betadine is tl1e best antiseptic cleansing agent, but
occasionall) acriflavine pack has been used.
Vaginal Pessaries
The pessaries ma> contain t11e following:
• Oesu·ogen to promote keratiniation of the epitl1elium
and to increase gl)cogen content a nd 'oaginal acidity.
The pessaries contain 0. I mg ( 1000 international uni ts)
or 1 mg (10,000 intemational units) oestrone.
• Antibiotics.
• Cortisone or bacteliostatic agen LS, Betadine.
• Specific fungicidal drugs, n)Stat.in ( 100,000 units), imid-
azole deri,oatives. ketocona.wle or the more recent ter-
conuole; antiprotoLoal and ot11er bactericidal drugs.
Bactericidal Creams
Bactericidal crmms such as u·iple sulpha cream, Betadine.
S"oabs should be taken for culture from t11e cervix, 'oagina
a nd the urethra and the appropriate antibiotic given sys-
temically or locally as soon as t11e o•·ganisms and tl1eir sensi-
tivities are known.
TOXIC SHOCK SYNDROME
Toxic sh ock syndrom e is a septicaemi c shock, reported fit'St
by Todd in I 978, which follows tl1 e use of vaginal tampons
during mensu·uaLion, and at tim es during the puerperium.
It is ca used by Staphylococcus f!'ltreu.s a nd ra rely by
J3·haemo lyti c strep tococci, botl1 o rga nis ms re lease the en-
dotOxin whi ch causes sudden pyrexia over 39.9•c, myalgia,
diffuse skin rash and oedemato us eryt11ema. The patient
ma)' suffer from vom iting, d ia rrhoea and h)•potension. Leu-
COC)•tosis, thrombocy tope nia a nd increased serum bilim bin
and liver enZ)'mes are noted. The b lood culture, however,
is sterile. Toxin and re lease of bradykinin acco unt for rhe
syndrome.
Treatment
The Lreaunem comprises correction of hypovolaemia with
inu""avenotLS Auid. 13-lactamase-resistant penicillin, cephalo-
sporin and gemamicin. Un less correc1Jy diagnosed and
promptl)' u·eated. The mortality ma) be around 15%.
Prevention
Vaginal tampons or contraceptive sponge (Today Sponge)
should never be left in tl1e vagina for more tl1an 24 hours at
a time.
ULCERATIONS OF THE VAGINA
Ulcerations of the vagina arc rare. Fo reign bodies such as a
retained pessary usua ll y ca use ul cera ti o n hi gh up in the
posterior vaginal fornix , and t11 e presence of granulatio n
tissue and unhealtl1y oA'ensive vagina l di sc harge are other
manifestati ons. Following longsta nding irritation, a n ulcer
may undergo malignant u·ansformation; hence, a b iopS)' is
mandatOI)' in suspicio us cases. Re moval of the ring pessary,
local douche and o ral an tibiotics ca n heal tl1e ulcer.
VENEREAL ULCERS
These are commonly seen on the \'lllva, blll occasionally t.l1e
vagina may also be involved.
TUBERCULOUS ULCERS
Tuberculous ulcers are mre and if UlC)' do occur, concomi-
tant lesions are commonly p•·esent on the cen·ix or t.l1e
vuhoa.

CHEMICAL ULCERS
Introduction of potaSSium pennanganate pessaries to induce
abortion has been a practice in some commw1ities. The
chemical irritation can cause ulceration, occasionally fol-
lowed by widespread cicau·i.£ation and stenosis of the vagina.
RADIATION ULCERS
Ulceration of the vagina ma) develop following radiother-
apy panicularl) in cancer of the cervix. Ulcers of this kind
do not heal readil); the) ma) cause adhesion and diswnion
of the vaginal vault.
TROPHIC ULCERS
These are observed in women suffeiing from procidentia.
VAGINAL GRANULATION TISSUE
T hese are seen in scars/va ult fo ll owing surgical procedures
such as vaginal hyste rec tomy or abdo mina l hysterectomy.
T he most common s ite is the vaginal va ult. Patients com-
plain of an offe nsive, occasionally blood-stained discharge
wh ich may pe1'SiSt for a few weeks to months after s urgery.
Cautet·ization of the granulation tissue gives relief.
SCARS, STENOSIS AND ATRESIA OF THE VAGINA
Sca1-ring of the vaginal and the par;l\laginal tissues is not
uncommon. The possible causes are i11iuries during child-
binh, extensi'e repair operations for genital prolapse, radio-
therapy for genital malignancy or chemical bums. Sevet·e
fulminant \1Jh'O\'<lginal infections in )Oung girls ;md puer-
peral or menopausal women ma) also lead to such sequelae.
AMOEBIASIS OF VAGINA
Amoebiasis of \'<!gina appears as a fungating subcutaneous
ulcer causing foul smelling discharge and postmenopausal
bleeding. The biopsy confirms the diagnosis. Oral Metroni-
clazole <100 mg twice daily for 7 cla)'S cw·es the ulcer.
CYSTS AND NEOPLASMS OF THE VAGINA
VAGINAL CYSTS
T he vaginal C)•St is rare, and is most commonly located in
the anterior vaginal wall. This is usuall y small, but may
attain a size of 7.5 em in diameter.
d1u·t arises from the remnants of the meso-
nephti c duct 11nd lies in the ante1·olateral aspect ofthe vagi-
nal wal l. A small cyst remains asymptomatic. A large cyst if
causing d)Spilreuniil requires excision.
InrlusiQII cyl>l is mainl)' seen at the lower end of the vagina
on its posterior surface and is caused by tags of mucosa em-
bedded inside the scar that later forms a cyst.
Bartholin C) Stat times extends into the vagina ;md causes
d) spareu n ia.
bulomdriotic ()'51 appears as a bluish bulge in the poste-
Jior fornix. It behaves similar to endomeuiotic cyst of the
vulva. It is u·eilted b) surgical excision.
CHAPTER 26 - BENIGN DISEASES OF THE VAGINA 335
VAGINAL NEOPLASMS
Tumours of the v11gin11 a1·e rare. In rare cases, a benign
wmour such as a fibromyoma can occur.
Malignant tumours are described in chapter on Malig-
nant Lesions of Vulva and Vagina.
KEY POINTS
• Leucorrhoea is a commo n complaint in women of
childbearing age. Apart from cenicallesions and non-
specific causes, specific 'aginitis is caused by gono-
cocci Trid1o1rwnas, Chlamydia and Mo11ilia and bacterial
vaginosis.
• Vulvovaginitis in children is not uncommon. lt is
mostly d ue LO fore ign bod)' or p inworm infec tions in
anal canal.
• Senile vagin itis due to oestrogen deficiency in men o-
pausal women ca uses dry vagina, dyspareunia and
tuin ary sympto ms, and needs to be trea ted wi tl1 vagi-
na l oestroge n.
• Bac te rial vaginosis is the most co mmo n vaginal infec-
ti o n caused b)' reduction in tl1e number of lac toba-
cilli. This allows Gard11ewlla, aerobic and anaerobic
orga nisms to over grow and produce typical discharge
with fishy odow: The clue cells in tl1e smear are pa-
tlJOgnomic of this infection. Dlll·ing pregnancy, it c;m
cause of chorioilmnionitis, premature rupture of
membrane and pretenn la bour.
SELF-ASSESSMENT
l. Describe normal commensals of vagina.
2. What are tl1e common causes of leuCOI"J-hoea? Discuss its
management
3. Enumerate and briefly desctibe the causes of ulcers in
the vagina.
4. Deso·ibe tl1e microscopic appearance of the nonnal
vaginal epitheliu m in iln ad ult woman. Describe the cyto-
logical changes observed during tl1e nonnal menstrual
C)•cle. What altermio ns in s u·ucture occur after onset of
menopause?
5. Describe the manageme nt of seni le vaginitis.
6. What are t11e ca uses of bacteri al vaginosis? How will you
trea t it?
7. Write a short note on vu lvovagin itis in a child.
SUGGESTED READING
llamill IIA. In: Nonnal V'dj.,rinal nora in rdaJion IO \'aj,riniris. Obslet
Cynecol Clin N Am 16:329-336, 1989.
JD. £,-aluation and m:uugemem of vagini1is. An upda1e for
primal')• care practitionel'>. Arch ln1 149:56.?-568, 1989.
PA. The Am J Obs1e1 Cynecol 165:
1163-1168, 1991.
O 'Connor Sobel JO. Epidemiology of recun-em \UhO \'aginal
Omdidiasis: ldenlificalion .md >tr-.tin diiTerentiarion of Candida
albicans.J Infect Oi> 15<1:358-363. 1986.
Peeters Piot P. Adhc.ion of Cxmfnm/M V<ljptllllisto vaginal epithelial
cells: Variable. affecting :tdhc.ion :tnd inhibition of MelrOnidazole.
Cenitourin 61:391-395, 1985.
 INFECTIONS IN GYNAECOLOGY

27 Pelvic Inflammatory Disease 29 Sexually Transmitted Diseases Including

28 Tuberculosis of the Female HIV Infection
Gen itaI Tract

336
 Pelvic Inflammatory Disease
Pelvic lnRammotory Disease 337 Key Points 346
Chronic Pelvic lnRammotory Diseose 343 Self-Assessment 346
Rare Variety of PID due to Actinomyces 346
PELVIC INFLAMMATORY DISEASE
Pelvic inflammatOI)' disease (PID) im plies inflammation of
the upper gen ital tra ct invo lving Lh e uLerus, fallopian tubes
as well as tl1 e ovaries. Because mosL cases of the PLDs are due
to ascending or b lood-borne infec Lion, the lesion is often
bilateral, though one LUbe may be more affected than the
other. The ovaries are so closely linked to the fallopian
tubes anatomicall) that they are incidentally involved in all
infecLions, and it is t11erefore cusLomal)' to consider inflam-
mations of the two organs together. The only excepLion w
this is invohement of onl) ovaries in mumps where the
fallopian tubes are not affected.
AETIOLOGY
Normally there exist SC\CI'lll nawml ban·iers LO the ascemof
pathogenic organisms from the vagina LO the fallopian
tubes. lmact hymen p1-events ascending infecLion. When a
young, unmanied girl presents witl1 PlD, it is more likely w
be tubercular in natlti'C.
The acidic pH of the vagi nal secreLion inhibits tl1e growth
of bacteria; the cervical canal has a relatively small lumen and
is nonnally filled witJ1 a plug of alkaline mucus. T he ciliary
movement of endomeuial lining in tJ1e uterus and the cervi-
cal canal is dir-ected downwards and discourages the upward
spread of nonmotil e organisms to the cavity of the uten1s.
This nalllral protective mec hanism is impaired during men-
su·uation, after aborLi on and delive l)\ as the cervical canal
becomes di lated, the proLecting ep itJ1e liu m of the endome-
u·ium is shed, and raw surfaces are presem in the cavity of the
uterus. The vaginal pH is rendering the gen ital
u·act more vu lnerable LO infection. ln addition to these
factors, intrauteline manipulaLions such as curettage for
e\·'llcuaLion in aborLion and manual removal of placenta
favour enU) and spread of pat11ogenic organisms. Intrauter-
ine contracepLive device (IUCD) is also a source of infection,
particularl) when it is not inu·oduced tulder aseptic condi-
tions. or introduced in the presence of a vaginal infection.
The most common cat.LSe of PID is sextudl)' trrmsmiUed
dileases (STD), tl1e incidence of which has 1isen in tl1e past
20 )'Cars. Gonococca l and chlam)'d ial infec Li ons are two
most common causes of aclll.e PID; tJ1e incidence of these
two cat.LSes vades in d ifferent co mmuni Lies. AboUL 60%-75%
of PLDs are caused by STD, of wh ich gonorrhoea acco tuHS for
about 30% in tl1e developed countries. The importance and
high incidence of chlamydial infection has been recognized
witl1 availability of culture faci li Lies and enzyme-linked immu-
nosorbent assay (EUSA) kits. Penicillinase-producing gono-
cocci resistant to penicillin have also been idenLified recently
in cultures in 2%-10% of the cases.
Gonococci and Cltill'nt)'dia travel up t11e genital u-act
along the mucolLS memb1-ane to reach the fallopian tubes
and calLSe salpingo-oophoritis. The organisms probably ride
up t11e tract along with t11e motile spe,·ms in a piggy-back
fashion. Sperms also help in transpo,·tation of Tricho11umas
similarly. Other organisms directly ascend along the lining
of the genital tracL This partly explains the absence of
gonococcal inflammatory disease in a woman whose
husband is ;uoospennic. Chlltmydi<t infection (obl igate
Gram-negative intracellular organisms) remains asymptOm-
atic in tl1e endocervix or produces minimum symptoms,
and tl1erefore tl1e infection goes unnoticed and unu·eated,
but the damage it causes to the tube is more devastating
than with gonorrhoea (fivefold). T he ce rvix and tl1 e urethra
are the common sites where Chlmnydirt lodge and ascend
upwards. The incide nce of thi s infection is noL easy to find
o ut in many coun u·ies beca use of tJ1e lack of culture facili-
ties. The development of immunological tests has now
made iL possible to detect tJ1c an Libodies in t11e sera of in-
fected patients. Gonococc i and Cltll11n)'dirt create an environ-
ment for seconda1)' invasion by other o rgan isms nonnally
residing in tl1 e lower gen ita l tract. OtJ1er organisms which
can caLLSe PLD include (i) mycoplasma (MycoplttSITUt hominis
and M. (ii) wbercle bacillus, (iii) viruses and
(iv) coli (30%) (Table 27.1 ).
Mycopuwrw lwmini.; is isolated in 50% of sexually active
women. but detected in onl) 7% of PID cases. MycoputSITUt
gmitalium is now a new organism that is seen to cat.LSe PlD.
Bacterial vaginosis can also cause upper genital tract infec-
tion. These organisms reach t11e Lube ,-ia the lymphatics
b) passing the endomeu·ium.
337
338 SHAW'S TEXTBOOK OF GYNAECOLOGY

despite tl1e Governme nt of India's liberal policy on

Table 27.1 Organisms Responsible for Pelvic induced abortions. Prutabortal ami puPrperal sepses are
Inflammatory Disease
therefore common occu1Tences. It is estimated that about
40%-50% of all PID cases in t11 e developing COtul tries are
Sexually transmitted
caused in this manner and t11 e rest by STDs.
Gonoooocus
Chlamycia • Minor operative procetlum such as Dilata tion and Curettage
Myooplasma and hysterosa lpingogram and o t11 er procedures can cause
Trichomonas ascending infectio n. 1\lanual removal of placenta and
Pyogenic evacuation of proclucLS of conceptio n are other imponant
Aerobes sources of infectio n in t11e upper genital u-acL
Staphylococci • The use of IUCDs has increased the incidence of PID
Streptooocd threefold. Most infections occur at the time of insertion
E. coli of IUCD. By observing proper asepsis at t11e time of
Anaerobes
insertion of IUCD, PI Ds ca n be avoided. This is not LO
Bacteroides tragi/is, Peptococcus, Clostridium
Actinomyces
condemn tl1is method of fami ly planning, but tO empha-
• Tubercu i<r salpingit is size the need for suict asepsis during insertion of the
device and careful follow-up of t11 e women wearing these
devices. Cram-positive anaerobes is reponed
in 7% of LUC D users, if t11e device is worn fo r more than
T he polym icrobial naw re of this infec tio n has been 2 years as against I % in non users. ft. is imporlfmtto note tltal
obse rved a nd some 40 mi croo rga nisms, bo th ae robes and barrier fmroen l. S 'IV mul fJehJit irifection.
anaerobes, have been im plicated in of PLD: • of tl1e fa llopia n tubes is blood bo rne in most
Aerobes. Bo tl1 Cram positive and C ram negative. cases and rare!)' ascend ing in naUi re.
Jrogilis (20%), fusobacteria, B. mela- • Pewic d ue to append icitis and d ive rticulitis may
ninogeuicu:,, anaerob ic cocci suc h as pep tococci and pepto- spread LO involve the fallopian tube of that side.
su·eptococci, clos u·idia, facultative anaerobes, Actinomyces
(Cram positive) and H. coli (30%-40%) . The PLD is a disease of young women, who are sexually
The infection by anaerobic organisms is greatly favoured and reproductively active. The promiscuity and frequent
by blood loss, anaemia a nd tiss ue damage such as infection change of sex partners are main I) responsible for PID in tl1e
occurring in sepLic abortion. A polymicrobial infection in developed countries, and a mongst sex workers. About 75%
PLD mandates the adm inistration of more than one antibi- cases of PID are due to STDs in t11e developed counuies.
otic covering Cram-positive, Cram-negative and an aerobic Septic abortions and puerpe•-al sepsis are t11e importam
bacte•·ia. a etiological fuctors in the developing co tmu·ies (Fig. 27.1 ) .
Ste1iliaLion operation pre,ents PID b)' blockage of the
• In India like many o t11er developing countries, many tubes. Apart from baiTier conu-aceptives, progestogen-
delive1ies are conducted at home by dais (untrained containing pills pro duce a tl1ick plug of mucous in the cervi-
midwives). Criminal abortions continue LO mke place cal canal and pre-.ent ascent of microorganisms.

'----Crypts of endocervix

Figure 27. t Sites of pelvic infections.

 12-1 .

35.1 .
751 .

I 2 3 339
pvev CHAPTER 27 - PELVIC INFLAMMATORY DISEASE

Westrom (1975) reported that women with one previous

attack of PLD are predisposed to ano ther attack in 12% of
t11e cases. Two attacks of PI D increase t11e risk to 35% and
t11ree attacks to as much as 75%. Golden (2003) reported
8% recun·ence in a woman witJ1 previous PLD versus l %
occu•·rence wim no histor> of PID previously.

PATHOLOGICAL ANATOMY
ACUTE SALPINGITIS
ln acute salpingitis, t11e fallopian tubes are swollen, oedema-
LOLlS and hyperaemic with visible dilated vessels on the peri-
toneal surface. ome degree of serous exudation is seen
around t11e fallopian tube. The sure sign of salpingitis is the
discharge ofse•·opurulcnt fluid from the fimb1ial end of the
tube at t11e Lime of laparoscopy or laparotOmy.
The mucous membrane is oedemawus, infiltrated wit11
leucocytes and plasma cells. In ascend ing infection, as seen
in gonorrhoea, t11e mucous membrane is first affected. The
inflammatory ex udate is discharged imo t11e lumen of
t11e tube which now distends, ma inly at the amp ullary end. Figure 27.3 Normal fall opian tube between Isthmus and ampull a
Note the convolutions of the pli cae.
The ulcerati o n of the muco us membrane t11at follows
leads to adhesions and Utbal b loc kage or narrowing of the
lumen which ma)' subsequen Ll)' be th e cause of inferti lity or ova•')', the sigmoid colon, adjace nt coils of intestine and
ectopic pregnancy (Fig. 27.2), compared with me normal posterior surface of the uterus. The wa ll of the tube is
pregnancy (Fig. thickened and the tube is tense wit11 pent-up fluid
Ln early stages, when the fimbrial end is not closed by (Figs 27. 1 and 27.5). On a rare occasion, t11e infection may
adhesions, pus pours out into t11e pelvic cavity causing pel- spread upwards to cause generalized peritonitis, paral)'l:iC
vic abscess. Even wall), with t11e sealing of me fimbria! end ileus and pelvic or even subdiaphragmatic and perinephric
by fibrinous adhesion, pus accumulates in the tubal lumen. abscess. Septic tJuombophlebitis, bacteraemia and meta-
The ovaries are imolved and a wbo-ovarian abscess (TOA) static abscess are rare nowadays, because of a prompt and
or tubo-oval'ian mass results, botJ1 getting sun·ounded by effective antibiotic t11erap).
adhesions. The ampullaq po•·tion of the wbe distends ln PLD following postabonal and pue•·peral infection,
more than the istJ1mic po•·Lion, resulting in a retort-shaped the pamogenesis is different. The infection spreacls tJuough
p)osalpinx. An acute p)Osalpinx is su•-rounded by adhe- the cervix via l)lnphatics to the cellular tissue in the broad
sions which fix it to the back of t11e broad ligament, the ligament, causing cellulilis. The fallopian LUbe is affected
from me outside and t11e mucosa last of all. The wall of t11e
tube is thickened considerably witJ1 hardl)' any distension of
the lumen. Evenwal involvement of mucosa ends up in
blockage of the fallopian tube by multiple imraluminal
adhesions.

Rgure 27.2 Acute suppurative showing the tubal plicae Figure 27.4 Bilateral tubo-ovarian abscess. II was impossible at
infiltrated inflammatory cells, desquamation of the surface operation to define or separate the ovaries from the tubes. (Soun::e:
epithelium and a transudation of inflammatory cells into the lumen of Pl.blc OOillail-&ookSde Press. http· IWWN.brooksidepress..OI'QI1"rrdJCts/
the tube (x48). Milltary_OBGYN/Textbook/ProblemSIHydrosalpinx640.pg.)
340 SHAW'S TEXTBOOK OF GYNAECOLOGY
Rgure 27.5 A retort-shaped pyosalpinx. (Soun::e: H. Fox (edloc1,
Haines and Ct>stetrlcal and Pathology, 3rd ed.,
London: Chtxdlil Ul.ingstone, 1987, pp. 411-456.)
Subacute PLD results from inadequate treaunent or from
reinfection by the infected panne r. Tube rculosis also mani-
fests in the form of rec un·ent pelvic infec ti o n due to second-
ary infec ti on.
CHRONICPID
Failure of acute pelvic infection to resolve or end resu lt of
ac ute infec tion results in chro nic wbo-ovarian masses.
These masses man ifest in the fo llowing forms:
• Hydrosalpinx
• Chronic p)Osalpinx
• Chronic imerstitial salpingitis
• Tubo-ovarian C)St and TOA
• Tubercular tubal-ovarian masses
Hydrosalpinx 27.6 ond 27.7)
H)dro.salpinx is the distension of the fallopian tubes by coUec-
Lion of fluid in the lwnen. If a p)Osalpinx or TOA responds to
antibiotics, the pus contained therein becomes ste•ile within
6 weeks of the initial auack, but the damage to the tube persistS
presenting as chronic p)osalpinx or h)drosalpinx.
A hyd•·osalpinx •·epresents the end result of a previous
acute salpingitis, and is often bilateml. It is retort-shaped
Rgure 27.6 Right-sided hydrosalpinx. The left appendage shows
less obvious but well-marked chronic salpingitis.
Figure 27.7 Hysterosalpingography showing bilateral hydrosalpinx.
swelling of th e wbe d ue to enormous d ilatati on of the am-
pullary region fi lled with a clear flu id and ma)' be as large as
15 em. The fimbria! end of the fa llopian tube is usually
closed; fimbliae are indrawn so that the o ute r SUJface of the
hydrosalpinx is smooth and rounded. The interstitial end of
the tube is curiously paten L, as Lhe dye can be visualized in
the ILtmen during hysterosalpingogram (Fig. 27.7). The wall
of the hydrosalpinx is thin and tmnslucenL At Limes, the
hydrosalpinx is mobile and can undergo torsion. Quite of-
ten, however. the outer surface is covered with adhes ions
which fix the h)drosalpinx to the back of the broad liga-
mem and the pouch of Douglas (POD). Histology reveals
flauening of the tubal plicae and exfoliation of the lining
epit11elium (Fig. 27.8).
Chronic Pyosalpinx (Figs 27 4 ond 27.5)
A chronic p)osalpinx is thi ck-walled swelling of the fallopian
tube, surrounded by dense adhesions and filled ''1th pus.
The inner wall is •·eplaced by a granulation tissue. A pyosal-
pinx is often fixed to t11e POD, poste•·ior surface of t11e
broad ligament and t11e uterus by dense adhesions.
Figure 27.8 The wall of a hydrosalpinx. Note the flattening of the
plicae (X360).
 CHAPTER 27 - PELVIC INFLAMMATORY DISEASE 3.41

Table 27.2 Stages of PID

Stage I- Acute salpingitis without peritonitis- no adhesions

Stage II - Acute salpilgitis with peritonitis - purulent discharge
from tubal ostia
Stage Ill - Acute salpingit is with superimposed tubal occlusion
or tubo·ovarian complex
Stage IV - Ruptured tubo-ovarlan abscess
Stage V - Tubercular salpingit is

Chronic Interstitial Salpingitis

In chronic imerstilial salpingitis, the wall of the fallopian
l.llbe is thickened and fibrotic, but there is no accLumtlation
of pus in tJ1e ILtmen. Involvement of the ovary in adhesions
resu ll.S in chronic salp ingo-oophoritis.
Tubo·Ovarian Cyst
Figure 27.9 Ult rasound showing pelvic abscess.
In Utbo-ovaria n cyst, a hyd rosa lpinx co mmunica tes with a
fo ll icul ar cyst of the ovary, whi le in TOA, pyosalpinx com·
arising from th e pelvis may be palpable. Speculum examina-
municate with an ovarian abscess. It is difficult to identify a
tion shows pLtrulem discharge from the ce•,•ical canal. A
normal ov;u·ian tissue in these pathological conditions.
torn cervix or damaged tissue is evident in postabonal sepsis
Tuberculous Form and criminal abortion. Swabs should be taken fi·om the cer·
''ix and high 'oagina for culture. In an acute stage, cen•ical
Pelvic tuberculosis is described in Chapter 28.
movement tendemess and tendemess in tJ1e fomices are
the onl) evidence of infection. Later (Fig. 27.10),
STAGING tender pelvic masses are felt in the lateral fornices. These
The spectrum ranges from mi ld-to-moderate and severe are fixed and at times palpable behind the utenLS in
PI D. Depending upon the severit)' of lllbal damage, Ga ines- POD. A pelvic abscess prod uces a n uctuating Lender
ville has described five stages of PID (Table 27.2). swelling in the POD, bulging into th e posterior fornix.
TOA fo 1mati on occ urs in 30% of the cases of PLO and is a
freq uent reason for hospitalizati o n.
SYMPTOMS AND SIGNS OF PID
ACUTE PELVIC INFEGION DIFFERENTIAL DIAGNOSIS
A )Otmg, sexually active woman is prone to PlD. The most ACUTE APPENDICITIS
common S)mptom of acute PLO is alxlominal pain. It is bilat·
era! and restricted to tJ1e lower abdomen. Pain spreads up- In appendicitis, the pain is initiall)' central, arow1d tJ1e
wards if generalized pe1i1.0nitis ensues. It is severe in me umbilicLLS and men localizes to the right iliac fossa. Vomit-
acute stages and is accompanied with high-grade fever. Vom- ing is severe, buttempera[Ure is not as high as in PIO. The
iting may also follow. The sexually U"l!nsmitted organisms may
cause dysw·ia and vaginal discharge. Mensu·ual inegularity, if
any, is d ue to preceding endomeu·itis in a case of ascend ing
infec ti on or clue to the amecedent aborti on or de livery. T he
pmie nt may develop abno nn al ute rine b leeding at a time
when mensuuation is not expected and the bleeding is often
profuse and prolonged. In criminal abortion, tJ1e patient may
deliberately conceal me history ofamenoni1oea, making tJ1e
diagnosis more difficult. ln case of a pelvic abscess (Fig. 27.9),
in addition tO me above S)lnptoms, the patient develops se·
ve•·e dianiloea and passes small and frequem loose motions
clue to rectal initation. ln chkmrydial infoction, symptoms are li!ss
pronounced and often tm asymptomatic course.
The patient witll acute PID looks ill with high tempera-
ture ( I 03-104°F). Tachycardia is present, and the tongue
shows deh)•dration and is coated. Abdom inal examination
shows distension co mbined with te nde rness and rigidity in
the lower abdo men . It is rare for an abdom inal swelling to
be palpated in ac ute salpingo-oop horitis. as me ten-
derness becomes less witJ1 treaw1ent, a tender fixed mass Rgure 27.10 Ultrasound showing a pelvic mass.
342 SHAW'S TEXTBOOK OF GYNAECOLOGY
lower margin of Lhe append icular mass can be reached, but
tl1is is not so in case of PI D. Vagina l discharge and
menstrual irregulariLies are absent in acute appendicitis.
EGOPIC GESTATION
Amenoniloea followed b) irregular uterine bleeding and
abdominal pain are tlle characteristic features seen in ecto-
pic pregnane). Cervical movement pain and a tender mass
dLUing per vaginal examination are tlle feawres of ectopic
pregnancy. Ca·iminal abo•·tion with history of amenorrhoea
may mimic ectopic pregnancy. Mostly temperature is nor-
mal or only slightly raised in ectopic pregnanC)'· The signs
of internal bleeding are absent in PID. Vaginal discharge,
leucocytosis and 1-aised erythrocyte sedimentation rate
(ESR) go in fuvour of a diagnosis of PID. Ulu-asound may
reveal bilateral tubo-ovarian masses.
DIVERTICUUTIS
Di verti culi tis may s imulate t11 e clinical p icture of PID, but it
usually seen after the age of 50 yea rs, whe reas PID is a
d isease of the yo ung, sex ua ll y ac tive fe ma les. T he signs of
infec ti o n are co nfined to the left iliac fossa in diverticulitis.
A TWISTED OVARIAN CYST
A twisted ovarian or paraova•ian C)'St (fimbria! cyst) causes
sudden pain in tile abdomen with vom iti ng, b ut pyrexia is
usually absent or of very low grade (Fig. 27. 11 ). Menstrual
irregularity and vaginal discharge are absent, and an
abdominal lump is felt distinctly, which is usually tender.
The nonnal-sized uLerus is felt separate from the lump.
Ulu-asound is helpful in making a diagnosis.
l nflammatoq bowel diseases and urinary u-act infection
are associated with bowel and tuinal') spnpLOms, and do not
usually ha,•e high fever o•· vaginal discharge.
RUPTURED ENDOMETRIOTIC CYST
Rupture of an endometriotic C)St is not a common event;
however, in ra•-e situation a ruptured endomeu·iotic cyst can
be mistaken fur PID. The patient with endomeu·iosis will
have suffered dysmenord1oea, meno•-rhagia and pelvic pain
before this acute episode. 13esides, the patient is afeb1i le
and has no vaginal discharge.
Rgure 27.11 Laparoscopy revealed torsion of fimbria! cyst (para-
ovarian cyst) to be the cause of acute abdominal pain.
SEPTIC ABORTION
Septic abortion may mun1c Lhe clinical features of PID;
amenorrhoea preceding tile abdominal pain is present in
septic abortion. A detailed clinical evaluation will help in
establishing a diagnosis of septic abortion. The treaunem
with antibiotics is similar in boLh t11ese conditions.
fitzhugh antis
CHOLECYSTITIS
Occasionally, a woman witll PID complains of acute right-
sided upper abdominal pain simulating cholecystitis. This is
due to a fib•·ous band extending from tlle right adnexa to
the under surface of the liver in PI D caused by gonococcal
and chlam)dial infection. This goes by the name of
Fiu.-H ugh-Cunis S)•nd•·ome.
INVESTIGATIONS
Clinical diagnosis of PID is acc urate in o nly 65%-70% cases,
a nd specific investi ga tions arc req uired to co nfirm the
diagnosis as we ll as to identi fy Lhe offe nding o rga n isms.
• Haemoglobin.
• Blood co unLS reveal rise in tot.a lle ucoc)•te co unt.
• ESR is also raised.
• Ceroical and high vagi11al swab wltnw for both aerobic and
anaerobic organisms is necess.1ry. Urethral swab culture
should be done, if gonorrhoea is suspected. For chla-
mydia! infection, a long-wire swab tipped witll calcium
alginate is used to collect the specimen from t11e tube,
tLretJHa and endocervix, and this is inoculated on cyclo-
heximide-treated McCo) cells for culture. Serological
microfluorescence test for detection of lgM and lgG anti-
bodies is useful. Pol) me1-ase chain reaction (PCR) test is
now a\<ailable for ActinOm)COSis is difficult LO
culture and is diagnosed histologically.
• To diagnose dtftllll)'dia, a culture from the endoce•vix is
necessary. Di1-ect chlam)dial en£yme immunoassay and
direct immunofluo1-escence examination of the smear
are also useful. In case of IUCD, vaginal smear should be
studied for the presence of Actiuomyces.
• Blood wltwrds needed if t11crc are features of septicaemia.
• Blood urea and serum electrolytes.
• Uriue can be tes ted by PC R for chl amyd ia! infec ti on.
One must be awa re, however, t11 at a hi gh vaginal swab
cultu re does not always indicate o r rep rese nt the bac te rial
flora p resen t in the upper gen it.a l trac t infec tio n. Atte mp ts
LO cultu re laparoscop ically asp irated material o r culdoce nte-
sis aspirate have been unSl\tisfactOI')'· Mo reover, gonococci
and chlamydia, which are t11e primary organisms involved,
are diffic ul t to culture once invasion by other pathogens
OCC LLI'S.
• in the past was used frequently LO rule out
an ectopic pregnane> and to establish tile diagnosis of a
pelvic abscess.
• LapMosropic examination though recommended and
pmcliced b) some should not be used in routine p•-actice.
This investigation is limited to cases in which diagnosis is
uncertain and it is not easy to aspimte pus for cultw·e.
T he pus extruding fro m th e fimbria! end and peritubal

adhesions is a sure sign of P ID. O th er signs of pelvic
infection besides e xudates are hyperaemia of tl1e fallo-
pian LUbes, oedema a nd fibrinous band of adhesions in
peri hepatic space (Fit:t.-llug h-C urtis syndro me ) men-
tioned above, seen in 15% of cases.
• Gm-1droe protein, an acULe-phase reactam protein generated
in response Lo innammation, is increased to 20-30 mg/ dL
or more, and it helps LO diSLingu.ish between infective and
noninfective mass.
• Ultrasound, computed tomQgraphy (C!J amlmagnd.ic Tl!SlJIIfJIIce
imaging (MRJ). TOA appears on ultrasound as a complex
C)Stic adnexa l or cukle-sac mass with thick in·egul:u· walls
a nd septations. ILoften contains imemal deb•·is :u1d echoes
(Figs 27.9 and 27.10). This is safer and noninvasive com-
pared LO laparoscop>: 3 D and 4D ultrasonography is used
nowadays LO define Lubo-oval'ian masses.
CT s hows a sp he ri cal o r tubula r strucwre, with a low at-
te nuation cen u·e, in add itio n to thi c k walls a nd septations,
but it is diffic ult to diffe re nti ate it from e ndometriosis. In-
te rn al gas bubb les, if see n, a re pa thognomon ic of inflamma-
to ry mass.
MRI does not provide mo re specific info nna tion than
ultraso und , and is muc h more expensive.
It iJ importtmt to the all msfs of PID for HfV and other
sexually infectiom. The parme r s ho uld also
w1dergo inves tigations fo r sex ually u·ansm ined infections.
In a menopau&"\1 woman, who-ovarian mass indicates prob-
able malignancy a nd sho uld be invest.igated accordingly.
CHRONIC PELVIC INFLAMMATORY DISEASE
The hisLOq of pre' ious pel' ic infection helps in tl1e diagncr
sis, but often this history is not fo•·thcom.ing and not
recalled by the patienL The patiem complains of constam
lower abdominal pain which geLS worse before mensu·ua-
tion. Low backache and deep d)spareunia caused by pelvic
masses prolapsed in the POD are common compla.ims.
Vaginal discharge may be absem and if presem, may be due
to chronic cervicitis. Meno•·rhagia, polymenon11agia, and
congestive dysm e non·hoea are aw·ibuted to chronic pelvic
congestion. Infe rtility results fro m blockage of the fall opian
tubes. Rectal irrita tio n may be complained of by few
patientS. T hese cle bilita ting symptoms ac t upo n the general
health of th ese patie nts. Abdom ina l pa in is due to pelvic
adhesions o r s upe rimposed infec tio ns.
Pe lvic exa mina ti on in c hro ni c PID is less painfu l than in
th e ac m e stage of the disease. The appe ndages are fo und
to be tender, thi c ke ned and fixed, a nd a n assoc iated fixed
retroversion of ute rus is a very co mmon finding. At times
tl1 e uterus and appendages are dense ly ad herent tO each
other, so the uterus ca nnot be defined separately from t11e
pelvic masses, thus forming a fix ed hard mass. A ' frozen
pelvis' is tl1 e descriptive term used in these cases.
DIFFERENTIAL DIAGNOSIS
frozen pelvis
Ectopic Gestation
Chronic ectopic pregnancy ma>' be easil)' mista ken for PID.
Pregnancy Lest, ulu-asound a nd laparoscopic examinat.ion
"ill confirm the diagnosis of ectopic pregnancy.
CHAPTER 27 - PELVIC INFLAMMATORY DISEASE 343
Uterine Fibroids
The sympLOms are very so also tl1e pelvic findings if
appendages are adherent to th e ute rus, giving ll1e impres-
sion of at1 irregular e nlarged utems. Fixi ty and tendemess
however go more in fmour of c hro nic PI D.
Pelvic Endometriosis
Pelvic e ndometl"iosis produces similar clinical features as
chronic PIO. Laparoscopic examination will confinn ll1e
diagnosis.
Ovarian Tumour
A benign ovarian tumour is often unilateral and causes
neitl1er menstrual pmblem nor dyspareunia. A malignant
ovarian wmour usuall y occu•-s in elderly women and is rap-
idl y growing; he nce, sympto ms com e up faste•· than in
chronic PI D. T he te ncle mcss is abse nt in a n ova 1i an tumo ur.
Ultrasound examina ti o n, CA-125 a nd fine-needle aspiration
cytology (FNAC) ca n be useful.
Tubercular Tubo·Ovarian Masses
Tubercu lar tubcrovali a n masses may present as rec urrent or
chronic PIO. It is some tim es uni la te ra l. Laparoscopic
e xamin a tion, endo me uia l b iopsy a nd c ulture he lp in estab-
lishing the diagnosis. PCR tes ting of e ndomeu·ial tissue can
also be done.
TREATMENT
A.im is to u·eaL infectio n, minimi:te wbal damage and pre-
vem adhesions. thus avo iding sequel of tubal damage.
TREATMENT OF ACUTE PID
The mild cases of acute PID are u·eated at home with
antibiotics. Moderate a nd se'ere cases of acute PIO need
hospitali.t.ation.
Treatmem modalities comprise following:
• Medical treaunent, antimicrobial
• Minim al invasive surgery
• Major surge•-y
Syndromic mat1agem ent - labo rato r-y tests take tim e and
may delay the trea tme nt. To avo id sequelae s uc h as blocked
tubes, chronic pelvic pain a nd infe rtili ty o r ec top ic preg-
nancy, tl1e mode rn manage me nt is to initiate antibiotics
whi le waiting for the fina l reports. This a s ma ll risk of
unn ecessaq' u·eaun e nt o r ove rtreaune nt, but is worthy.
Hosp ital manage ment consists of followin g:
• Rest.
• lnu·avenous nuids in the presence of dehydration or vom-
iting and correction of e lectrolyte imbalance. Ryle's rube
aspiration may be needed in periwnitis or distension of
abdomen. in which case correct intake-output d1art
should be maimained.
• Analgesics. o nce the diagnosis is co n finned.
• A11tibioticJ.. Because of the damaging effect of gonococci and
cldamydia o n tl1e fallopian wbes a nd pol)lnicrobial nature of
tl1e infection, it is mandaLOI)' to instiwte antibiotic ll1e1-apy
at the earliest and not wait for the cultw·e resultS.
344 SHAW'S TEXTBOOK OF GYNAECOLOGY
l n most cases of PI D, bo th ae robes and anaerobes form
t11e bac terial flora, hence it is essemial to administer combi-
natio n of a ntibiotics to cure the disease and preve nt perma-
ne m damage to the fallo pian tu bes. Initially, intraveno us
route is resorted to, but as the infection settles down, o ral
me rap) ma> be started . When t11 e cui LU re re port is available
or if the patient fails to respo nd to the antibio tics, an
appropriate change in the antibio tic tllerapy will be needed.
Antibioti cs effective a •·e as follows:
• At.ithrom)cin 500 mg for 14 days.
• Oox) C)cline 100 mg b.i.d. for 14 days.
• Clindam)cin 450 mg q.i.d. for 10 da)S.
• Gemamyci n 80 mg IM 8 hourl y for 5 days.
For managing a case of PI D, t11e guidelines given by CDC
are extremely useful a nd h elp in bette r management of a
case (Table
Table 27. 3 CDC Guidelines for Treatment
of PID (2015)
Recommended Parenteral Regimens
• Cefotet an 2 g l.v. every 12 hours
PLUS
• Doxycycline 100 mg orally or l.v. every 12 hours
OR
Cefoxltln 2 g i. v. ei.'Bry 6 hours
PLUS
Doxycycline 100 mg orally or I.v. every 12 hours
OR
Cllndamycl n 900 mg l.v. every 8 hours
PLUS
Gentamicin loading dose i.v. or l.m. (2 mgl kg), followed by
a maintenance dose (1.5 mg/ kg) every 8 hours. Single daily
dosing (3-5 mgl kg) can be substituted.
Alternative Parenteral Regimen
Amplcilln/Sulbactam 3 g J.v. every 6 hours
PLUS
Doxycycline 100 mg orally or i.v. every 12 hours
However, fo r subac ute cases or tllOse wh o can take anti-
bioti cs orall y, a regime n has been suggested by CDC as given
in ·rable 27.1 .
T he side eJJects of clincla m)•Cin are skin reac tion, nausea
and vo miting. O tl1e r anti bio ti cs useful a re cep halosporins,
and pe ni cill in witll be ta-lact""mase inhi bitors.
T he fo llowing are the newe r antib iotic regime ns:
1. Cefoxitin 2 g i. v. &-ho urly+ Doxycycline, 100 mg i.v. fo l-
lowed by o ral ro ute .
2. Azitl1romyc in 500 mg i.v. &-ho urly for 2 days, then orally
fo r
3. Ofloxac in 400 mg orally b.i.d . for 14 days. Cefo tetan 2 g
i.v. 12-ho url) plus clOX)Cycline 100 mg b.i.d. o rally/
i.v.. Drugs are co ntinued fo r at least 48 ho urs after the
clinical imprO\eme nL After the discha rge from the
hospital. dOX)C)cline is co ntinued 100 mg fo r 10-14 days.
4. Levofloxacin 500 mg b.i.d. fo r I I days with or witllOut
meu·o nida.t.Oie.
Table 27.4 Subacute Cases Who Can Take
Antibiotics Orally (the fo llowing regimen
have been suggested by CDC)
Recommended Intramuscular /Oral Regimens
Ceftriaxone 250 mg l.m. In a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
OR
Cefoxltin 2 g i.m. in a single dose and Probenec id, 1 g
orally administered ooncuiTently In a single dose
PLUS
• Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHO UT
• Metronidazole 500 mg orally twice a day for 14 days
OR
• Ot her pare nteral t hird-generation cephalosporin (e.g.
ceftizoxime or cefotaxlme)
PLUS
• Doxycyc line 100 mg orally twice a day for 14 days
WITH or WITHOU T
• Metronidazole 500 mg orally twice a day for 14 days
5. Clindamycin 900 mg i.v. every 8-ho urly plus gentamicin
in a loading dose i. v. or i.m. (2 mg/ kg) fo llowed by main-
tenance dose (1.5 mg/ kg) 8 ho urly (regimen co ntinued
for at leas t 48 hours afte r tl1 e clinical improvement) .
After discharge fro m tl1 e hospi tal, do xycycline is given
100 mg b.i.d orall) fo r 10- 14 days or clindamycin 450
mg orall) <I times a da) for 10-14 days.
ewer cepha lospo.-ins, i.e . ceftiLo xime, cepha lota.x ine
a nd ce fuiaxone, may be gi, en. In penicillin-resistant gono-
cocci, a moxicillin 3 g orally, metronidaLole 500 mg i.v.
8-hourly, and ;uitluom)cin I g single dose for gonon-hoea
and chlamy<lia a•·e tl1 e alternatives.
Royal College of Obstetricians and GynaecologistS
(RCOG) green top guideline n ow recommends a single
close of i.m. Cefu·ia.xo ne 250 mg followed by oral doxycy-
cli ne 100 mg twice daily witl1 metro ni dazole 400 mg twice
daily for 14 clays as outpa ti e nt trea tme nt o r ceftriaxone i.m.
followed by Azith romycin I g per week for 2 wee ks.
Partner shoul1l be ond treated. T here is no need
to remove IUC D if the woman responds to antib io tics. A
failed response calls fo r its removal. Ba n·ie r co ntraceptives
s hould be reco mm ended Ulcrcafter.
Surgical Treatment
SLU·gery may be needed fo r tl1e fo llowing:
• Drainage of a pe lvic abscess b)' colpoto my (Fig. 27.12) .
• Dilatatio n and evacuation o f septic products of co ncep-
tion o r fo r hae morrh age in postabona l se psis.
• Acute spreading pe .-ito ni tis no t respo nding to a ftLII
co tu·se of d1 e mo th erap). The prese nce of pocke tS o f pus
in pelito neum ma ndates laparo tOm). Laparo tomy, drain-
age o f p us and inse•·ti on o f drainage may be lifesaving.
• Intestinal obsu·uctio n.

Figure 27.12 Posterior colpotomy for pelvic abscess.
• Suspected intesLinal irti ury in a ctiminal abonion.
• Ruptured TOA.
Minimal Invasive Surgery
Minimal invasive surgery may be possible in selected cases
for following conditions:
• The si£e of the abscess is more 1J1an 10 em.
• The abscess fails to respond to antibiotics in 48-72 hours.
• Abscess collection in POD.
• Pockets of pus collection in abdomen or peh·is.
Ultrasound·guuled Vllginol ospimtion of pelvic abscess with
or without drainage )ields 70% success. Sequelae include
rupture of abscess du•·ing aspiration, pelvic vein thrombosis
and chronic infection.
Perrutmuoul ahlceM llrainage (PAD) under CT/ ultrasound
guidance of abdominal mass and pyope•·itOneum yields
50% success and reduces the need for major surgery, with
its associated morbidity a nd mo rta li ty. It also preserves the
ovatian funcLion and s ho rtens the hospital stay.
bowel injw·y is a risk in abdom inal dra inage.
Disrulvrm111gl'.l of PAD are septicaem ia, bladder and bowel
inj ury, haemorrhage and rec urre nce.
Minimal invasive surgery may resu lt in late complications
of recw1·ence, chronic PID, LUbal blockage and chronic
pelvic pain. The minimal surge •)' has th e advantage of
minimal ovarian tissue damage in youn g women.
SURGICAL TREATMENT OF CHRONIC PID
Chronic PLO neecls a surgical u·eatmem as the condition in·
dicates the end result of acute infection and that some form
of pelvic patholog) has ensued. Surge•)' depends on the age
and parit) of the patient, the S) mp10ms and pathology.
ln a )Oung woman, conservative surge•)' in the form of
salpingectom) and salpingo-oophorecLOmy is pe.-fonned.
When extenshe damage precludes conservative manage-
mentor when the patient is multiparous, total abdominal
CHAPTER 27- PELVIC INFLAMMATORY DISEASE 345
hysterectomy with bilateral salpingo-oophorecwmy is
needed.
ln a mild case of PID adequately treated, the tubal
damage may be minimal but the infection may lead tO infer-
tility. Such patients need some form of tuboplasty/ in-vitro
fertiliau.ion depending on the site of tubal blockage.
Tuboplasty is required if the tubal lumen is blocked.
Hysteroscopic fulloposcop) or laparoscopic salpingoscopy
should assess the extent of clamage and decide the success
rate of tuboplasty.
laparoscopic breaking of extemal adhesions either by
elecu·ocautery is indicated if the tubal blockage is due to
external adhesions.
If NF il conshlered IU!Cf'M(IT)', rrm(IV(Jl of h)vlrosa.Lpinx or
clipj>ing of both ltWel llwulll be wukrtakP11 brfore /VF This helps
to imjJrave lllillii.Ccell mte and jm'llmt oclOjJir pwgnancy will! IVF.
Hysteroscopic balloon p lasty or ca nnulation is success-
ful if the tubal block is due to lumina l debris or a mi ld
stricture.
BOER -
MEISEL
PROGNOSIS
Boer-Meisel S)'Ste m of prognostic evaluation has been
described and depends on fo llowing:
• Extent of adhesions.
• Nature of adhesions, suc h as Oimsy or dense adhesions.
• Size of hydrosalpinx.
• Macroscopic condition of hydrosalpinx.
• Thickness of the tubal wall.
END RESULTS
PiO remains the source of considerable mo•·biclity in the
form of chronic pelvic pain, menot-rhagia, ectopic preg·
nancy (tenfold) and infenilit)\ which would in tum require
further surgical procedures, both investigatoq• and thera-
peutic. Other S)'mptoms are backache, dyspareunia and
vaginal discharge, recun·ent PID.
It has been stated that despite adequate treaunem, 15%
of patients fail to respond to antibiotics, 20%-25% have at
least one t'Ccun·ence and 20% develop chronic pelvic pain
(Te Linde). About 15% of patients suffer from infertility and
8% of th ose who conceive will have an ecwpic pregnancy.
PREVENTION OF PID (Table 27.5)
• Safe and Clean Bitth Practices: Hospita l de livet)' is ideal.
Realizing that the co unU)' ca nnot provide enough beds and
that it is not eas)' for the rural women to come tO the urban
cenu·es for deli vet)', the Government of India has started
u·aining programme for dail in asep tic tedHliques. This
may help t'Cduce the incidence of puerperal infection.
• Safe Abortion Practices: Induced abortions are carried
out free of cost in govem ment institutions tO avoid
criminal abortions in India. Though one contin ues to see
such postabortal septic cases admitted to the hospitals,
the number has de fin itel) come down during t11e last two
decades or so.
• Conu-aception. Ban·ie•- methods prevent STD. O ral
conu-acepti,·es, especially minipills, are also effective.
346 SHAW'S TEXTBOOK OF GYNAECOLOGY

Table 27.5 Antimicrobial Prophylaxis for include the cilia t)' movement of the endosalpinx
Gynaecological Procedures downwards, the petiodic shedding of t.he endome-
Procedure Antibiotics Dose u·ium, the thick cervical mucotLS plug in t.he endocer-
' ical canal and the acidic pH of t.he vagina.
Hysterectomy Celazolin 1-2 g single dose i.v. • The natut-al protecti'e barl"ier may get breached
Celoxltin dut·ing mensu·uation, abortion and the puerperium;
utet·ine instrumentation or the inset·tion of an It..: CD
Celotetan ma) initiate infection.
Metronidazole 500 mg i.v. 8 hourly for • Bot.h aerobes and anaerobes ma) be implicated;
24 hours however, amongst the common causes of infection
are STDs catLSed b) Cltkmr)'dia and gonococci. Septic
Hysterosalpln· Doxycycline 100 mg b.i.d. for
go gram 5days
abortions are often the result of pregnancy termina-
tion carried out under unh)gienic conditions. Bleed-
MTP/D&C Doxycycline 100 mg orally 1 hour ing, anaemia, tissue damage and lack of proper
before and 200 mg asepsis predispose to this life-tlu-eatening condition.
after the procedure • infection usual I)' catLSes chronic PI D. It is a
blood-bome infec tion which affects bot.h t.he adnexae.
• In PI D the patie nt suffers from manifestations such
IUC D ca uses PID in 5%. To avo id PID, it is necessary as abdom ina l pa in, leuco rrhoea, menorrhagia, con-
to see that o nl)' u·ained personnel imrod uce the device ges tive dysmenorrhoea, dyspareun ia, backache and
under aseptic condiLio ns. Vaginal infection sho uld be inferti li ty. The ute rus is ofte n reu·ovened witl1 re-
u·eated before inscnion of the device. sui cted mobi l it)' and the re may be tl1ickening of the
• Sex ed ucation. Young women should be educated regard- appendages whi ch arc painful on palpation.
ing the risk of STD. The awareness of AlDS and its related • Use of ba n·ier conu·aceptives, observance of proper
complications should promote safe sex practices and use asepsis during insu·ume ntal manipulations and a
of ban·ier methods of conu-aception. prompt treaunent of suspected infection are the best
• Female condom known as Femshield has been recemly approaches to safeguat·d t11e patiem fi·om infections.
introduced, which covers the cervix, entire vagina and • Prophylactic antibiotics eluting surgery can reduce
the external genitalia, and is highly effective not only as a incidence of PID.
ban·ier method, but is also protective against AIDS and • Sex education, using ban·ier conu-acepthes, can reduce
STD. Femshield may ha,·e a beLLer compliance than t.he sexually u-ansmiued infections and tlterebya,oid PID.
male condom.
• Contact u-acing and u·eaunent of parmer is also
necessal').
2-6 weeks SElf-ASSESSMENT
2501000 IV iv
gid oral 100
mglhgd I. What are the catLSes of PIOs?
→

RARE VARIETY OF PID DUE 3-12m

TO ACTINOMYCES
ActinmnycPs are anaerobic Cram-positive filamentous, non-
sporing bacteria caus ing infection often associated with
IUC D use. The incidence is 7% wit.h IUCD worn for more
than 2 yea rs aga inst I % in non users. The woman develops
abdom inal pain, abno rmal b leeding and discharge.
Sulp hur gran ul es ca n be recognized. T he infection is
u·eated with 250,000 units/kg dai ly of penici llin i.v. in four
d ivided doses for 2-6 weeks. Thereafter, oral 100 mg/ kg
da ily in d ivided doses is adm inistered for 3-12 months.
Other antibiotics arc tetracycline, erythrom ycin, clindamy-
cin and chl oramph enicol.
KEY POINTS
• PID implies inflammation of the upper genital u-act
im ohing the ULenLS and the adnexa.
• auu-al baniers exist to protect the ascent of organ-
isms from the '<agina to the upper genital tract; these
2. Discuss t11e clinical feawres and management of acute PID.
3. What are the complications and sequelae of PIDs?
SUGGESTED READING
Arulkumaran S. Clin Obstcc Cynaecol 2009, Ehcvier, UK.
Drugs for sexually infections. Treat Cuidcl Med Leu 2004;
2:67.
J effreyS Dung.tn, Lee I'' Shulman. Year Book of Obstetrics, Cynecoloj,ry,
and Women's llealth. 30 I, 2013.
john Bonnar, .J, Ed. Recent Advances in Obstetrics and Cynaccology
16:165, RCOC Press, London 2010.
Soper DE. Pelvic inflammatory dbea..c. Ob>tcl Cynecol 2010; 116:419.
Studdj. Pr<>l,.,. Obitet Cynaecol. 9:2.'19, Churchill Uvingstone, Edinburgh,
1991.
Thompson SE, Brooks C, Eschcnlxtch DA. ct al. Iligh failure r-dles in
outpatient ITeatment of s;tlpingith with either tctrdC)dine alone or
penicillin/ ampiciltin combinat.ion. Am J Obstet Gynccol 1985; 152:635.
 Tuberculosis of the Female
Genital Tract
Introduction 347 Differential Diagnosis 352
Pathogenesis 3 47 Treatment 353
Genital Trod lesions 348 Prognosis 354
Clinical Features of Genital Tuberculosis 350 Key Points 354
Investigations 351 Self-Assessment 354
INTRODUCTION
(TB) has been recognized as a debilitating dis·
ease since ancient times. But the credit for the first authentic
description of genital wberculosis is attributed to NA
Morgagni (1744) who first described the a utopsy findings of
genital tuberculosis in a )Otmg woman aged 20 years who
died of tuberculosis. In his report, he clearly mentioned
that the utems and tubes were filled with caseous material.
Robe•·t Koch discovered the organism Mycobacterium tubercu-
losis in 1882. Since the early pan of the twentieth cemul")',
the incidence of general tuberculosis and iLS consequence,
pelvic tuberculosis ha,·e progressively declined in the devel-
oped counu·ies, so much that the disease has become r:u·e
in man>' indusu·ialited counui es of Europe and America.
However, it still continues to be seen amongst the destitme,
immigrants of Asian and African descent in th e UK and in
tl1e inner city communities of the USA. T he disease contin·
ues to be rampant in develo ping counui es of Latin America
and Asia. It is ende mi c in India. T he ac wal incidence of
pelvic tuberc ulosis is d iffic ult to assess as many patients are
asymptomatic and the d isease often co mes to light on l)'
inciden talI)' dw·ing tJ1 e course of in vestigation for a gynaeco·
logical compl aint. C Schaefe r ( 1970) repo rted that 4%-12%
of women dying from pulm onary tuberculosis have evidence
of genital invo lvement. He furtJ1e r mentioned that 5%-10%
of infertile women suffer fro m tuberculosis. In India, PK
Malkani (1975) reported an incidence of 9.3% in infertili ty
patients in New Delhi. Pad ubidri V. from New Delhi re-
ported tuberculosis in 4% of all endo metrial aspirations
examined. Usha Krishna et at. ( 1979) from Mumbai re-
poned an incidence of in 13% of infer-
tile women. Chiu-a Kumar et al. (2000) from Darbhanga
(Bihar) reported an incidence of gen ita! in
18.6% of infe11.ile women. SurvC)'S from Mum bai about
the prevalence of tube•·culosis amongst infertile women
reponed by se'eral aULhors have been mentioned here
- R MercllaJlt (1989) repo rted an incidence of 14.7%, FR
Parikh et al. ( 1995) reported gen ital TB as the cause of infer-
tility in 15.3% a11d BM Desai et al. ( 1995) reported a high
incidence of 39% in patients referred for assisted reproduc-
tion procedures. Classicall), female ge nital
(FCT) has been described as a disease of yo tmg women witl1
80% diagnosed between the ages of 20 and 40 years, aJ.
though the disease has also been reported in older women
;u·ound menopause and occasionally eve n thereafter. V Falks
( 1980) repo11.ed that 16% of his patientS of genital tubercu-
losis from Sweden were aged more than 50 )Cars.
PATHOGENESIS
The causative agent is mostly M. tnbnrulo.1is (95% ), but in a
few cases it is caused by tJ1c M. /xroil, (5% ), particularly in
underdeveloped coun u·ies whe re effective tubercul osis con-
t rol programs for ca ttl e arc not in place and paste1.11ization
of milk is no t ro utinely practiced. These orga nisms are iden-
tified o n routine staining of infected materi al with Ziehl-
Neelson 's ac id-fast stain. Geni ta l Lttbercul osis occurs almost
always secondary to a primary focus e lsewhe re, t11e common-
est site being tl1e lungs (50%), fo llowed b)' other sites such
as lymph nodes (tJO%), the kidnC)'S, joints, gastroin testinal
trac t or as part of a ge neralized mi lia ry infec tion. The mode
of spread is generally haematoge nous or via lymp hatics, and
rarely from direct co ntiguity with an inu·aabdom inal organ
or affected peritOneum (C Schaefer, 1976; AM Siegler,
1979). Once the genital tract has been colo nized, tl1e granu-
lomata containing viable wbercle bacilli fonn witl1in t11e
vruioLtS pelvic organs. Following the development of tuber·
CLLI;u· h) persensitidt), tllese foci become generally silent
for m;u1y >ears. before reactivation of tJ1e focttS takes place.
The active growth and increase in blood tO t11e geni-
tal organs arow1d menarche constitutes the event leacling
to iLS reacti,<ation and establishme nt of the disease process.
347
348 SHAW'S TEXTBOOK OF GYNAECOLOGY

The genital infecl.ion thus acquired in childhood may re-

main dormant unLit puberty. As a rule, the Jallapitm tubes ttre
till! fint to be hence the disease is commonly
bilateral in disu·ibul.ion, with subsequem dissemination to
other genital organs and the periwnewn. Bilateral pelvic
lymph nodes invohement often follows. Vulvovaginal in-
volvement is usuall) secondar) to uler·ine involvemenL
Pr·imal') genital wberculosis is rare; there are repons in
the literature of cases of pr·imar-y genital tuberculosis affect-
ing the vulva and cervix, in which the male sexual partner
has been suspected to be the source of the disease (I % ).
The presence of AI. organisms in the semen of
men suffering from urogenital tuberculosis has been well
documented. Apart fr·om semen being a source of infection, A
the practice of using saliva for lubrication before inter-
course b)' some men may also be a source of infect.ion in
cases of open pulmonary tuberculosis.
Pathology of genital tuberculosis:
The genera l disu·ibution of involvement of reproductive
organs in cases of ge nita l wberc ulosis has been stated b)'
Schaefer as fo llows:

I. Fallopian wbes: 90%-100%

2. Endometrium: 50%-60%
3. Ovaries: 20%-30%
4. Cervix: 5%-15%
5. Vulva and vagina: < I%

In a more recent surve> of more than 1400 cases of genital

tuberculosis b) ogales-Orti:t et al., they fotmd involvement
ofthe fallopian tubes in I00% of their cases, endomeu;tun in
79%, m)omeuium in 20% , cervix in approximately 25% and
the ovaries in on I) II % of cases.
When the wbercle bacilli infect a susceptible host, the ini-
t.ial reaction is a pol) morphonuclear inflammator-y exudate.
Within 48 hours this is replaced by mononuclear cells \\hid1
become the pl"imary site for inu-acellular tubercle replication.
As cellular immunity de,-elops, destruction of the wbercle
bacilli begins, leading to caseation necrosis. Later, react.ivat.ion
of the lesion leads to t11e classical gJ-anulomawus lesion char-
acterit.ed by cenu-al caseation and neo·osis surrounded by
concenuic layers of epitl1clioid cells and giam cells witl1 periph-
eral disuibul.ion of lymphocytes, mo nocytes and fibroblastS.
GENITAL TRACT LESIONS
Deta iled desc ripti on of lesions is as fo ll ows:
Fallopian tubes: Invo lvement of tl1 e tubes is almost
100%, and is bilateral. It is seco ndar)' to haematOgenous
spread from a primat)' focus us ually in the lun gs, and less
common I)' from lymphatic spread from the bowel or direct
u·ansperitoneal extension from a nearby focus such as the
appendix or the large bowel. The wbal mucosa is the most
favour-able nidus for blood-borne spread of tl1e disease
resulting in endosalpingitis - usually bilateral. It is the
earliest lesion with a propensit) for u-ansluminal spread 1.0
the ovru") and endomeu·ium. TintS, the fallopian tubes play
the central role in the initiation and dissemination of pel-
vic tuberculosis, although occasionall)' the cervix ru1d
endomeu·ium can be infected pr·imar·ily from the blood-
stream. The fallopian tubes may appear nor·mal initially
but in minimal disease, they may be thickened with a
whip-like consistency. There may be evidence of tubercles
on the surfuce (wberculous exosalpingitis). At Limes, fol-
lowing a direct extension of tuberculosis from adjacent
organs, tl1e exosalpingitis manifestS in t11e fonn of dif-
fusely spread miliar-y tubercles on the serosal surfuce of
the fallopian tube, the ampullary pan of the tube appears
di lated with the fimbria! end open and pout.ing. This
lesion has been descl"ibed as the tob(tCCtl-jJQrtth appearance
(Fig. 28. 1).
ln more tl1an 50% of cases, the tubes are cl ilatecl, with
the ir ex ternal surfaces appearing ro ughened clue to ad he-
s ions or may show tl1e prese nce of greyish tube rcl es, these
may be di scre te or confluent. On cut sec tion, the lu men
reveals the presence of )'e llowish grey caseo us material or
fl uid along witl1 blood (tuberc ulo us haemaLOsalp inx) and
P>'Osalpinx. At times, violin string ad hes ions are noted be-
tween the right fallopian Lube and the unders urface of
the liver, known as Fiu.-1-lugh-Curtis syndrome. Leakage of
infected material into the peritoneal cavity cat.l.Ses periwbal
abscess, tuberculosis peritonitis and ascites.
In 20% of cases, the lUbes assume an elongated retort-
shaped 'll1e tubes remain patent in almost25%-
50% cases of genital wberculosis with a minimal disease,
but as the disease advances, reactive fibrosis seLS in and the
tubes get occluded. However·, e'en in the advanced fonn of
the disease presenting witl1 bilater-al wbal masses the fim-
briae are often spared, giving the tubes the t) pi cal tobacco-
pouch appearance (Figs 28.2 and 28.3).
 CHAPTER 28- TUBERCULOSIS OF THE FEMALE GENITAL TRACT
Rgure 28.2 Bil ateral t ubercul ous pyosalpinx. Note t he retort-
shaped tubes, absenoe of surfaoe tuberc les and adhesions.
Rgure 28.3 (A) laparotomy picture of a patient having mutliple
miliary tubercular deposits all over the bowel, peritoneum and uterus.
(B) Pus extruding through the fimbrlal end of fallopian tube- a sure
sign of genital tuberculosis.
Microscopically, gran ulomas a nd d1ronic inflammatory in-
filtrate may involve the full thickness o f the tubal wall; on occa-
sions tJ1ese tellt.'lle gran ulomas are difficult tO find. The ampui-
Jary pan is tJ1e most common to be affected, me fimbriae and
interstitial pariS oftJ1e tubes are often spared. The bmmoftJ1e
auack is borne b) tlle endosalpinx, it often exhibitS focal or
widespread reactive adenomatous hyperplasia whim may be
severe enough to be mistaken for carcinoma. The diagnosis of
tubal tuberculosis is based on the demonstration of acid-fust
bacilli in tlle tissues, or by positive cultw·es or by guinea pig
inoculation. It is a well-known fact tllatthe tubercle bacilli are
349
difficult to demonsu-ate even fl uo rescent tedllliques.
Hence, tJ1e o nus of initial susp icio n lies squarely on the
patJ1ologist reporting tJ1e slide. Presently, with availabilit)' of
tJ1e polpnerase d1ain reaction (PC R) ted1nique based test,
tJ1e diagnosis of tuberculosis can be established witll greater
certainty in samples of suspicious tissue. The granulomas may
be single or confluent \\ith a \'llliable tendency to frank
caseation witJ1 tJ1e sun·otmding muscular la)ers showing a
dense l)lnphOC) tic infilu-ation and patdl)' areas of fibrosis.
Caseation necrosis is not uncommon in cases. The
mucosa often exhibi iS a hyperplastic adeno matous pattern
witll a complex network of fused papillae, a nd has been associ-
ated witll a hig her incidence of ecwjJic jrrt'gnmuy (F Novak and
JD Woodruff, 1979). Whether this predisposes to tJ1e occur-
rence of future adenocarcinomll is debatable (Novak and
Woodruff, 1979). The differentilll d iagnosis includes foreign
body gran ulomas us uall y related to previous hysterosalpin-
gography or surgery, sa rcoidosis, Cro hn disease or associated
wi tJ1 EntervbitVJ venniwl1tri:..
Uterus - tuberculosis of the e ndo me trium: The e ndome-
trium is invo lved in abo ut 50%-60% of cases of gen ital tu-
berculosis. Gross i)' the e ndom e trium appea rs unre markab le
in the majolit)' of cases because of cyclic mensu·ual shed-
cling. Endomeu·ial h isto logy reveals the c harac te •istic les io n
showing central caseation, surro unded by ep ithe lio id cells
and stroma infilu-a ted with gia nt cells (Fig. 28.4A and B) .
T uberc ulosis is a descend in g infec tio n from the fallopian
tube , and tl1e cornual ends are tJ1e first to be involved.
28.4 (A) and (B) Tuberculous endometritis depicting typical
giant cells in the stroma (x115). (Source: Textbook of G,tnaecology,
lnda: Else\4er, 2008.)
350 SHAW'S TEXTBOOK OF GYNAECOLOGY

Occasio nal ly the re may be ulce rative, granular o r fungat-

ing lesions. On o ther occasions, the uterine cavi ty may ap-
pear smootJ1 and devo id of endome u·ium, atte mpts at curet-
tage yielding scanty o r no material. The cavity may appear
shmnke n due to unde rl) ing fl brosis. The tu bal ostia may
appea r recessed a nd narrowed, like golf ho les. In 2%-5% of
cases, total destructio n of th e e ndo meuium wir.h resulting
amenon·hoea seconda r) to end o rgan fa ilure may lead to
p)ometra formatio n, in case the imem a l os gets occluded.
At times th e ca,·ity may be partially o r extensively obli terated
with intrauted ne adhesions appea•·ing as strands, ridges or
thick bands (Asherman S)•n drome) .
Endometrial lesions are frequently focal and typically im-
mature because th ey ten d to shed monthl y except in cases
of amen orrhoea or pyometra. It is believed that r.he endo-
metrium is regula d y re infe<:ted from the tubes or from the
basal layer of the endometrium which is not shed mon thly.
Gran ulomas are best identified on endomeuial sampli ng on
day 21- 26 of the cycle o r within a few hours of the o nset of
me nses (Fig. 28.'1) .
Ovaries: T hese are involved in 20%-30% of cases of geni tal
tubercul osis. Most freq ue ntl y tJ1is is pe•ioop horitis resulting Figure 28.5 Hypertrophi c tuberculosis of vulva. Note considerable
from spread from tJ1e acljaccnt fallopian LUbes, whe n the ovary oedema of labia majora and elephantiasis-like appearance of labi a
seems to be encased witJ1in ad hesio ns. Howeve•; iunay so me- minora. (Source: From: Madeod and Read, Gynaecology, 5th eel.
Limes fo llow a haematogeno us spread and cause caseating Ch.lrchill, 1955.)
gran ulo mas witl1in the parenchyma of t11e ova•y.
Cervix: ln most cases, the re a re no gross changes in the
cervix. Ulce raLive lesio ns are unco mmo n. Occasio nally a ce rvico-vaginal smears. Ulcerative lesio ns o ften heal by fi-
polypo idal h)pe rtrophic lesion mimickin g ca ncer of tJ1e brosis ca usin g vaginal stenosis. l?.ecw-vaginal fistula is a rare
cervix ma> be see n. Microscopy may reveal scarce granulo- co mplicaLion of ge ni ta lw berc ulosis.
mato us lesions surroun ded b) la rge num bers o f lympho-
C)'tes. ReaCLive h) perp lasia of t11 e gland ular epithelium may
lead to papilla fo nnatio n, someti mes th ere may be evide nce CLINICAL FEATURES OF GENITAL
of epithelial at) pia. On examinatio n, the patie m reveals TUBERCULOSIS
presence of an ulcer on t11e ce rvix covered witll
brown offensive d ischa•·ge which it may bleed o n to uch. It is an important obsel"\'lltion t11at about I0%- 15% o f
Cervical bio psy helps in establishing a diagn osis of wbercu- women suffering fi·om genital tuberculosis a re asymptomati c
losis. As a result of im olvemen t of th e endocervical mucosa, and 15% of them may have successfully conceived earli er.
there is increase in secretion of mucin. The cervi cal involve- However, the leading presen ting complain tS in women suf-
ment is mostJ y du e to descending spread fi·om the infected fering from geni ta l tubercul osis include infertility, men-
uterine cavity, t110ugh occassionall y, it may be p•·imarily strual irregularities, abdominal pain, vaginal discharge and
from tra nsmission of infe<:tio n from the husban d suffering suspicion of neoplasm. Fistula fonn ation is a .-are occur-
from ge nita l tube rculosis through sexual inte rcourse. rence. Sometimes general symptoms of low-grade feve•·,
Vulva and vagina: Tuberculosis of the vulva is rare com- weight loss, faligue a nd a feeli ng of lis tl essness ma y raise the
pared to rest of the female genital tract (I %) . Vulval lesions suspicio n of hitJ1e rto unsuspected d iagnosis of geni tal tuber-
arise by a di rect exte nsion fro m lesions in tJ1e upper ge nital cul osis. Pelvic examinalio n often reveals no tJ1ing significant;
u·act, o r as an exogeno us infec ti o n. C hi ld ren as well as adults in 20% of cases tJ1e ad nexae ma)' feel tJ1icke ned or co rd-like,
may be affec ted. infectio n may a •ise fro m spu tum tubo-ovarian masses ma>• be palpable. T hese may be te nder
or th ro ugh sexual intercourse witJ1 a parme r suffering fro m if seconclalil)' infec ted. In cases of no nhealing sca rs follow-
eithe r tube rcu lar epid idymitis or re nal tuberc ulosis. Bartho- ing surge ry, a lwa)'S suspec t tJ1e possibilit)' of tuberc ulosis and
li n's gland may be affected at times, often unilaterally with a b iops)' fi·o m the scar tissue will reveal tJ1e d iagnosis.
foc us of tuberc ulosis elsewhe re in the body. ln all cases, Clinical features of female genital tuberculosis are as
lymph nodes wo uld be involved. Bartho li n's gland may reveal follo-w-s:
indu ration o r abscess formation. With tJ1e rece m epidemic of
HIV sweeping thro ugh many counu·ies glo bally, tJ1e reduced
• lnfe rtilit)
body resistance has favoured an upsurge in tuberculosis. • Me nstrual i1·regulari L)
Qinicall) a vulval lesion ma> appear as a discharging ulcer, • Abdo mina l pa in
sinus or a nodular h)peru·ophic lesio n (Fig. 28.5). A vagi nal
• Vagina l discharge
no(:llLie ma> ulcerate and cause a d isdlarging sinus. Mia·os- • Abdo mina l mass
cop)rre,•eals the L) picai LUbercula r g.-anul oma. • Fistula forma ti on
Ulce ralive vagina l lesions whenever prese nt :u·e always • Ectopic pregnane>
found to co-exist with ceni cal d isease. Tubercul:u· vaginitis
• As)lnptoma ti c in LOo/o-20% cases
has also been re ported. The di agn osis has been made on
 CHAPTER 28 - TUBERCULOSIS OF THE FEMALE GENITAL TRACT
Infertility (pri mary or secondary): Th is is an impor-
tant presenting symptom. In fact, in 35%-60% cases in-
fertility may be the on I) complaint for which the patient
seeks medical auention. Of these women, about 75%
present with primaq infertility and 25% give history of
previous conceptions. In almost half of these cases, there
ma> be a histoq of a past infection or contact with a per-
son suffering from tuberculosis. In any suspicious case, it
may be wise to obtain a histological repon on the endo-
metrium early in the course of the work up for infertility.
Infertility is attributed to tubal damage and endometrial
adhesions (Asherman syndrome), and at times ovarian
damage.
Menstntal ir regularity(amenorrhoea, hypomenot-rhoea,
menorrl1agia): It has been obser-ved in 10%-40% of cases.
T he menstrual diswrbances reponed include menorrhagia,
menometrorrhagia, intennenstrual bleeding, oligomenor-
rhoea, hypomenorrhoea, ame no rrhoea a nd eve n postmeno-
pa usal bleeding. In the West, dysftm cti o nal bleeding is more
freq uen tl y enco untered, whereas in Ind ia oligome no rrhoea
a nd hypo menorrhoea a re seen mo re freque ntly assoc ia ted
with genita l tuberc ul osis. T his has been aw·ibuted to the
higher associa ti on with pul mona ry disease in our country.
Tuberc ulosis sho uld be suspected if pubeny me norrhagia
does not respond LO med ical therapy.
Chronic pelvic pain: This pain may be d ull ac hi ng in
type, sometimes aggravated premensu·ually, or it might be
intermittent in nature.
Vaginal discharge: Blood-stained vaginal discharge, post-
coital bleeding, leucorrhoea and serosanguinous/ seropunt-
lent discharge from ulcers are occasionally encoLunered
from lower genital tract tubercular lesions.
Abdominal mass: Some women may present with a mass
in the abdomen, which consistS of rolled-up omentwn,
with dense adhesions to the uterus and adnexae. The his-
tory of associated mensu·ual disturbances accompanying
the presence of fixed abdomino-pelvic mass should raise
the suspicion of genital tuberculosis. Encysted ascites, mat-
ted intestinal loops, uterine pyometra and adnexal masses
ma>' p•·esent as lumps. A doughy feel on palpation of the
abdomen is suggestive of wberculous periton itis. Other
symptoms include dysmenon11oea, dyspareuni a and re-
peated episodes of pelvic infla mmatory disease ( PID). ln a
yo ung, unmarried girl presen ting with a pelvic inflamm a-
tory mass, it is almost alwa)•S of a tube rcul ar o rigin . PID
whi ch fa ils to respond LO the sta nda rd u·eatme nt and
rec urren t P10 is ofte n d ue to w berculosis.
Fistula for mation: T his co mplicati o n ge ne rally follows
s urgical in terven tions such as d raini ng of a n abscess, or
abdom inal h)'Sterectomy.
Ectopic pregnancy: Women witl1 genital tuberc ulosis
rare ly conceive. Howeve t; patien lS successfully treated for
the disease have a high risk of ectopic pregnancy. The high
risk is attributed to residual tubal scarring ca using narrow-
ing and disLOrtion of the tube.
Prospects of future childbearing: Treaunent of patientS
with genitalwberculosis for infenility has generally rielded
poor results. In case pregnanq occurs, t.he t-isk of eCLopic
pregnanq and abottions is substantially high. However, Jive
pregnancies have been reported. In women wit.h a LUbal
disease but ha,'ing recepti,,e endomeu·ium and a nonnal
ute•·us, cases of successful pregnancy outeomes have been
reported with assist.ed reproducti'e t.echniques. However, in
351
case of t.he endomeuium being unfavourab le and nonre-
ceptive, surrogate pregnanq• may need to be considered.
INVESTIGATIONS
General: Routine imestigaLions ma> reveal nothing signifi-
cant.
I. Complete blood count: A differential leucocyte cow11.
ofi.en shows the presence of lymphlX)•wsi5.
2. Er)'t hrocyte sedimentation rate (ESR): This is frequently
raised. However, f.SR is a nonspecific investigation.
3. Mantoux test: A posiLive test is indicative of exposure to
tubercle bacilli in the past. It has been reported lO be
positive in mot·e than 90% of cases. A negative test goes
against tuberculosis. QuantiFERON test is supetior to
Man LOI.LX leSt.
4. Hysterosalpingography reveals fea tures suggestive of
ge ni talwberc ulosis in man>' patients, whe re e ndo me u·ial
b iopsy has fa iled to reveal the d iagnosis. Hysterosalpin-
gograp hy sho uld not be pe rform ed if geni tal tube rculo-
sis is suspected because of risk of sp read of infec tio n. If
performed in an asymptomaLic woman, it may show th e
following patterns( Figs 2!l.G-28.8 ):
• A tigid nonpetistaltic pipe-like tube (lead pipe appear-
ance)
• Beading and variation in the fi lling
• Calcification of the lUbe
• Cornual block
• A jagged fluffiness of the wbal outline
• Tobacco-pouch appearance of hydrosalpim: and pyo-
salpinx
5. The enzyme-linked immunoabsorbent assay (ELISA)
tests - lgC and IgM: In recemtimes, ITI)CObactet·ial puri-
fied protein antigens used in ELISA have been favour-
ably evaluated.
6. Ultrasound examination: It can reveal an abdominal
mass, but cannot identify its nature. However, ulu-asound
guided nne-needle aspiration cytology (FNAC) from the
adnexal mass is feasible, as is USC-guided u-ansvaginal
Figure 28.6 Tuberculous tubes and uterus injected after removal.
(Source: From: Stallworthy, 1952, JObst Gynaecol Br Emp.)
352 SHAW'S TEXTBOOK OF GYNAECOLOGY
Rgure 28.7 Beaded appearance of the fallopian tube and extrava-
sation of the a.;e in pelvic tuberculosis.
Rgure 28.8 HSG showing a reduced size of the uterine cavity with
irregularity of lumen outline and adhesions suggestive of Asherman
syndrome. (Co!rlesy: Dr K.K Saxena. New Detll.)
tri-cut biopsy of the peritoneum as an altemative to lapa-
roscopic biopsy of the peritoneal tissue.
7. Endometrial histology and PCR testing: Endomeui um tissue
is obtained by D&C/hystcroscop)•<lirected biopsy. T he ideal
time for planning tJ1is procedure is tJ1e late premenstrual
phase, tJ1e reaso n being Ul<H tJ1e tubercles are present near
tJ1e superficial layers of tJ1e endomeuium and are shed dur-
ing mensU1tation. The endomeu·ial scrapings are divided
into three portions: (i) for lti5tofxtilwlogy, (ii ) for PCR !liSting
and (iii) for Al •B (111(/ t 11ltnw. 1l1is test has been used
successfull)' for detecting in endome uial biopsy
taken from affected tissues. PCR is a rapid, sensitive and spe-
cific method of detecting mycobacterial DNA, and report is
available witJ1in 2'1 hours. False negative resul tS are reported
in 8% cases and false positive resultS in 10.20% cases.
Guinea pig inoCldation and tissue culwre; ln case of posi-
tive culture, tJ1e bacterio logist should furt11er attempt
tot) pe tJ1e bacillus and test iLS sensitivi ty. Acid-fast stain-
ing of endomeu·ialtissues to detect M. tubemtlosis is not
accurate.
8. H ysteroscopy: This often reveals the presence of sp1·
echiae, partial obliteration oftlle ca,·ity, recessed golf-hole
appearance of wbal ostia or rare ly me presence of ulcers.
9. Laparoscopy: Diagnostic laparoscopy is widely used to
establish t11e cUagnosis of genital tuberculosis/ abdomino-
pelvic tuberCldosis. Tuberculous lesions can be seen on
t11e parietal peritoneum, intestinal serosa, omentLUn,
SLLrface oftJ1e uterus and fallopian tubes (tJ1 icke ned rigid
tubes/ h)drosalpinx, p)osalpinx, tubo-ovarian adnexal
masses) and perihepatic adhesions may be presenL
Histolog) and PCR testing from selected tissue biopsies
often help to settle the diagnosis.
10. T issue biopsy: Local excision tissue biopsies fi·om sus-
pected lesions from the lower genital lldCt (vulva and
\'<lgina) submiued for histology help to establish the
diagnosis.
ll. Chest X-ray (CXR): To detect site of primary lesion.
12. Radiography of bones: In case of suspected tuberculous
pathology.
13. Nucleic acid ampljfication technique (NAAT) detectS
tuberculosis wi tJ1in a few hou t'S co mpared to cultu re.
14. CA 125 is at Limes raised, but is nonspec ific.
Other testS Lobe conside red in selec ti ve situa tio ns include :
15. Gas chromatography: A d irec t de mo nstrati o n of co m-
pounds charac te ri sti c of m)•Cobacteria shows great
promise (90% sens iti ve) to provide rapid diagnosis.
16. SAFA (so luble antigen fl uoresce nce amibody) test has
been evaluated, the drawback being a false positive
reporting of II %. It is no longer used.
17. BACTEC:This is a rapid culture method where rad ioac-
tive carbon labelled substrate suc h as palmitic acid or
formic acid is used as a marker for bacterial growt11. lt
takes 5-7 da)S to culture.
18. Gene expert It is a new test in u·ocluced for diagnosis of
drug-resistant wberctdosis. It is based on PCR. Initially
tllis test was introduced for wbercular meningitis cases,
but is being explored fo•- diagnosing dmg resistance in
oilier fonns of LUberculosis.
19. Semen culture: Advised in patientS witll VI.IIVO\'<lginal
tuberculous lesions.
20. Biodlemical mariters: Ascitic fluid is tested for the pres-
ence of markers such as adenosine deaminase activity.
The test is highly specific sensitive.
DIFFERENTIAL DIAGNOSIS
T he cli nician has to co nside r several other possibilities be-
fore se ttling on tJ1 e diagnosis of FGT:
1. Ovarian cyst, broad ligament cyst, fluid: T hese
cystS are fixed and immob il e. However, th e menstrua l
histoq• is us uall)' no rm a l unlike in women with tuber-
c ular enC)'Sted lesion. An)' histo ry of previo us extra-
genital tuberculosis goes in favo ur of gen ita l tubercu-
losis.
2. PID: Infertility and mensu·ual disturbances are common
to bot11 PlD and FGr. However, history of frequem recur-
rences or a failure of response to treaunen t sho uld raise
the SLLSpicion of genital tuberculosis.
3. Ectopic pregnancy: i-l istoq of amenorrhoea, abdomi nal
pain and the presence of a unilateral adnexal
mass should raise the SlLSpicion of ectOpic pregnancy.
Urine pregnanC)' Lest, trans,<agina l sonography
colour Doppler blood flow studies and diagnostic
 CHAPTER 28 - TUBERCULOSIS OF THE FEMALE GENITAL TRACT 353

laparosco py sho uld he Ipin the diagnosis and manage-

mem of th e case. Table 28.2 Drugs Used In Resistant Cases
4. Carcinoma cervix: In wo men prese min g with local cervical Drug Dose Side Effects
lesions (ulce r, poi)'J)Oida l growth ) clinical findings such
as lack of indu muo n, lack o f friability should raise suspi- 1. Capreomycln 15-30 mglkg l.m . Auditory, vestibular
cio n o f alte rnati\e pa tho logy. Tissue biopsy and histo- and renal toxicity
logical e xaminatio n will help to se ttle tl1e issue. 2. Kanamycin 15-30 mglkg l.m . Auditory, vestibular
5. Elephantiasis of the vulva: Filariasis oflhe vulva can mimic and renal toxicity
h) per·trophic LU be rculosis o f the \'lrlva. Biopsy helps tO
3 . Ethionamide 15-30 mglkg i.m. Hepatitis
establish th e d iagnosis. hypersensitivity
6. Pregnancy: Am enon·hoea and a bdominal mass may raise
the suspi cion of pregnancy. 4 . para- 150 mglkg Hepatitis, Gl tract
7. Puberty and bleeding due to Aminosalicylic
other causes need to be excluded. acid
8. Fungal infections and sarcoidosis cause granuloma- 5. Cycloserine 15- 20 mg Psychosis, oonvul-
tOllS lesions - histologicall y r esembling tubercu lar (1 g maxi mum) slons, skin rash
granulomas.

TREATMENT
add e th ambuto l, 15 rn g pe r kg body we ight in a single
Most patients are in good hea lth and there is no need for dose after breakfas t o r 50 mg pe r kg/ body we ight twice
hospitali zation. Only those who have fever and abdomina l week ly during th e Firs t 2-3 months. Eth amb utO l sho uld
pain are admitted to iJ1e hospital in iJ1e initia l stages of the not be adm iniste red for a longe r pe riod as it may affect
u·eaunenL the vision (opuc ne uritis) a nd ca use skin rash. Ophthal-
mic examination is manda tory be fo re starting the drug.
Oral conu·aceptives sho uld no t be co mbined witl1 rifam-
CHEMOTHERAPY picin. Pyrid oxine (B6 ) I 0 mg da ily prevents peripheral
The fin t line of t reatmnrt is with cmtitubercular drugs (Cate- ne Luitis. The o ra l co ntrace puves a re less e ffective in tl1e
gory l drugs) (Ta ble 28.1 ) . WHO reco mme nds rifampicin prese nce o f rifampicin , as the la tte r interfe res witl1 tl1eir
(450-600 mg d ail) de pending upo n tl1e body weig ht) abso rpu o n.
co mbin ed with 300 mg o f isoniazid da ily in a single oral Resistant cases associated with HIV need extended
dose befo re brea kfast. Ri fa mpi cin is he pa to toxic and liver ment for a >ear.
functi on tests (U ·- fs) should be under ta ke n befo re insti- The new drugs inu·oduced in resiStant cases are ( la ble 28.2)
tuung this d rug. Pyrazinamide is a new o ra l drug ( 1.5- as follows:
2.0 g da ily in two divided d oses) whi ch is very effective
aga inst slow multipl) ing o rganisms a nd enhances the ef- • Capreom)cin
fect of r·ifa mpi ci n, but ca uses hyperur·icaemia. The mod- • Kanam)cin
ern therapy consists o f ri fampicin, isoniazid, ethambutol • Ethionamide
and pyrazinamide for initial 2 months, followed by rifam- • jxJrt•Aminosalicylic acid
picin and isoniazid biweekly for another 4 months. This • Cycloser·ine
short COUt'Se gives qui ck a nd successful results and pre-
vents eme rgence of drug-resistam bacilli. Some prefer to The main reasons fo r a failure of treallllent are d ue LO
noncompliance and inco mple te treatment.
For good complia nce, Revised Natio nal T B Con u·ol
Programme (RNTCP) of India in 2004 inco rpora ted DOT
s u·a tegy (d irect obse rved u·eatm ent). It covered 87% of
Table 28.1 Chemotherapeutic Drugs for TUberculosis the popula ti on with 72% d e tec tion ra te and 86% treat-
mentsuccess, with a seve nfo ld decli ne in dea th rate from
Drug Action Side Effects 29 % tO 4%.
Rifampicin Bactericidal Hepatotoxic, fever,
10 mg/kg o.d . purpuric rash, orange DOTs - a short course therapy o f 6 months.
daily urine First 2 months
• Isoniazid - 15 rng/ kg body we ight
Isoniazid Bactericidal Hepatotoxic,
• Rifampicin - 450-600 mg
5-10 mglkg o .d. peripheral neuritis,
• Pyrazinamide- 30 mg/ bod) we ight
daily hypersensitivity
• EiJ1ambutol - 30 mg/ kg bod) weight
Bactericidal Hepatitis,
25-30 ITlQI1<g o.d. hyperuricaem ia Three umes a wee k.
Ethambutol Bacteriostatic Optic neuritis, skin rash
15 mglkg o.d . Next 4 months - conunu e wi th Ri fa mpi cin a nd Isoniazid
(same dose) three um es a week.
354 SHAW'S TEXTBOOK OF GYNAECOLOGY
Resis tant cases (S-mooth course)
First 2 montJ1s -streptomycin three Limes a week + four
drugs as above
Third month - Four drugs as above
ext 3 montJ1s - lsoniaL id, rifampicin, ethambutol (same
dose ) three times a week.
HIV-TB patients shou ld also receive Highly Active Ant.i-
reu·oviral Therap)' (HAART) therapy.
PlACE OF SURGERY IN TREATMENT OF FEMALE
GENITAL TUBERCULOSIS
Surgery is gene1-ally avoided; however, may be needed if them
are ofprogression of the disease, persistent active lesion,
persistence inflammatory masses, i.e. pyosalpinx and
pyometra; persistence of symptOms, i.e. pain, menorrhagia
and persistence of fistula, despite th e chemotJ1erapy.
Con u·aind icaLions to surgery a re aCLive lesio ns e lsewh e re
in the body and p lasti c ad hesions of bowels. A ny atte mpt to
sepa ra te the acU1esions wo uld result in inj ury LO bowel and
fistula fonnaLi on. Surgery s ho uld be p receded b)' seve ral
weeks of chemothe rapy, fo llowed by a f ull co u rse of ch em o-
tllerap)'·
TYPES OF SURGERY
• Total hysterectomy with re moval of ovaries and the fallo-
pian tubes. It is vel') rarel) req uired nowadays.
• Vulvectom) in cases of h) pe ru·ophied vulva.
• Tuboplast) is co nu-aindicated. Any surgery on tl1e tube to
improve fenilit) would cause reac tivation of tl1e disease.
Moreover. fertilit) ca nnot be restO red when the LUbal
walls are damaged.
• Removal of adnexal mass in a )Oung woman.
• Drainage of p)omeu-a.
• Fistula •·epair.
FOLLOW-UP
The patient needs to be followed up for at least 5 years, as
reactivation of tJ1e lesion during this period has been re-
poned. A yearly, or when indicated earli er, endomeu·ial
biopsy should be carried out to ch eck for any reactivation.
Hysterosalpingogram is however not advisable, as it m ay re-
ac ti va te the dormant infection.
PROGNOSIS
Nearl)' 90% of the cases get c u red witJ1 c hemotherap)'·
However, prospects of fe rti li ty are extremely low in me re-
gion of 10% on ly. Of those who conceive, 50% have a tubal
pregnancy, 20%-30% abort. Only 2% of women witll geni-
tal tuberculosis will have live birtJ1s.
IN VITRO FERTILIZATION (IVF)
Women successfull) u-eated for genital tuberculosis are
now offered assisted reproduction by in vitro fenilization.
RS Marcus et al. have •·eponed 10% success , the
endometrium is normal. Ho we,·er, pregnancy rates follow-
ing JVF-ET are lower in treated cases of genital tuberculosis.
KEY POINTS
• of tJ1e genital u-act is common in India, and is
secondar) 10 plim<ll') focus in the lungs (50%) ,lpnph nodes
(40%). LUina•) u-act (5%) and bonesandjoims (5%).
• The infection primalil) attacks tJ1e fallopian tubes
causing PID. Later it spreads downwards, causing uter-
ine S)nechiae and Ashennan S)ndrome. Cen·ical and
vulval lesions are \CI'} ra•·e.
• Ve•1' often, genital tube rculosis remains silent and
goes unnoticed. lnfe•tility, amenorrhoea, abdominal
mass and pain de,elop in an advanced stage.
• Endometlial biopS)', laparoscopy and blood tests help
to discover its existence.
• Newe•· techniques such as PC R, NAAT and BACTEC
rapid culture methods whi ch offer res ul ts in 24 ho urs
and 5-7 days, respectively, a re now bein g e mployed.
NAAT de tects tuberc ulosis in a few ho u rs.
• Trea unen t is essen t.i all )' med ical. Ca•ego ry I d rugs
g ive n for a perio d of 6 mo nths is tJ1e sta nda rd o f u·eat-
me nL In dntg-resista n t cases a nd HI \/-pos itive cases, a
lo nger du ra ti o n of trea unent with Catego•)' ll may be
need ed.
• Su rge•'}' ma)' be required if the d isease persists a nd d oes
not respond to dmgs, a nd the u·eatment is hysterec-
tomy and bilateral sal pi ngo-oop horecwm y, and removal
of tubo-ovarian mass in a young woman.
• Reactivation ma) occur within 5 )Cars; therefore, follow•
up becomes necessa•1·
• Pregnane) rate following treatment is onl)' 10%, of
which one-third abort and another 50% develop
ectopic pregnane).
• H igh degree of suspicion is required in an as)lnpwm-
atic woman, especiall) in an infertile woman.
SELF -ASSESSMENT
I. Desclibe tJ1e pathogenesis offemale gen ital tuberculosis.
2. Desclibe tJ1e lesions oftJ1e fe male genital tract caused by
tu berc ular infection.
3. How would you investigate a case of s uspected geni tal
tuberc ulosis?
4. DesCJibe tJ1e common cl ini ca l ma nifesta ti o ns of ge ni tal
tuberc ulosis.
5. How woul d yo u u·eat a patient of gen ita l tube rcu losis?
SUGGESTED READING
Ah,·,mi 0\1, Arun liN, Ranjana B, Shirish B. Genital tuberculosis.
J Oh.tct G)-naccol Family Welfare 199:;;1: 14.
Bhattachary.t !'<, Banclji AK, S, ct al. Endometrial tuben1.1I<>Sis
(A ten )car >tudy of 525 c-&c>).
Bhattacharp P. ll)pcrtrophic tubcrculo>i> of 1he nlh"a. Obstet G)nec:ol
1978: 51:225.
Chhabra S. Genital a baffiing di>ea.e. J Obstel Gynaec:ol
India 1990: 40:569.
Cocttcc LF. Tubera•lou; \aginith. S Afr 1972; 46:1225.
Clcemobilsky B. Endorneuiti> .md infcnilit). Fenil Steril 1978; 30:119.
Dalal AR. \'enkatesan R. M.magernent of genital tubercuiO>is. In Tank
OK, Sar.ura l:B. Patel MK (ed>). Po>tl-,•r.tdltate Frontiers in Obstetrics
 CHAPTER 28 - TUBERCULOSIS OF THE FEMALE GENITAL TRACT 355

and Cyn ac"t:ology. 2nd Ed. New Delhi, FOGS! Publications, J. P. Krishna UK, Sathe AV, Mchm I I, ct al. Tuberculosis in in fertility.] O bstet
Brother.., 1999. Gynaccol India 1979; 29:663.
DalyJW, MonifGRG. lnfcctiotl> di>c>o.s<.'S in Obstetrics and G}necology. In Kumar C. Sinha S. Lapar<»eopic C\'ltluation of wbal facl(lr in cases of
Monif (c-d). M)cobactcria. 2nd Ed. Phihldelphia, llarper & Row, 1982 . infcrtilit)"· J Ob>tcl G}n.wcol India 2000; 50:67.
[}as S. Chaudhari P. Cenical tubcrculo.is in su spected carcinoma cer- Lattimer JK. Col more I IP. Sanger G, ct a!. Tran,mission of genital Ut-
,;x.J Ob>tcl Gynac'<:ol India 1993; 43:453. bcrcuiO>i> from hu;band and "ifc ,;a the .emen. Am Rev
Desai SK. Allahab.ldia G:-1 (c'<b). lnfertilit) and Tubcrculo.is-Current si> 1954: 69:618.
Concepb. :-lc" Ddhi,Jaypc'C Brother.. Publishers, 1995. Manjari Mridu. Khanna S. SK. Genital tubera tiO>is. Indian
Desai SK. En dometrial rt'<:cpthit) in genital tuberculosis ..) O bstet C,n- J Pathol Microbiol 1995; 42:227.
aecol lndia 2002: 52:2!1. Is A. Fortin R. Genit•il tubcrculo.i> Acta C)10I 1975; 19:79.
Deshmukh K. Lopez]. :\aidu AK. Genital tuberculosis..) Obstet G)-nae- RJ. Genit<illllberculo>i> and infertility.] Reprod 1989;
col lndia 1987: !17:289. 34(7):468.
Dodhwal V. Kum.1r S. S. SonohystcrOh..-aphy in e\aluating intra- JW. llolt S Gilmour I e1 al. \'uh-ar tuberatlosis. Tubercle
uterine pathologj•.J Ob>tet Gp>aecol India 2001; 51:11 3. 1979: 60:1 73.
Falk V. K, A1,>ren G. Genital tuberculosis in women . Analy;;s Munshi MM. Chiddanvar S, Patel A. Tuberculosis in gynaecolog)•.
of 187 newly di:.gno>e-d ca= from 47 Swedish hospitals during the lndi:.nJ !"athol Microbiol 1993; 36:3.?6.
ten )c'dt period 1968-1977. Am .J Obstet Cynecol 1980; 138:933. l'\a1,.-pal M, P..d D. Genital tuberculo>i>= A diagnostic dilemma in O PD
Frydman R. Eib>ch it tl, Belac'>ch·AIIart .J C. Gen ir>tl tuberculosis-in fertil- patients. .) Obstct Gynaccol l ndia 2001; 51:127.
ity tre-ate-d "it h IVF-ET. J In Vitro Fert Em bryo Transf 1985; 4:184. Nogal<eS-Ortiz F. Tardncion I, FF'. Tit e Path olOj:,'Y of female
Gu pta N, Arora I lL, Gupta A. Tubercul osis of th e female genital tract. ttJbt:rculo>i>: A 31 year stud y of 1436 cases. Obstet Cynecol
J O bstet Gyn accol lndia 1991; 4 1:238. 1979; 53:422.
Gu rg"an T Unn an B, I I. Ge nital tuberculosis. Fe rtil Steril 1996; Nov-ak ER, Woodru lf J D. 1ov-dk's Gynaccologic and O bstetric P.a thol-
65:367. ogy, 8tlt Ed. Philadelph ia, WB Saunders, I 979.
llalbrcecht I IV. ll calcd ge nital tuberculosis. O bstct Gyn ecol1957; 10:73. Parikh FR, Nadkarn i SG, K:un at SA, ct al. Genital tuberculosis in infer-
Jcdbcrg II. A study on genit al tuberculosis on women. Acta Obste tric tilit y. Fcrtil Stcril 1995; ()7:497.
Gynccol Scand 1950; 31(Suppl): 11 7 Prcrni IlK, Kum ar A, Kum arS. Cervical tubcrculosis..J O bste t Gynaecol
Khcrdckar M, Kh cr A, Sh ann a AD. Tuberculosis of the end ome trium: India 1990; 40:826.
A h i>topathological study of 355 c>o.s<.'S. Indian j Pathol Microbiol Ridley CM. Re-cent Ad v-.m ccs in Vulval Disease. O turchill Livingstone,
1977; 20:39. Edin burgh, 198.'>.
 Sexually TransmiHed Diseases
Including HIV Infection
Vulvar Infections 356 Practical Approach to Common Vaginal
Genital Ulcers 358 Infections 369
Vaginitis 362 Hepatitis B Virus 369
Human Virus Infection 365 Key Points 369
Contraception 368 Self-Assessment 370
Sexually Transmitted and Infertility 369
The term 'sexua ll)' u·ansmitted d iseases (STDs)' refers to a
\'<lriet)' of clinical syndromes a nd infec tions caused by patho·
gens that can be acq uired a nd u·ansmined through sext.tal
activity.
It has become a global threaLLO the heallh of the popula-
tion. and its increasing incide nce is clue to promiscuity and
frequent change of partners. S) mpLOms caused by infec-
tions of th e lower gen ital u-act are amo ngst the most com-
mon complain ts in mnaeco logic patients. Genital tract in-
fection can lead to pehic infla mmatoq• disease (PlD ),
infe•·tility and ectopic pregnancy if the fallopian tubes are
involved. Viral infections are liable to cause mlval and
cal cancers. Obstetric complications include repeated preg-
nane)' losses, inu-auterine fetal death, neonatal eye and
throat infections, and septicaemia . Vertical u-ansmission to
t11e fetus and neonate is known to occur in women with
syphilis and hum an immunodeficiency virus (Hl\1) infec-
tion. Antenatal routin e testing and u·eaunent can avoid or
red uce risk of tl1eir u-a nsmission.
Of all th e vaginal infec tio ns kn own, bacterial vaginosis
(BV) acco unts fo r 40%-50% of cases, mon ilial infection
20%-25% of cases and Tri.clwm.rm(Lf infec tion 15%-20% of
cases. T he othe rs are ra re, though the incidence of chla-
mydia ! infec ti on is increasing.
Types of vaginal infections:
• Bacterial - Syph il is, go no rrhoea, chlamyd ia! infection,
lymphogranu lo ma, Mycopkwna gmitnliwn infection, chan·
croid
• Viral - Huma n papillomavirus (HPV), herpes simplex
virus (HSV), l i!V infectio n
• Protozoal - Tri.clwnwtul.l vagitwlis infection
• Fungal - Candida I infection
• Infestations - Scabies, pediculosis
Most of the genital uact infectio ns are se xually transmit·
ted. 1-lowe\er, unscreened blood transfusions can also
spread S) phi lis, H IV infection and hepa titis B. Other rare
356
causes are use of infec ted needles and shari ng of LOileLS or
towe ls.
WLVAR INFECTIONS
The nonnal vu lva is composed of the skin consisti ng of
stratified squamous epithelium. It con tains sebaceous, sweat
and apocrine glands, tulderl) ing subcuta neoLLS tissue and
the speciali1.ed Banholin 's glands. Vuh-ar pnu·itLLS and bum·
ing account for approximate ly 10%- 15% of presenting
complaints. Following infections can affect \'Uiva:
PARASITIC INFECTION (PEDICULOSIS PUBIS)
Pediculosis pubis is one of the most contagious STDs caused
by c1-ab louse or Phthin.Mjmbi;. It is also u-ansmined tl11·ough
intimate contact an d shared towels or sheets. The parasites
deposit tJ1eir eggs at t11 e base of hair follicles. T he louse
feeds on hu man blood (Fig. 29.1).
CUNICAL FEATURES
T he pa ti e nt co mp lains of in te nse itchin g in the p ub ic a rea;
there may be the p rese nce of a vulva r rash . T he inte nse
itchi ng can ca use inso mn ia, irritatio n and social e mbar-
rassmenL
DIAGNOSIS
Diagnosis is estab lished o n inspection - find ing of eggs/ lice
in t11e pubic hair. The lo use can be ide ntified under tJ1e
microscope.
TREATMENT
Local applicatio n of pennetlwin cream 5% - two applica-
tions 10 da)S apart - to kill newl) hatched eggs or local
applicatio n of gamma-benL.Cne hexachlo•icle l % as lotion/
cream or shampoo after showe•ing so that the chug effectS
last for 12 hours on 2 successhe clays. This treaunent is
 CHAPTER 29 - SEXUALLY TRANSMITIED DISEASES INCLUDING HIV INFECTION
Figure 29.1 Crab louse (Phthirus pubis). (Source: Robert S. Dill,
Associate Professor, Biological Sclenoes, Bergen Community College.)
contraindicated in pregnant and nursing mothers. Al l
clothes should be properly laundered.
SCABIES
lL is u-ansmiued through close contact/ fomites and caused
by itch mill'.
CUNICAL FEATURES
lL generall)' alfeclS the flexure aspeclS of lhe elbows and
mislS, bullOCks and the external genitalia. The adult female
burrows beneath the skin to Ia) ilS eggs. The patienlS suffe•·
from intense burning along with intenninem episodes of
intense itching/burning. Itching is more severe at nighL It
may present as papules, vesicles or burrows.
DIAGNOSIS
It is estab lis hed o n microscopic exam ination of skin scrap-
in gs u nder o il.
TREATMENT
lL consislS of local app lication of pe•methrin cream 5%
twice a day for 2 s uccessive days or app lication of 30 mL
of lo ti on over the e nLire s kin s urface, leaving it o n for
12 ho urs. Pruritus may persist for a whil e; thi s s ho uld be
con u·oll ed with a ntihi stam ines. Treatment sho uld be with-
he ld during pregnancy a nd lactation. Clothes s ho uld be
properly la undered.
MOLLUSCUM CONTAGIOSUM
!tis a benign vi•-al infection caused by lhe poxvirus. I tis spread
by close sexual or nonsexual contact and by autoinoculation.
The incubation pe•iod mnges from seveml weeks to months.
CUNICAL FEATURES
The patient presen IS with a crops of small domed vesicles,
with cemral umbilication measuring I-5 mm in size. White
waxy material can be expressed out of it.
357
DIAGNOSIS
Giemsa staining of the discharge (white wax')' matelial) re-
veals inu-acyLOplasmic molluscum bodies confirmatory of
the diagnosis.
TREATMENT
It consislS of evacuation of the white material, excision of
the nodule with a dermal curet and treaunent of the base
with Monsel's solution (ferric subsulphate) or 85% uichlor-
acetic acid. C•)Othe•-aP> and electrocoagulation may be
considered as an altemative tJ1erap).
CONDYLOMATA ACUMINATA (Figs 29.2 and 29.3)
Also called venereal warts, tJ1ese are caused by tJ1e H PV, which
is a small DNA double-SU'llnded virus. These warlS spread dif-
fusely over the whole of tJ1e vulval area. The verrucous
growths may appear discrete o r coalesce LO form large cauli-
growtJ1s. They affec t tJ1e s kin of tJ1e labia majora,
perineum , pe riana l region a nd vagina. T he growtJ1s are seen
in women of tJ1e c h il dbearing age and are main ly sexually
u·ansm iLLe d. Vagina l d isc ha rge, use of oral contracep tives and
pregnancy favour tJ1e ir growth. There are seveml varie ties of
tJ1e H PV of whi ch HPV 6, 11 , 16 and 18 as well as 3 I, 32 and
33 are of significa nce to tJ1e gynaecologist. HPV 6 and II are
implicated in tJ1e development of condyloma acuminatum,
and HPV 16 and 18 a•'C implicated in the developmem of
cancers of tJ1e cervix and vulva. The presence of koilocytes
constitutes the histological marker for tJ1e virus. Apan from
koilocytes, oilier histological features are perinuclear halo,
multi nucleation, organophilic C) to plasm, acanthosis and
chronic inflammatory infiluate. Dysplasia may be seen in
wans in elder!)' women. The t) ping of ' 'irus is based on DNA,
DNA h)b•·icliation and pol)lnemse chain reaction (PCR).
HPV is a small D A virus, 55 nm in diameter, is epitJleliou·o-
pic and con1ributes to 15% of all cancers. In )'OLmg women,
tJ1e infection is u-ansient; it disappears in 90% of cases without
Figure 29.2 Condyloma acuminatum of the vulva. (From Russell
AH: CMOer of the vl.lva In Leibel SA, Phllps TL, eels: Textbook of
radatoo oncobgy, ed 2, Phladelphia, 2004, Saurders, p 1180.)
358 SHAW'S TEXTBOOK OF GYNAECOLOGY
Figure 29.3 Condyloma accumlnata: Hypertrophic stratified squamous
epithelium arranged In knuckle-like fronds. The epithelium shows acan -
thosis and papillomatosis. (O:x.rtasy: Dr Sandeep Malhtr, AIIMS.)
anyalteration in DNA. In older women and immunocompro-
mised persons. it often persists and progresses to carcinoma in
situ in 30% of cases in 1-3 )ears and cancer of the cervix. Both
squamous cell carcinoma and adenocarcinoma can occur.
Condyloma is associated \\ith vulval, vaginal and
cancers in 20% of cases. Cen ical cancer accowlts for about
80% of HPV-related cancers.
DIAGNOSIS
Colposcopic swdy of this lesion aided by acetic acid applica-
tion is important in the diagnosis of lesions on the cen•ix and
I% toluidine blue staining for the vulval lesions. Toluidine
blue dye is washed off "1th 3% acetic acid I minute after ap-
plicati on on the vulva. The abno nn al vulval skin \\ith the ab-
normal nucl ei retains the blue d)<e, whereas the normal skin
all ows the dye to be washed off. Acetic ac id ca n cause burning
in the vu lva, and it should be diluted to 50% before use. Vulval
skin is first smeared "1tJl water-solub le K-Y jelly and then
treated with di lute acetic ac id. The vascular pauern is studied.
T he abnormal areas stained with toluid ine b lue are biopsied.
COLPOSCOPIC FINDINGS
Meisels desctibed colposcopic appeara nce of condylomas as
patches of raised projection of aceLOwhite epithelitun with
speckled appearance. I mmunochemical tecl111ique can
demonstrate vira l antigen in the tissue sections.
TREATMENT
Young women with Aat cond) loma may be obset·ved for
6 months, especial!) when it develops dtu·ing pregnancy,
because the lesions often disappear spontaneously. Local
application of podoph)llin 25% in alcohol or podophyllin
20% in tincture bem.oin for 6 ho urs claily or 25% trich lor-
acetic acid plus 5% Auorouraci l catt5es sloughing off of small
warts in 3-4 clays in 70%-80% of cases. The treaunem may
need to be repeated weeki) as the warts recttr at 3-6 weeks'
interval. Local podoph)llin cream (podofilox) is also avail-
able. This u·eatment is, however, contraindicated in the first
uimester of pregnane> because the drug is absorbed imo the
circulation and is C) totoxic, cattsing abortion and petipheral
neuropathy. This u·eaunent is also cont.-a indicated in vaginal
and cenicallesions because of severe inAammatory reaction
provoked at these sites. The larger lesions are best removed
by diathenny loop or laser ablation. The surgical excision of
a localit.ed growth is another alternative. Associated S)•philis
and malignancy need to be excluded. The husband of the
infected woman sh ould be u·eated simultaneo usly or pn>-
tected ft·om infection by advising the use of condoms.
Vulval rmd v agiualwar/J during fJrf'f,T11fU1i)' mmulate CIJ.fiSarnan
section to r1void laryngiti1 in t.heTJNnwte.
Lately, lkic et al. advoca ted th e use of interferon in th e
form of local o inune nt o r crea m or intralesional injec tio n.
T he cream is app lied four to five Limes da il y I g eac h time
( I g contains 2 X 106 IU), with LOLa l dai ly dCLse of6 g for
8 weeks. Ninet)' per cent of lesions regres.s b)' this applicatio n.
lm.-amusc ular injec tion of2 X 106 IU of interferon daily for
10 days yields 90% success. Side effects are fever, myalgia and
headacl1e. Cnwm iJ pwfemd to injeftion, as till' inlier is p(li1'iful.
Interferon inhibi!J the viral and cellular grcnuth. lmerferon
apy is avoided eluting pregnancy. Apa11. from Sttrgery, tl1e
warts can be removed b) Cf)OSurgery, diatl1enny or laser.
Neer:l/e:;:, to Ml)i biO/JS)' i.1 11Wtulatory• w rule out 11Uiligrumt)'· Pap
S111£ltr of till! ceroi:< i.l a!Jo wquiml to ruk out CI!'I1JialiTTUIIigntmcy.
Other measures include the following:
• Improve bod) immunity with antioxidants such as
min C and folic acid.
• Avoid smoking.
• Vaccines at 0, I and 6 months before exposure tO sexual
activity in adolescent girls and bO)S are available, though
they are expensive. Bivalent vacci ne against HPV 16
and 18 is known as Cervarix. Quadrivalent vaccine
against HPV 6, II , 16 and 18 is known as Gat·dasil or
Silgard. The hi gh cost of vaccine precludes the prophy·
lacti c use in general populatio n. Cervarix is given at 0,
I and 6 months. Gardasil is given at 0, 2 and 6 months.
Recemly, two doses of IIPV vacc ine given at 0 and
6 mo nths have bee n found to be effec tive. I nosiplex is an
immuno modul ato r whi ch is used as an adjunct LO con-
ventio na l th erap)'· Orall )', iL is give n 5 mg/ kg daily for
12 weeks. About 20% co mp lete response a nd 40% partial
response are reported.
• lmiquimod cream app lied three Limes a week for
4 months cures 75% of cases of condylomata acc uminata
b ut recurs in 15% of cases. Some develop local erythema-
lOLLS reaction to the cream.
GENITAL ULCERS
Sexually transmitted infections (STls) such as ge nital her-
pes, granuloma inguinale (donovanosis), l)lnphogranu-
loma venereum ( LGV), chancroid and S)philis often pres-
em with ulcerati\e lesions of the \Uh<a.
 CHAPTER 29 - SEXUALLY TRANSMITIED DISEASES INCLUDING HIV INFECTION
GENITAL HERPES
It is a recurrent STD caused by the double-su-anded DNA
virus of HSV group (aim® 80% ml! tyfJe II infections). The preva-
lence of the disease has reached epidemic proportions in
the developed counuies of the world. The incubation peri{)(/ is
3-7 days. HSV t) pe I accounts for only 30% of vulval lesions.
It mostly affects women between 20 and 30 years of age.
CUNICAL FEATURES
Primary Infection
1l1e patient often complains of constitu tiona! spnptoms sud1 as
malaise, fever and vulval paraesthesia. followed by appearance
of vesicles on the vulva resulling in ulcers which are shallow and
painful. These often coalesce. Mulliple a'Ops of vesicles and
ulcers tend to occur in 2-6 weeks. The lesions peak in 7 days
and last for approximate!)' 2 weeks. T he o utbreak is self-limite d.
llte lesions hea l "1thout scar1·ing. Viral sh edding, however,
te ncls to co nlinue for weeks after the appearance of lesio ns.
Recurrent Herpetic Lesions !Fig. 29.4)
T hese a re ge ne ra ll )' of s ho n er dura tio n a nd m ild e r in
seve rity of S)•mp to ms. Prodro ma l symptoms o f b urning o r
itc hi ng in the affected area often preced e the attacks. Sys-
temic symptoms arc genemll y absenL Abo ut 50% of th e af.
fected women experience th eir first recu rrence within
6 months and have on an average of about four recurren ces
\\1thin the first rear; ther·eafter, the episodes of recurren ces
tend to occur at var·iable intel'\'<lls. Latem herpes virus
residing in the dorsal root ganglia 54 may get
reactivated whenever the immw1e system gets compromised
as seen during pregnancy or any other immunocornpro-
mised states.
COMPLICATIONS
Known rare complicalions include encephalitis and winary tract
involvement causing retenlion of llline. severe pain or bou1.
Figure 29.4 Recurrent herpes genitalis. (Source: Wikimedia
commons.)
359
Table 29.1 Recommended Regimens for Treatment
of Herpes Simplex (CDC, 2015)
Acyclovir 400 mg orally thrM times a day for 7-10 days
OR
Acyclovir 200 mg orally five times a day for 7-10 days
OR
Valaciclovir 1 g orally twice a day for 7-10 days
OR
Famciclovir 250 mg orally thrM times a day for 7-10 days
"Treatment can be extended 1f healng IS ncomplete after 10 days
of therapy.
DIAGNOSIS
Diagnosis is esse n liall)' b.'\sed on cl in ical inspec tion o f m e
lesio ns; imm uno logic or cyto logic tests are no t very sensi-
tive; vira l c u ltures fro m swabs ta ken from u1e base of th e
vesicles a re posili ve in 90% of cases. In 6 weeks, nucle ic acid
a mp li ficatio n test ( NAAT ) offers g rea ter se ns iti vity u1a n th e
c u lwre. Bio psy reveals c ha rac te ri stic 'gro und g lass appear-
a n ce' of Lhe cellul ar nucle i and n um ero us s mall intracellu-
lar basop hili c pa rliclcs and acidop hi lic inclusio n bodies.
CyLOlogy s h ows m ultinucleated giant cells. T h e antibod y
detection in serum and PC R staining is also d iagnosti c. An-
tibodies can be detected 2 weeks after the infection.
TREATMENT !Table 29. 1)
• Aims of m e treatme nt include the following:
• To shorten the dur-ation of the attack.
• Prevent complications.
• Prevent recurrences.
• Diminish •·isks of transmission.
• The virus cannot be effecti,el) eradicated
• ln severe cases, administer ac)clovir 5 mg/ kg body weight
intravenously eve I") 8 hours for 5 days.
• Treat prima•) outbreaks.
• Prescribe 200 mg aC)clovir five limes daily omlly for
5 days. Local applicalion of acyclovir cream provides relief
and accelerates healing of local lesions. Thus, trl!ittment ro-
duce5 till' d11mtion and of the attack but does rwt f>revent
lttlii1U)' tiftllf' diSPaleorepi\{)(IR:, ofwwmmce. Valac iclovir 500 mg
b.d. o r famc ic lovir 125-250 mg b.d. is also effeclive, g ive n for
7 d a)'S.
• Cente rs fo r Disease Con u·ol a nd Preve nlio n (C DC) has
g ive n g uide lines fo r the effecti ve trea un e nt o f he rpes
s im p lex infectio n (Table 29).
• Cou nselli ng: 'J11e couple is advised to abstain from intercou rse
from ute time of experiencing procb"Omal S)mp to ms un til to-
tal re-epith elialitalion of the lesions takes p lace. T h ese pati ents
are more StL5ceptible to Hl V infection and outer STDs.
• Caesarean section is recommended in the presence of
active infection to avoid neonatal infection.
Vaccine against genital herpes is not )et available, but
immune enhancers reduces Ute frequenC)' of recurrences.
lmiquimod is being tried, but clinical u·ial is lacking.
GRANULOMA INGUINALE (DONOVANOSIS) (Fig. 29 .5)
The causative organism for granuloma inguinale is CalJm·
matobacterium grcmuwmatis. It is a Cram-negative bacillus
360 SHAW'S TEXTBOOK OF GYNAECOLOGY
Figure 29.5 Granuloma inguinale. Omarlupi, Vandana Madkan,
Step/'en K.Tyring. Joumal d the American AcadEmy of Dermatology,
Tropical delmatology: Bacterial tropical c:lseases, 54(4) 2006.)
causing ch ronic ulceralive infectio n of the vulva. It is pre-'ll-
le nt in th e tropics. It is not o nl)' highly contagio us but also
u-ansmi ued thro ugh re peated se xua l or no nsexual contacLS.
The l-1 2 weeks.
CLINICAL FEATURES
It begins as a painless nodule which laLCr ulcerates to fonn mul-
tiple beef)' red painless ulcers that tend LO coalesce; the vu i\Q is
progressively desU'O)>ed, and minima l adeno patl1y may occur.
DIAGNOSIS
Mi croscopic examinatio n of sm ea rs fro m tl1e lesion/ biopsy
specimens re.•eals pathognomonic intracytoplasmic Dono-
van bodies and clusters of bacteria witl1 a bipola r (safety
pin ) a ppeam nce (Gram negative). Blue-black stained o r-
ganisms are see n in the cytoplas m of mo nonuclear cells.
TREATMENT (Table 29.2)
Table 29.2 Recommended Regimen for Granuloma
Inguinale (donovanosls) CDC 2015
Azlt hromycin 1 g orally once per week or 500 mg dai ly lor at
least 3 weeks and until all lesions have completely healed
Alternative regimens
Doxycycline 100 mg orally twice a day lor at least 3 weeks and
until all lesions have completely healed
OR
Ciprolloxacin 750 mg orally twice a day lor at least 3 weeks
and until all lesions have completely healed
OR
Erythromycin base 500 mg orally lour times a day lor at least
3 weeks and until all lesions have completely healed
OR
• Trlm ethoprim-sullamethoxazole one double-streng th (160 mg/
800 mg) tablet orally twice a day lor at least 3 weeks and until all
lesions have com pletely healed
LYMPHOGRANULOMA VENEREUM
It is an un commo n STO that affecLS men mo re co mmo nly
than wo men . It is ge ne rally prevale nt in Africa and Asia.
RISK FACTORS
• Sexuall y ac tive before the age of20 yea rs
• Mul tiple sexua l partners
• Low socioeconomic status
• Histo ry of having s uffered from ot11e r STDs
The incubati o n peri od is 7-21 da)'S.
PATHOPHYSIOLOGY
The caLLSative o rga nism is Chl£1mydia traclwmatiJ (a n) o ne o f
the ' L' se rOt) pes l. 2 and 3), an in u-ace llular C ram-negalive
bac teria. Si'Xualtrammission: In wo me n, the o rganism is car-
ried by 1)1nphatic drainage fro m the ge nita l lesio n to
the perirectal node, both in gu inal and pe lvic l)•mph nodes.
Rec ta l involve mem is common in fe ma les and occ urs by
contig uous s pread from the perirecta l nodes, lead ing to
proctOcolitis and rectal s u·ict:ure formatio n. The drainage is
primari ly to tl1 e inguinal nodes, leadin g to bubo formation;
this m ay burst, ulcerate or cause sinus. It can also affect the
uretlua, per·ine um and cervix.
CUNICAL FEATURES
The lesio n star1S as painless vesicoptlStular e ruptio n that
heals spo ntaneotLSiy. After some weeks, tl1e seque lae of lym-
phatic spread begins with hardly an y clinical manifestatio ns.
The ge ne ra l features are fever, headac he, malaise and
an.hralgia.
DIAGNOSIS
I L is esse nti ally a cli nical d iagnosis. De te rmination of
LCV is exu·em ely difficult until the late sta ge of the
disease.
INVESTIGATIONS
The Frri te.11 based o n d elayed skin h) pe rsensiti,'ity to the
a ntige n beco mes posilive 2-8 wee ks afte r pri mal") infectio n.
The complement jiX£1lion test is mo re sensith e than the Fre i
Les t. C ulture ca n be grown, and inclusio n bodies in the
s mear can be de tected. DNA probing is specific.
COMPLICATIONS
Compli cations a re as a resu lt of sca r tissue formati on. It
includes tl1e foll owing: (a) proc titis, (b ) seve re stricture
form ati o n leading to intestinal obstructi o n, (c) rectovaginal
fisw lae follo wing stricture fonnati on and (d) vul var cancet:
TREATMENT (Tobie 29.3)
Table 29.3 Treabnent of Lymphogranuloma
Venereum (CDC- 2015)
Recommended regimen
• Doxycycline 100 mg orally twice a day lor 21 days
Alternative regimen
• Erythromyci n base 500 mg orall y lour times a day lor
21 days
 CHAPTER 29 - SEXUALLY TRANSMITIED DISEASES INCLUDING HIV INFECTION
MYCOPLASMA GENITALIUM
MJc&plasma genitalium, flrst discovered in 1983, is an intra·
cellular organ ism wh id1 lacks cell wall and is not stained
by Gram stain. It is difficult tO culture and takes weeks or
months. NAAT and PCR are t.he det.eclion t.ests. o com-
mercial Lest is available. The infec1 ion causes urethritis, en-
docervicitis and PID.
TREATMENT
• Moxifloxacine 400 mg o.d. X 7 days
or
• A.t.ithrom) cin 500 mg Stat and 250 mg every 6 hour X 4 da)S
CHANCROID (SOFT SORE)
It is an acut.e STD caused by small Gram-negative bacilli
ducreyi (mwerobe). It is common in the underde-
veloped co unuies of the world. It affec1s males five to ten
Limes more often than fema les. It may faci li tat.e the spread
of HIV infec ti on. It is high I)' contagio us, but. it. req uires the
presence skin for e nuy T he incuba-
tion fJeriiXl 3-6 days.
CUNICAL FEATURES
Lnitiall)', there appears a small pap ule that develops in to a
painful pust.ule LhaL ulcerates. Mulliple lesions at various
stages of developmen L mtl)' be evident at one and the same
Lime. The ulcers are shallow, ragged and painful. Often, a
LUlilat.eral inguinal I) mph adenopathy may be evident in
50% of cases. Recurrence rat.e at the same site has been
observed in 10% of cases. The ulcers are sharply demar-
cated without induration. Distal spread is rare. In 10% of
cases, soft sore is associated with S)philis or herpes.
DIAGNOSIS
This is based on investigation of the purulent discharge
from the lesion or aspirat.e from the lymph node showing
the typical extracellular 'school of fish' appearance on
Gr-am staining. Culture, en£yme-linked immunosorbem as-
say (£U SA) and PCR staining can also be used as diagnostic
tests.
TREATMENT
Recommendations include th e following op ti o ns:
• Azithromycin 1.0 g orall y as a single dose with 98% effec-
ti veness.
• £ryth rom)'c in 500 mg orall y eve ry 6 ho urs for 7 days.
• Alternatives include ceftriaxo ne 250 mg i.m. as a single
dose or oral Lrimethoprim and sul phamethoxazole (Bac-
u·im OS) b.i.d. for 7 days o r oral ciprofloxacin 500 mg
b.i.d. for 3 days.
• Spectinomycin 2 g i.m. as a single dose.
• ll1e woman should be screened for ot.her STDs.
SYPHILIS (Fig. 29.6)
It is an STI caused b) the motile spirochete Treponmw plllli-
dum. Hwnans are nawral hosts. IL also spreacls b)•contact "ith
broken skin/ intact mucous membrane. The most frequent
enu·y sites in the female include t.he \'lllva, vagina and
361
Figure 29.6 Hard c hancre of syphilis. (Source: Logical images, www.
logicaimages.oom)
CLINICAL FEATURES
When the disease is unu·eated, i1s nawra l evolution is as
follows.
Primary Syphilis
The classic lesion designated as the chancre appears with in
9-90 days from tl1e fl rsL exposure. The mac ular lesion be-
comes papular and tl1en ulcerates. The ulcer(s) is painless
and firm. witl1 a punched out. base and rolled o ut edges.
LeftLLnattended, tl1ese heal witl1 in 3-9 weeks. There occurs
an accompan)ing painless inguinal, discrete lymphadenop-
athy. The latent period is 8 weeks after inoculation and
3-6 weeks after chancre. The serological 1est becomes posi-
tive 1-4 weeks after chanc•·e.
Secondary Syphilis
This is e\idence dissemination of the spirod1etes.
Onset of systemic manifestations includes symptoms
such as malaise, headache, loss of appetite, sore tl1roat and
the appear-ance of a generali£ed symmetric, as)•mpLOmaLic
maculopapul ar 1<\Sh on the palms and soles ofLhe feet. It is
not uncomm on LO flnd a adenopa tl1y in 50% of
cases. Condy!Jmwll1lata are a classic finding; tl1 ese are highl y
contagious exop h)'tiC broad exc rescences tl1 at ulcerate.
T hese are common!)' seen on the vul va, perianal area and
upper thi ghs. After 2-6 weeks, it passes imo tl1 e phase of
latent syp hilis. No clinical man ifest.atio ns are present; how-
ever, tl1 e serologic test for syp hil is is positive. T his stage lasts
for 2-10 weeks (Fig. 29.7).
Tertiary Syphilis
Syphilis left untreated may deve lop into tertiary syp hilis in
about a third of the affected patients 5-20 years after rhe
chancre has disappeared. The remains latent in t11e
remaining persons. Manifestations of diffuse organ system
involvement include tl1e following:
• Manifests as meningitis, tabes dorsalis or
paresis and mental disease.
• Cardiosyphilis: Manifests as \'llh ular disease, ao•·Litis and
aneUI')Sm.
• Skin manifestaJions such as gummas.
362 SHAW'S TEXTBOOK OF GYNAECOLOGY
Figure 29.7 Early condylomas of secondary syphili s.
Du ring pregnancy, S)•philis can cause la te abortion and
stillbinh . Congenital syp hilis in newborns manifests few
weeks after birtJ1.
LABORATORY INVESTIGATIONS
These in dude tJ1e following:
• Primar) S) phi lis: Dark-fleld microscopy of chancre scrap-
ings reveals spirochetes. Serological test (VO RL test) at
tJ1is stage is negati,e.
• Seconda•1• S)philis: Oark-fleld microscopy of scrapings
from cond)lomata !aLa spirochetes. Serological
test (VORL test) is posithe. lmmunofluorescem tech-
nique is also available.
• Tertiary S)•philis: erological test (VO RL test) is positive.
Lumbar puncture and exami nation of cerebrospinal fluid
are recommended in cases of Stt5pected neurosyphilis.
• Confim1at011' tests such as the fluorescent titre antibody
(FTA) absorption test a nd the mi crohaemagglutination
assay for antibodies to TrejJO!lfll!fl f>rdlidmn (MHA-TP) are
advocated. T he important point to remember is that a
falwposit.ive VDIU. in !Vfmum with systemic lupus erytlte-
mul other conditions.
• Biopsy may be needed to d iffere ntiate it from tuberc ular
and cancerous ul ce rs.
• PCR testing is now ava ilab le.
TREATMENT
The following are recommended:
• Screen for other STOs and HIV infection.
• Counselling about treatment, expected course of tl1e dis-
ease. •·isk offetaltransmission and itS sequelae in the case
of pregnane).
• Treal.ing all sexual partners of the infeeted
• Specific u-eatment: (a) Intramuscular injeclion of2.4 mil-
lion units ofbenathine penicillin after a test dose. Male
pa•·tner should recei\e the same close preferably on
the same clay. (b) lf latent disease is present for over a
year, t11e dose of penicillin is •-epeated weekly for 3 weeks.
Patients who are allergic to penicillin should undergo
desensitization or tlle) should be prescribed el")•lhromy-
cin. dOX)C)cline or atithrOm) cin as an alternative dn1g.
Altemal.ive drugs for person sensitive to benzathine
penicillin
• DOX)C)cline 100 mg b.d. X I I days.
• El")rthromycin 500 mg q.i.d. X 14 da)S.
• ALitllrom)cin 500 mg o.d. X 10 da)S.
• Amoxicillin 500 mg q.i.d. X 14 da)S.
• During follow-up, ser·ology titres should show a decrease
by fourfolcls after 3-6 months.
• Recommend use of ()ll n·ier contraceptives LO prevent
spread of the disease.
• Seek joint consultation with a specia list in STDs.
• All newborns to a motJ1 er who was found to be VORL
positive s hould receive neonatal prophylax is in tl1 e form
of procaine penicill in for 14 dti)'S.
VAGINITIS
GONOCOCCAL VULVOVAGINITIS
This is an STD that can lead to seq uelae adversely affecting
subsequent reproducLive functions.
EPIDEMIOLOGY
The causative organism is a Cram-negalive intracell ular
diplococcus called Nei.s.sma g01wrrl101'(ll". The incubalion pe-
riod is 2-10 days. The vaginal squamous epithe lium is resis-
tant to gonococcal infeCLion. The gonococci attack tl1e co-
lumnar epitJ1elium of glancls of Skene and Bartl10lin,
uretllra, cervix and fallopian tubes. It ascencls in a piggy-
back fashion attached to tJ1e sperms to reach the fallopian
tubes. It is destrO)ed easily by Ch)'ing, heat, sunlight and
disinfectantS.
Sill$ for brvterittl nxovery: These include t11e uretJua, cervix,
anal canal and pha11'nx. Prindfxtl of invtL\·ion: These in-
clude columnar epi tJ1 elium of the genital tract, tra nsitional
epithelium of tJ1 e urethra and Ba11.holi n's gland. Infection
rates: T he li keli hood of contra cting infection is 35% for men
from wo men and 75% for women from men. Childh ood in-
fection occ urs due to contamination "1th infec ted material.
DIAGNOSIS
Early clinical Gonorrhoea causes an asymp to m-
a tic infec tion of th e pharynx, ce rvix and ana l canal/
rec tum. These inc lude urinary freq uency
and dys uria, dyspareunia, rectal discomfort and vagina l
discharge. Vulvovaginal/peri neal infection often res ul ts
in inflammation, discharge, irritation ca us ing pruritus
and dysuria. Examination reveals swolle n , painful exter-
nal genitalia. purulent vaginal discharge, ery1.hema sur-
rounding exte.-nal urinaq meatus, opening of Bartl10lin 's
ductS. vaginitis and endocer' icitis.
Late cliniatl jindilllJl: Bartholinitis, Bartllolin 's abscess,
Bartholin ·s cyst, wbo.ov;u·ian abscess, p)osalpinx, h)drosal-
pinx and blocked tubes. The disseminated infection may
lead to pol)-a•·tllralgia, tenOS) no' itis, dennatitis, pe•·icarditis,
 CHAPTER 29 - SEXUALLY TRANSMITIED DISEASES INCLUDING HIV INFECTION
endocarditis, meningitis and ophthalmologic manifestations
causing conjunctivitis and uveit.is. End result of chronic pel-
vic infection causes chronic pelvic pain, dysmenorrhoea,
menorrhagia, infert.ilit) with fixed reu'Oversion and at times
dyspareunia. In the past, it was 1he cause of neonatal oph-
thalmitis occurring in newborns born to infected mothers.
The routine practice of instilling in all neonates sulphacet-
amide/ ant.ibiotic e>e drops has helped control this problem.
As much as 509"o-80% of women ma>• remain aspnptomatic.
lABORATORY INVESTIGATIONS
These include Gram St<lining of smear prepared from any
suspicious discharge. The tenninal urethra and endocervix
are fuvoured sites for obtaining the discharge. Culture fi'Om
urethra and ce1vix on Thayer-MarLi n medium or blood agar,
and McLeod chocolate agar in 5% C02 moist aunosphere is
performed.
Complement fixation tests and PCR staining a re also
possible.
NAAT from wine, e ndocervical discharge: though 90%
sensitive, is now in vogue. If NAAT is positive, there is no need
of culw re.
Self-collec ted samples yie ld similar resultS to that pre-
pared b)' the physic ian.
Laparoscopy reveals, apart fi·om tubal disease, a band of
fibrous tissue on t11 e right side su·e tchin g from the fallopian
tube to the undersurface of the liver (Fitz-Hugh-Curtis
syndrome) (Fig. 29.8).
COMPLICATIONS
PlO. p)osalpinx formation, tubo-ovarian abscess, ab-
scess. followed later on b) h)d•'Osalpinx fonnation, infertilicy,
me nsu·ual d isw rbances, chronic pelvic pain, dysmenorrhoea
and d)spareunia.
TREATMENT
Treaunent options include the following ( rable 29. 1) :
• cefoxitin 2.0 g i.m. plus probenecid 1.0 g orally,
followed by 14 clays of u·eaunent ,,;tll or·al. Doxycycline
Figure 29.8 Laparoscopic view of gonococcal and chlamydia!
infection showing Fitz-Hugh-curtis synd10me. (Courtesy: Dr VM3k
MaiWah, Nsw Delli.)
363
Table 29.4 Treatment of Gonorrhoea (CDC-2015)
Recommended Regimen
Celtriaxone 250 mg l.m. In a single dose PLUS azith10mycin 1 g
orally in a single dose
Alternative Regimens
If ce!triaxone is not available:
Cefixime 400 mg orally In a single dose PLUS azith10111ycin 1 g
orally in a single dose
100 mg b.i.d. for 14 days or oral. Tetracycline 250 mg q.i.d.
for 14 da)-s.
• Ceftriaxone 250 mg i.m. + 1.0 g probenecid orall y,
followed by oral. doxycycline I 00 mg b.i.d. for 14 days or
oral te u·ac)'Cline 500 mg q.i.d. for 14 days.
• Oral ciprofloxacin , levofloxacin o r ofloxacin 400 mg
b.i.d., fo llowed by 14 da)'S of cli ndamyc in 450 mg orally
q. i.d. or me u·onidazo le 500 mg b.i.d. fo r 14 days.
• Injection spectinOill)'Cin 2 g i.m. single dose.
• Surgeq' includes drainage of abscess, excisio n ofLhe C)'St,
tuboplast)' for wbal infe rti li ty.
• Treat the male paru1er as we ll and loo k for chlamyd ia!
infection and syp hi lis.
CHLAMYDIAL INFECTION
Chlamydia! infection is common in yo ung, sexually active
women but rare after t11e age of 40 years. About2%-10% of
pregnant women are found to have this infectio n during
the antenatal period and it accountS for I% of all abonions.
The incubation pel"iod is &-1 I days. It is sexually u-ansmit-
ted during vaginal and rectal imercourse.
Ozlam)'dia is a small Gram-negative bacterium,
an obligate intracellular parasite tllat appears as inu-acyto-
plasmic inclusion body, and is of two va•·ieties, one t11at
causes LGV a nd tl1e other non-LGV, which causes nonspe-
cific lower genital tr-act infection. Often, the infection is
silent and the woman is asymptomatic but may develop
vaginal discha•·ge, dyswia and fi·equency of mictUJition, and
at times cervicitis. Sometimes, chl amydia! infection may
cause Reiter syndi'Ome with arthritis, skin lesions, co njuncti-
vitis a nd genital infec ti o n. It also ca uses perihepatitis and
Fitz-Hugh-C urtis synd rome s imilar to t11a t caused b)' go no r-
rhoea. During pregna nC)', abortio n, pre te rm labo ur and in-
trauterine growtl1 reta rdation (IUGR) may occ ur. Newborn
may suffer from conj unctivitis, nasophaq,ngiLis, o titis media
and pneumonia. Pneumonia may deve lop in 6 weeks to
3 months after vaginal de livery. The ce rvix is the first s ite of
infection but the disease may sp read upwards to develop
PLD and spread to t11e paru1er and neonate. lt can cause
chorioamnionit.is and preterm labo ur if infection occurs
dLuing pregnancy.
By ascending upwards, it ma> cause salpingitis and infer-
tilit)'• though the S) mptoms of salpingi1is may go unnoticed.
The tubal damage is, howe,er, more severe than that caused
by gonococci.
In the endocen'ix, chlam)dial infection alters spenn
parameters. F•-agmentation of D A causes loss of motility or
dead sperms- tllis resultS in infertility.
364 SHAW'S TEXTBOOK OF GYNAECOLOGY
DIAGNOSIS
The use of Auorescein-conjugmecl monoclonal antibody in
imrmmoAuorescence tests on smears prepared from urethral
and cervical secretion allows a direct diagnosis of the infection.
IgM antibodies can be detected in 30% of cases of recem infec-
tion. Cervical smear shows leuCOC) tes but no organisms. £USA
can also de tea the antigen. Cltkmryduz is cultured from the cer-
vical tissue in 59'o-15% of as) mptomatic women. Polpnerase
and ligase chain reactions a•-e fast, highly sensitive and specific
tests (96%) and now considered 'gold standard' in the labora-
tory diagnosis. Ulipath-UK (clear view) is a simple, rapid and
bedside test.
Cervical ecLOpywith bleeding on tOuch and mucopurulent
discharge is seen when the cervix is infected.
Chlamydia) infection and gonococcal infection often
coexist and both attack the columnar epitl1eli um of the
genital tract and ureth ra. Urine ca n be cul wred in sus-
pected chlamydia) infection. Urine for PC R is simple a nd
acc urate to perform. NAAT is also possible.
TREATMENT (Tobie 29.5)
Du ring pregnanC)', eq'thro myc in o r a mo xicilli n t. i.d . or
q .i.d. is given for 7 days. Contac t trac in g, avo idance of sex
or barrier contraceptive is necessary tO avo id rec u rrence.
TRICHOMONIASIS
In clinical practice, this is amongst the most common SIDs.
Nearly half of the patients who complain of pn.uin.LS vulvae har-
bour this organism. It is almost entirely a disease of the child-
bealing age. though )Oung girls and posunenopaLLSal women
are not all immw1e. The•-e is no doubtthauhis infection is sexu-
ally u-ansmissible. but in some instances, it can be acquir-ed by
inadequate h)giene or the use of an infeaed person's towels,
bath or clothes. Its ingress to the "agina is favoured by a low
gene1-al 1-esistance pa•-ticluarly when the pH is raised such as
dwing a mensm.aal pe1iod (pH !>-6). It is not w1common dur-
ing pregnancy and is often associated \\ith gonococcal infection.
Trirltomonas ll(ll,rilllllil> is a actively motile and
sliglnl)' larger than a leucocyte and is anaerobic. Three
types of arc known. Men may harbour Triclw-
11Wnasvagi1uzlil in the urethra and prostate. A trichomon ad
Table 29.5 Treatment of Chlamydlallnfectlon
(CDC- 2015)
Recommended regimens
• Azithromycin 1 g orally In a single dose
OR
• Doxycycline 100 mg orally twice a day for 7 days
Alternative regimens
Erythromycin base 500 mg orally four times a day for 7 days
OR
Erythromycin ethylsuocinate 800 mg orally four times a day for
7 days
OR
Levofloxacin 500 mg orally once daily for 7 days
OR
Ofloxacin 300 mg orally twice a day for 7 days
Figure 29.9 Trichomonas vagina/Is. The protozoa are seen only in a
wet film and are of varying shapes. They may be adherent to a squa-
mous cell, or they may be attached to pus cell s (diagram after Glen
Li ston).
has fo ur a m e ri or flage lla a nd o ne poste ri o r flage ll um, a nd
they move a long the m ucous membrane (Fig. 29.9 ) . T he
postelior Aage llu rn is respons ible for mo ti lit)'·
SYMPTOMS
About 20% of cases 1-emain asymptomatic - others deve lop
symptoms 4-28 days following sexual contact with an infected
parlller or contact with an infected material. About 70% of
cases show t)pical discharge, whicl1 is profLLSe, thin, creamy or
slightly green in colour, irritating and frot11y. The vaginal walls
are tender and angl') looking, and tl1e discl1arge caLLSes pnui-
tLLS and inAammation of the vul\'a. There are often multiple
small p unctate strawberry spots on the '<aginal \'l!Ltll and pon.io
'<aginalis of the cen·ix (su-awbe.-.1' '<agina). The char-acteristic
frothy discharge is almost diagnostic, but tJ1e presence of sec-
ondary infection may alter and mask this initial sign. The pa-
tiem may also complain of UJina•1' symptoms such as dysw-ia
ar1d frequency, and a low-gmde UJ-etllritis may be discovered
on examination. Abdominal pain, low backache and dyspareu-
nia may also be complained of, if pelvic infection occurs.
DIAGNOSIS
In all s uspected cases, it is necessa ry to examine a wet film
preparati on under tl1e microscope. T he prepa ra tio n s ho uld
be fresh, a nd tl1e tempera ture s ho uld be a t least 35•c. Triclw-
monos is in cons tan t mo tion, whic h d is ting uishes it fro m pus
cells (le ucocytes) (Fig. 29.9 ). 'f iidW11W1WS is us uall)' acco mpa-
nied by a m ixed group of secondary infec ti ng o rgan isms s uc h
as Eschericltill coli and patJ1ogenic cocci. If t.he we t fi lm stained
with Gram stain or Leishman stain is negative, tl1e parasite
can be c ul tured. The culture is 98% re liable. Triclumwntzs may
also be diagnosed on a smear stained for cytology. The other
sensitive techniques include PCR and antigen testing. Pap
smear shows greyish-blue pear-shaped su·ucture witl1out t11e
Aagella. PCR and AAT are more sensitive teStS but are
hardly needed in routine clinical practice.
TREATMENT (Tobie 29.6)
Male parmer should be u·eated at tl1e same time with one
of the aforementioned drugs.
 CHAPTER 29 - SEXUALLY TRANSMITIED DISEASES INCLUDING HIV INFECTION 365

Table 29.6 Treatment of Tric ho monas Vag initis

(CDC-2015)

Recommended regimen
Metronidazole 2 g orally in a single dose
OR
Tinidazole 2 g orally in a single dose
Or
Secnidazole 2 g orally In a single dose
Alternative regimen
Metronidazole 500 mg orally twice a day for 7 days

Meu-onidat.ole and •-elated drugs are best avoided in the

Figure 29.10 Mycelial tang les of yeast pseudohyphae in KOH wet-
firstu-imester of pregnancy. Recun·em infection is u·eated with
mount preparation. (Sourt:e: Hacker NF, Gcmbone JC, Hobel CJ.
tinidazol e 500 mg q.i.d. and vaginal pessary 500 mg b.d. for
Hacker and Moore's Essentials of Obstetrics and Gynecology. 5th ed.
11 da)S. Prolonged usc causes pano·eati tis, ne uu·openia and Philadelphia: ElseiAer, 2010.)
new·opathy. Breastfeeding is co nu-aindicated dwing therapy.

relief. Rec wTen t infections require fluconazole orally 150 mg

CANDIDAL (MONIUAL) VAGINITIS every 72 hours for doses and t11en weekly dose for a
lt is a fungal infection caused by yeast-like microorganisms few weeks.
called Ctmdida or Mouilia. The commonest species caus ing
human disease is Ctmdida albiams, which is Gram positive • N)•Statin pessary b.d. X 10 days
and grows in acidic medium. It may be sex ually u·ansm itted. • Miconazole cream 2% X 7 days
Almost 25% of women harbour Candula in the vagina. • Clou·imazole 100 mg vagina l tab let X 7 days or l % cream
for 7-10 days
RISK FACTORS • Ketoconazo1e 400 mg dail) X 5 days
These include promiscuit), immunosuppression, HfV infec-
tion. pregnanC), steroid therap), following long-tenn broad-
spectnun antibiotic therap). use of oral conu-aception pills, HUMAN IMMUNODEFICIENCY VIRUS
diabetes mellitus, poor personal hygiene and obesity. INFECTION
CUNICAL FEATURES HfV infection made its first appea1-ance in 198 1, and tl1e
Prlll'itus vulva is the cardinal spnptom. lt is often accompanied was disco,·ered in 1983. Since then, it has spread very
by \'<lginal in·itation, d)Stuia, or both, and passage of thick rapidly and reached epidemic proportions (Fig. 29.11 ).
curdy or flaky discharge. Speculum examination reveals vagi- Acquired immunodeficiency syndrome (AJDS) is tl1e
nal wall congestion, with curdy discharge often visible at the clinical end stage of HIV infection, resulting in severe
vulml mucocutaneous junction and in the poste•·ior fomix. in·eversible immunosuppression and acquisition of various

DIAGNOSIS
It is essentiall y based o n clinical findings. T he diagnosis can
be confirmed o n microscopic examination of a smear of the
vaginal disc harge u·eatcd with I 0% KOH solu tio n, wh ich
dissolves all o tl1er cellular deblis, leaving the mycelia and
spores of the Ctwdida (Fig. 29. I0). G ram staining of the GP-110
disc harge or Pap smea rs may also reveal the presence of
Ctmdid.t1. C ulture on Sabo ura ud's agar or Nicke rson's me-
dium he lps ide ntify CandidlL
Pap smear shows th ick red-sta ined hyp hae and dark red
spores. The colonies on culture appear as black rounded
colonies, l -2 mm in diameter witl1 yeast-like odour.
TREATMENT
Local inu-avaginal application of antifungal agentS such as im-
idaLole.micona.wle, douimaLOie, bu1oconazole or terconawle
'aginal pessa1ies or creams used for 3-Q clays is effective. A si n-
gle oral dose of fluconaLOie 150 mg has been found to be ve1y
effective. ldeall), botl1 parUlers should be u·eated and tl1e
w1derl)ing predisposing factor con·ected to give long-tenn Figure 29.11 HIV virus.
366 SHAW'S TEXTBOOK OF GYNAECOLOGY
opportunistic infections and cancers. AIDS is the th ird gen-
eration ofSTDs. Prevalence was 0.39% in 2004 and 0.3% in
2009 (from 2.6 million to 2.39 million in 2009). There are
worldwide efforts to contain further spread of this deadly
infection. Most affected people are young below the age of
25 years. It is common among homosexuals and intravenous
drug users. as well as results from blood transfusion and
pednatal transmission from infected mothers.
MICROBIOLOGY
HIV is a small RNA retrovints. HI V-I and H!V-2 are members
of the Len tivirus subfamily. The vint5 gains enu·y into the cell
through CD4 1-eceptor on the surface ofT cells, u<u1Sa·ibes
genomic RNA into DNA and then integ.-ates into the DNA of
t11e host cell. It •·emains as provin ts until tl1e life ofthe cell. lt
replicates within t11e host cells at t11e expense ofthe host cell
resources. When cell dea th occu rs, t11e H IV viral load is re-
leased in large nu mbers. II IV cells show p reference for hu-
man T cells, where it can lie dormant for many years. HfV-I
is a more severe vims, and III V-2 is a slowly progressive vims.
EPIDEMIOLOGY
High-risk gro up inc ludes sex workers, with othe r assoc iated
STDs, smokers, cocaine users who a t-e imm unocompro-
mised and also t11ose who have rece ived infected b lood
transfusion. The majority of HIV-infected patients belong to
tlte childbearing age. Spread of tlte disease occurs through
sexual contact (homosexual and heterosexual), through
shared tLSe of infected needles among intravenotLS drug tLS-
ers, and through comact with infected body fluids such as
blood. semen. ,·aginal secretions, saliva, tears and breast
milk. In tl1e past, many people got inadvenemly infected
through adminisu-ation of HIV<ontaminated blood U<II1Sfu-
sions. Health care workers handling infeCled suqjects are
vulnerable to tl1e infection. The virus infects macrophages,
white cells and 1:helper lymphocytes (T. cells).
Following initial infection, antibodies develop in 2-3
weeks' time and tlte per·s on becomes seropositive. At times,
it may take as long as 6 months. This petiod is known as
'window pedod'.
NATURAL COURSE OF THE DISEASE
M ter infec tion, tl1e person ma)' remain or mani-
fest symp toms ,,1 tl1i n 3-6 weeks; thet-e at-e nonspecific features
such as feve•; headac he, malaise, myalgia, atthralgia, rash and
gasu'Ointestinal upset. T hereafter, t11e patiem e me rs tl1e 'asymp-
tomatic p hase', lasti ng for 8-10 )'Cars. Evidences of compro-
mised immune-like generalized enlargemem of l)•mp h nodes
ma)' become evident with in 3 years, wiLh a d t'Op in CD4 coun ts.
T he sympton1S of AIDS complex begin to manifest such as un-
explained fever, r-ashes, Lhrush, weight loss, fatigue and diar-
rhoea. AJD><:Iefining disease includes opportunistic infections,
tuberculosis (TB), Kaposi sarcoma and cervical cancet:
RetrovinLS has a core protein witlt an envelope of glyco-
pt'Otein. It can be destrO)ed b) steriliLation at56°C for half
an hour or witlt the use of h) pochlorite, lipid solvents and
glutaraldeh)de.
Hori.t.omal u-at1Smission from male to female is higher
than that from female to male. This is because of tlte larger
vaginal area exposed to infection and small abrasion tltat
occLu·s during intercourse. Male-to-female transmission per
intercourse is 0.2%-0.5% but only 0. 1% from female to
male. Ln a man, tltis infection does not interfere witlt fertility
in tlte initial stages. Witlt advancing infection, it can catLSe
ord1itis willt oligospennia and aspermia and viscotLS semen.
In a woman. infertilit) is unlike!), but vertical transmission LO
L11e neonate is a big l'isk. Seminal wash in intrautetine in-
semination and in viu·o fertiliLation (IVF) removes tlte
and is emplo)ed if the man alone is infected.
CUNICAL HIV INFEOION
The median time from acquiting infection to full-blown
AIDS is about 10 )Cars. The clinical features of tl1e disease
include the following:
• Generalized lymphadenopathy
• Unexplained fever
• Malaise, fatigue, artl1ralgia, weigh t loss and cachexia
• O ral lesions - ap hthous ulcers not respo nd ing to usual
trea ll'llen t, th rush a ncl leucopla kia
• Reacti vatio n of herpes zos te r
• Recu rrent oral and genita l herpes, ca ndidiasis skin infection
• T hromboC)•topenia
• Mo lh.LSc um con tagios urn, condylomaL<'l ac uminata and
basal cell carcinoma
• OpporttUlistic infections such as Pnl'lmUJC)'Stis cnrinii pne u-
monia (PCP), toxoplasmosis and cytomegalovirus infection
• Tuberculosis
• Peripheral neuropathy, encephalopallly, meningitis, my-
opallty. meningitis and dementia
• Kaposi sarcoma and cancer of the cervix
• Pe.; natal transmission
The WHO estimates tllat by tlte tum of the last century
(AD 2000), about 3 million women worlch1ide had died of
AIDS. About! 0 million children were the ' 'iCtims of petinatal
infection, and many of these were orphaned. The incidence
of HfV-positive cases in antenatal clinics has •·isen from 2%
w almost 4%-5% over tlte last 15 years. Many Hl\1-infected
women choose to become pregnant, continue their preg-
nancies in spite of counselling and avai lability of medical
termination of pr·egnancy ( MTP) services.
PERINATAL HIV TRANSMISSION
T he rate of peti nata l u-a nsmission v.1tho ut d rugs is esti-
mated to be 20%-30%. It ma)' occ ur as transplace ntal trans-
missio n, inu·apatlllm sp read of d isease or postpa num trans-
missio n Uli'O ugh lac tati on. The highest risk of vertical
transmission of the d isease is d uring labour. Ad min is u·ation
of an tiviral drugs to tlte mother d uri ng pregna ncy and de-
livery has bt'O ughLdown the inc idence of vertical u·ar1Smis-
sion of H IV significantly to I%. Neon ma l administration of
antiviral drugs and avoiding lactation have further made a
downward dent into the incidence of neonatal disease.
DIAGNOSIS
Diagnosis of HrV infection is based on the initial screening
test for specific antibodies using ELISA, tLSually agai11St the
core antigen or envelope antigen. All positive tests are con-
finned by western blot. The median time between acquiring
infection and AIDS is about 10 )ears. Clinical progress of
 CHAPTER 29 - SEXUALLY TRANSMITIED DISEASES INCLUDING HIV INFECTION
u1e disease is monitored on the basis of CD 4 co unts. It pro-
vides the basis for thera pe u Lie interven Lion.
• At CD4 counts of > 500/ mL, patients do not demonstrate
evidence of immunosuppression.
• At CD4 counts of 200-500/ mL, patients are likely to de-
velopS) mptoms and in need of interven Lion.
• At CD4 counts of < 200/ mL, patients often present witll
oral tllrush, unexplained fever and increasing lass itude.
The 'window pet·iod' mentioned earlier mandateS repeat
test for antibodies in 6 months in a suspected case because of
false-negative t"esttltin the firstsample. Testing fonin.IS becomes
positive earlier Ulan testing for antibodies (,,;ndow petiod).
TREATMENT
• Screening fo r HI V should be offered to all pregnant
women and all u1 ose at risk.
• Pregnant women suffeti ng fro m HI V infec tio n are at an
increased ri sk of infec Li ons such as T B, bacteti al pneumoni-
tis and PCP. Proph)•laxis aga inst PCP includes aerosolized
pentamidine. It appea rs to be safe d uri ng pregnancy. Cotri-
moxazole (TMP/ SMX-DS) is presctibed LO prevent oppor-
ttmistic infec tions; Pap smear is done pe tiodically.
NACO
Wiu1 a view to control HIV infection, u1e National AIDS
Control Organization (NACO) was established in india.
Along wiu1 other voluntal") and foreign collaborations,
this organiation works towards:
l. Mapping and screening high-risk cases of HI\1 infection,
i.e. sex workers, single migmnts, IOt"l")' drivers, homosexuals
and it'\iectable drug abttsers.
2. Treating HI V-infected cases free of cost and follow-up.
3. Avoiding spread of infection from husband LO wife, and
vice versa, through adoption of bat-rier contraception
and preventing spread to offspring u1rough adoption of
proper hygienic practices.
4. Taking care of affected children and o•·phans.
5. Educating the public, parti cularly the adolescents, re-
garding sex ed ucation and conu·aceptives.
STRATEGIES TO PREVENT PERINATAL TRANSMISSION
• Decreased fe ta l vira l ex posure by preventing chorio-
amnion itis and dec reasing th e d ura ti o n of labo ur.
Decrease th e co ntact of the fe tus from infected ma ter-
na l fluids b)' preventing ru p wre of membranes and
mucosal infla mmatio n. Th is prac tice has led to in-
crease in ra tes of e lective caesarea n section.
• Initiate :t.idovudine (Reu·ovir) u1erapy. lf me matemal
CD4 count is less Ulan 500/ mL and u1e viral load by DNA-
PCR is 10,000 copies/ mL, u1en it is advised to initiate zid-
ovudine at 14-16 weeks of gestation . The recommended
dosage is 600 mg per da) in two LO three divided doses.
The drug is teratogenic in the first ttimester (neural tube
defect) and causes maternal anaem ia and neuu·openia.
• A lt•rger viral load with a /Qw CD4 a)lmt mandt1tes triple-tlmg
tlu!Tll/J)' after proper coun.selling.
• intrapartum therapy consists of adm inistration of zid-
ovudine 2.0 mg/ kg i.v. during the first hour of labour,
367
followed by 1.0 mg/ kg per ho ur througho ut the rest of
labour. Avoid amniotomy, feta l scalp e lectrodes and
intrauterine pressure catheters. Later, advise on safe sex
practices (barrier contraception) and postpartum con-
traception. It is preferable LO avoid lactatio n. However,
in poor countries, this advice ma) not be practical where
exclusive breastfeeding (not even water) is advised.
Fetal thero/J)•: Maternal adminisu-ation of Lidovudine is as-
sociated witll decreased risk of vertical transm ission by as
much as two-thirds in mildly affected as)lnptomatic women.
Matemal Lidovudine Ulerapy is followed by 6 weeks of
neonatal therapy in oral doses of 2.0 mg/ kg i.v.
every 6 how-s for 6 weeks.
in tlle latest revised guidelines for treati ng HI V infection
during pregnancy, WHO recom mends use of u·iple-drug
regimen through out pregnancy comprising lam ivudine,
tenofovir and efaviren:t irrespective of the CD4 co unts.
ANTIRETROVIRAL THERAPY (ART)
Optio ns for direc tJ y trea tin g III V-infec ted women have
greatly increased since the introductio n of zidovud ine, a
re trov iral drug that inhibi ts reve rse transc riptase. Early tri-
a ls wiut zidovudine monothe rapy demonstrated a s urvival
advantage a nd de la)' in tJ1 e progressio n of AIDS-defining
illnesses. More recent stud ies have foc used o n combina-
tion L11erapies such as zidovudine with didanos ine or zal-
citabine. Zidovudine with lamivud ine may be a superior
choice (Fig. 29.12). Protease inhibitors such as riLOnavir
and indinavir appear more efficacio us, possibly because of
better bioavailabilit). Data from short-term clinical trials
suggest that combinations of Lidovudine with ritonavir or
indinavir demonsu-ated d t-amaticall) improved viral bur-
dens and CD 4 counts. The combined therap)' is popularly
known as highly active antiretro,·it-al tllerapy (HAART).
Three or more dn•gs in combination with different modes
of action are used in 1-lAART.
Latel)\ 'WHO has come out with revised guidelines for
the treaunentofH IV infection in 2016.
in HIV-positive women, the main gynaecological prob-
lems to deal wiu1 are as follows:
I. To detect out er associated STDs and t reat utem.
2. Prevent furuter viral load (horizo nta l u·ansmission) by
using barri er conu·acep tives.
3. To avoid pregnancy and vertical u-a nsmission to Ule off..
sp ting by using conu·ace ptives. Bani er meU\Ocls are no t
effective, so 'dual conu·acepLives' are recommended b)' add-
ing honnonal co nu-aceplives or emergenC)• con u·acep tives.
Efavirenz 600 mg
lamivudinr WO m>:.:
Tenofovir Distpr.mil
Fumarat£> :w
Tablets IP ;
Figure 29.12 ART in pregnancy.
368 SHAW'S TEXTBOOK OF GYNAECOLOGY
4. Regular Pap smear to detect cervical intraep ithe lial neo-
plasia (ClN ). l::xcisional therapy is superior to ablation to
avoid recurrence if Cl N exists.
5. Vitamin A improves immunity. Avoid smoking and drug
abuse.
6. Hepatitis B: Hepatitis B virus (HBV), a D A can be
u-ansmiued sexuall), though the parmer may remain an
asymptomatic carrier, more so in HlV infected patients.
The u-ansmission is a'oided b)• proph)lactic vaccine
I m L att:ero, first and sixth months.
A single dose of nevit-apine du•·ing labour and to the
newborn reduces the risk by 50%.
PROPHYLAXIS
The medical and oth er pc•'Sonnel exposed to the viral infec-
ti on should receive combined dntgs within 2-4 ho ut'S of
exposure but de finitely not late r than 72 h ours. Needless to
say, it is im portant to sc reen th e women for o th er SfDs and
treat the m.
CONTRACEPTION
Barrier methods in the fo rm of condom help prevent hori-
zontal transmission between the paru1ers. Th ough female
condom is also effective, diaphragm use does not protect
t11e woman, as considerable portion o f the vagina is exposed
to infection. Spermicidal agents also are no t effective. Cir-
cwncision in males has proved to reduce the horizontal
transmission b) 70%.
If me woman is taking antivi t-al drugs, intrautetine con-
u-aceptive device (IUCD) can be insened. lf not on thet-apy
or if she is suffering from other STDs, IlJCD is not suitable
for contraception, as it increases t11e •·isk of PlD.
Ot-al combined pills are excellent agaillSl
pregnancy but do not protect against vit-al infection. Rat11er, t11e
antiviml drugs r·educe the bioa,'<lilability of t11e conll'llceptive
honnot'lCS, making t11em less effective t11an in 1-UV-negative
women. ThC)\ howevet; will improve t11e conll'llceptive effect of
t11e condoms.
Surgical met11ods arc not conu-aindicated but require ad-
ditional condom use to also prevent h orizontal transmission.
Dual conu·aception, one to stop transmission of infection
(barrier) and one to prevent pregnancy, is strongly recom-
me nded.
Oral pi lls are contra ind ica ted if t11e woman is taking ami-
T B dntgs. Cerazette (p rogestogen-on ly pill) is permissible
as a con traceptive pill or 3-montll l)' progestogens such as
DMPA is effec ti ve.
DRUGS
Several drugs are now avai lab le, but HAART (co mbination
of dmgs) is the best cho ice.
• Zidovudine 300 mg b.d.
• Lamivudine 150 mg b.d.
One of the aforementioned drugs plus one of the following:
• Tenofo,•ir 300 mg daily
• elfina,•ir 1250 mg b.d.
• Lopinavir/ ritonavir three capsules b.d. or ind inavir
800 mg daily
Instead ofzidovudine, stavudine 30-40 mg b. d. depending
upon the bod) weight can be given.
Instead of lamivudine, didanosine 400 mg daily (250 mg
in a thin woman) ma> be added.
Dllring therap), haemoglobin, total leucocyte count
(TLC), differential leucOC)Le coum (D LC) and liver func-
tion tests should be perfol'lned periodically. These dmgs
cause lactic acidosis, which can cause pregnancr-induced
hypertension. The ch·ugs contraindicated during preg-
nancy are amp•·enavir and a combination of stavudine and
didanosine.
The successful treaunent does not preventu-ansmission.
It definitely reduces t11 e vira l load and reduces t11e risk of
transmission.
lf an H £¥-negative woman insists o n pregnancy, intra-
uterine inseminati on wi t11 washed se me n is safe. T he virus
does not a ttac h to t11e sperm, and se men helps get rid
of the vin.ts. Unpro tec ted inte rcourse on ly around ovulation
is an op ti on, t11o ugh it Jn:'l)' ex pose the woman to a slight
risk of infec ti on. An lil Y-positive woman should use a bar-
rier met110d but ma)' be offered in traute rin e insemination
a t ovulation so t11at t11 e man is protected.
Breastfeediug: l::ither exclusive breastfeeding or total artifi-
cial feed is the mode of n uu·itio n to the neonate. Mixed
feeding with breast milk and formula feeds increases t11e
risk of viral transmission and hence, contra-indicated.
All newborns to 1-UV-positive mothers are given
for a dLU-ation of 6 weeks. The) can receive all immunizations
except the BCG vaccine if t11e) are HIV positive.
PROPHYLAXIS
An aLLempt to de,·e lop '<aginal microbicides has failed, but
it is hoped that tenofovir may prove more specific in pre-
venLing infection in future.
Tenofovir \<aginal gel is expected to reduce u-ansmission
by 40%. No toxicity (renal) has been repon.ed so far.
SCREENING (Table 29.7)
Table 29.7 Screening Recommendations for
STDS (CDC, 2015)
Routine laboratory screening for common STDs Is Indicated for
sexually active adolescents .
• Routine screening for C. tracrcmatls on an annual basis Is recom-
mended for aUsexually active females younger than 25 years.
• Routine screening for Neisseria gonorrhoeae on an annual
basis is recommended for all sexually active females younger
than 25 years.
HIV screening should be discussed and o ffered to all adoles-
cents. Frequency of repeat screenings of those who are at risk
for HIV infection should be based on the level of risk.
The routine screening of adolescents who are asymptomatic
for certain STDs (e.g. syphilis, trichomoniasis, and BV, and
HSV, HPV, A virus (HAV] and HBV infection) is not
generally recommended .
Cervical cancer screening begins at the age of 21 years.
 CHAPTER 29 - SEXUALLY TRANSMITIED DISEASES INCLUDING HIV INFECTION
SEXUALLY TRANSMITIED INFECTIONS
AND INFERTILITY
A link between STis and infertility is well recognized. Ac-
cording to the WHO repon, almost 90 million STI-related
infertilit) cases are recorded annually. The highest preva-
lence is reported in sub-Saharan Af•;ca. The risk faCLors for
acquiring an STI are )Olmg age when indulging in sexual
activity (younger than 30 years), multiple sex pru·mers, no
use of barrier conu-aceptives and sex workers.
STis cause infertility both in men and in women by sev-
eral mechanisms.
Gonococci and C. tmchom£tlis are mainly responsible
for infertility, with other o•·ganisms playing a minor role.
Recently, M. genitaliwn was discovered to be on e of the
causal agent of infertilit)'· With decreased prevalence of
N. gouorrlwn1, C. tmclwmflli:. is now the commonest organ-
ism causing infe rti l it)'·
In a ma le, gonorrhoea ca uses urethritis initially, but chronic
infection can ascend to ca use e pid idym itis and orc hitis and
damage the uppe r ge nita l u-act. IL is repo rted that unilateral
epidid)•mo-orchitis results in infe rtility in 25% of cases, but
bilateral infec tion is responsib le for as much as 40% of cases
of infertilit)'· In women, it causes PID and tubal damage.
Chlamydia tmclwmati:. is ofte n a silent infection in both
sexes (75% in females, 50% in ma les), b ut it cat.lSes exten-
sive drunage in the fallopian tube and impairs sperm mor-
phology and sperm function by causing fragmentation of
spenn nuclei, reducing motility and apopwsis (spenn
death) via lipopol)saccharide component of Chlamyditt ru1d
inu-acellular changes in the t)rosine phosphorylation in the
spenn. \\'ith uithrom)cin or doxycycline, infection cru1 be
emdicated, but l"eCuiTence is not uncommon. Therefore, it
is suggested that a \'<ICcine such as that developed for HPV
is the best option to pre,enL chlam)dial infection and is
w1der resea•·ch.
M)'COf>lasma grmitalitml is sexually u-ansmiued. It colonizes
in the cervix, ascends upwards and causes PlD in the fe-
male. It is difficult to culture because it takes months LO
cultivate and ot11e1·mycoplasmas overgrow in the meantime.
Now witl1 PCR, it is possible to detect this organism.
PRACTICAL APPROACH TO COMMON
VAGINAL INFECTIONS
A woman is liable tO several infec tions in tlte lower genital
u-act, most common of whi ch are gonon·hoea, clllam)'dial in-
fection, 1'riclto11WIUIII infection, monilial infec tion and BV. T he
tests and culuu·es take tim e, are costly and imi te more visits to
t11e clinic.
Lately, therefore, 'syndromic management' approad1 is
implemented. This consists of giving multiple-drug tlterapy in
one sitting and comprises I g azithromycin, 2 g meuunidazole
and 150 mg AuconaLole. Only t.hose who fail to respond or
tJ1ose who are resistant are subjected 10 detailed investigations.
The following are tJ1e advantages of this approach:
I. One visit
2. Cost-effecti,·e in most cases
3. Quicker u-eaunent
369
Disad,·rultage is perhap> the woman wi ll •-eceive unnecessary
multiple tJ1erapies if only one organi.sm is involved.
HEPATITIS B VIRUS
HBV is a DNA vil'llS tltat can be u-ansmiued sexually, tJ1ough
the partner ma> remain the as)lnpwmatic ca1-rier. This in-
feCLion can be a'oided by proph)lactic vaccination
I mL of hepatitis B \'<ICcine at 0, I and 6 months.
STDS IN ADOLESCENTS
There has been an upsurge in the inciden ce of STDs
amongst the younger generation in present times. Eco-
nomic and social libe 1-alization, widespread education ,
increase in social networking opportunities, migration for
work, greater opportunities for inte ra ction and in termin-
gli ng between the sexes, and c hanging mora l values in
soc iety have con tributed to this increase in tlt e prevale nce
of STDs.
T he incidence of STOs is hi gher in homeless people,
runaway ado lescents and those in detention fac ilities. T here
has been a nol.iceable rise in the incidence of chlamyd ia!
infections and venera! warts. The practice of HBV vaccina-
tion has reduced the prevalence of hepatitis B infections.
HIV infections are more common amongst drug users and
alcoholics. Adolescents are often tempted to respond tO
their physical and emot.ional changes by indulging in high-
risk sexual behaviours to gain peer group approval; tJ1ey are
often igno•-am of the consequences that may follow or wil-
fully choose to ignore them. It is not umlSual to find them
in relationship with multiple parmers and failing to LlSe bar-
,;er conu-acepthes. Clinicians treating adolescents should
bear in mind to use on-site single·dose antibiotics whene\'er
possible because of tlte unreliability of adolescentS to return
for treaunent. This opportunity should be utiliLed to edu-
cate them about tlte use of condoms and to recommend
immuni£ations whenever a''<li lable. An auempt should be
made to u·eatthe partner as well.
KEY POINTS
• STis mos tl y affect youn g people a nd yo un g women in
reproductive years. S)•philis, go no rrhoea, chlamyd ia]
infec tio n a nd, latel)', I IIV infection a re recognized as
majorST is.
• Cond)•loma ac wni natum is catLSed b)' H PV infection
(HPV 6, 11 ). 1-ligh-risk HPV infec tion (HPV 16and 18) is
closel)' associat.ed with development of inu-aepithelial
neoplasia and subseq uent invasive carcinoma of tJte vulva
and cervix. lt requil-es adequate U"eaUllem and follo\\•up.
• HPV vaccine is now available as p•uphylactic vaccine
against HPV and needs to be gi,e n ideally before tlte
stan of sexual a eLi\ it).
• Herpes \irus ll accou nts for •-ecurrent painful vulval
ulcers. Ac)clodr oinunen t or o •-al drug is tJ1e treat-
ment of choice.
• S)philis is a systemic disease which StallS as genital
infection, posing health problem in cardiovascular
370 SHAW'S TEXTBOOK OF GYNAECOLOGY

(CVS) and cenu-al nervous S)Stems (C S) in long-

standing cases. It can cause late a bo ni ons, slillbin.h
and congenital syphilis.
• Gon ococcal and chlamydia ! infeclions often aLLack
the urethra and cause vagin al infeclion. Ascending
infec tion is responsible for wbal damage, PID and
infertility.
• C hl amyd ia is a silent infec tion b ut inflicts more tubal
damage than gonorrhoea.
• Trichomonal and monilial infection s can be easily
recognized clinically and u·eated. Rec urrent infection
needs prolonged therapy.
• AIDS is a life-threatening health pro ble m. HAART is a
pro mising therapy both for the woman and for her
offsp•·ing, and verlical u-ansmission can be reduced
from 30% to 2%.
• HIV-positive women need regula r follow-up with Pap
smear, dual conu-aceplives and screening for oth er
STDs.
• BVaccounts for40%-50% of cases of vaginal d isc harge,
20%-25% for monilial infec ti on and 10%- 15% for
Tridumunws infeclion.
SELf-ASSESSMENT
I. Enum erate the STDs encountered in clinical practice.
2. Discuss the man agement of chl amydi a! infection.
3. How would you manage a palient with gonorrhoea?
1. Disc uss the management of HI V infecti ons.
5. Disc uss the proble ms of STDs in adolescents.
SUGGESTED READING
American College of Obstetricians and C,.nccologhb. llcahhcare for
Adole>ccnb. \\'a.hington, DC: ACOG. 2003.
Bu.-.tcin GR. Ga)dos CA, Diener-We:.t M. et al. Incidental chlamrdial
u-.tchornath infections in inner-city adolesccm fcmak'>. 1998;
280: 521-26.
llolme. KK. PA, Sparlin PF, e1 al. Sexu.tlly T ransmiued Diseases.
3rd Ed . t-lcw York, McGraw-II ill, 1999.
Rc1-i><.'<l guiddincs for I ffi' co•mseling, lt::Sring, and reft..-r.d and revised rec-
01nmenda1ions for I ffi' 1mmen. fi.>r Dise-ase
Control Pre1e n1ion. MMWR Recornm Rep 2001; 50( RR-19): 1-86
Sexually transmiued diseases, treatment guidelines. Cent ers for Disease
control and Preve ntion. MMWR ReconHn Rep 2002; 5 1(RR-6): 1- 78.
 URINARY AND INTESTINAL
TRACT IN GYNAECOLOGY

30 Diseases of the Urinary Tract 32 Injuries of the Genital Tract and

31 Urinary Fistula and Stress Urinary Intestinal Tract
Incontinence

371
 Diseases of the Urinary Tract

Common Urinary Symptoms 372 Pregnancy and Urinary Problems 378

Diseases of the Female Urethra 376 Key Points 378
Urinary Fisluloe 377 Self-Assessment 378
Ureteric Obstruction 377

Urinal')' S)' mptoms are freq ue nlly co mp lained by the

gynaeco logical patients. Gynaecological diso rders and
pelvic operations often CO tHribute LOwards the ir occ u r-
rence or aggravatio n. On occasions, the underly ing - -- -a - ..a-__,J....-_ Full bladder
disease may be neurological and has no gynaecological at rest
bearing. Hence, it is important for l11e gynaecologist tO
identify urinar) problems attributable to gynaecologi-
cal causes in order to insLitu te rational therapy. The
establish menL of a proper diagnosis will call for a de- angle
tailed histof). meticulotLS examination and often a full
urological workup including laborateq' testS, cystOs-
copy, radiological evaluation, cyswmeu·y and ultra-
sound scanning.
Often a sole kidney may be located in the pelvis a nd
mistaken for a tumour. The consequence of iLS removal
in a mistaken identity is very obvious.
Because of the close association between the urinary and
genital organs embryologicall y, malfonnation of one organ
may also reveal ma lfonnation of the other and it should micturition
be searched for.

COMMON URINARY SYMPTOMS

Common w·inary S)' rnptoms include diffic ul ty in micturition,
re ten tion and inco ntine nce of urin e (Fig. 30.1 ).
Acute urinary retention follows s udden inab ility
to void urine. The conditio n ca uses discomfort and Figure 30.1 A tracing of the urethra and the bladder: (A) At rest and
pain. Catheterization yie lds a large vo lume of urine. (B) during micturition.
Detailed imerrogation often reveals the un derlying
cause. An attempt sho uld be made to excl ude the neuro- AClJTE RETENTION OF URINE (Table 30. 1}
logical causes (especiall) in patientS who experience
CAUSES
inability to void urine but experie nce no painful se nsa-
tion). Most patientS with disorders of bladder sensation Several conditions ma) lead to the occurrence of retention
experience pain rather than lack of bladder se nsation. of UJine.
Elderl) women, smokers and those with chemical expo-
sure are vulnerable to bladder cancet·; accompa nying POSTOPERATIVE RETENTION
haematut·ia must raise the StLSpicion of underlying Urinaqr retention is common after surgical operations of
cancer. the vagina and perineum. Postoperative oedema may cause
372

Table 30.1 Causes of Acute Retention of Urine in
Gynaecology
1. Postoperative retention
2. Retroverted gravid uterus
3. Urinary infection
4. Prolapse of the uterus with cystocele
5. Tumours impacted in the pouch of Douglas
6. Ectopic pregnancy
7. Advanced cancers of cervix, vagina and vulva
8. lmper1orate hymen
obstruction to the flow of u•ine, and pain in the pelvic
region may lead to a reflex spasm of the bladder sphincter.
Radical operations such as Wertheim's hysterectomy in-
volves ex tensive dissection causing de nervation of the blad-
der, leaving the patient with an insensiti ve bladder result-
ing in retention of urine with overflow. T he treatment of
postoperative reten tion co nsists of tim e ly and contin uous
cath eterization unti l tJ1 e resid ua l urin e vo lume comes
down to less tJ1 an l 00 m L. Urinary an tiseptics and ana lge-
sics should be concorn itan tJ)' admin istered. Spina l and
epidural anaesthesia acco unts for reten tion of urine in the
first 12-24 hours of the postoperative period. Surgery for
su·ess urinary incontinence and the vagina also can cause
retention of urine.
PUERPERAL RETENTION OF URINE
After deliver), the patient is often unable to appreciate the
filling of the bladder as a resultofbruisingofthe vagina and
painful perineal wound.
OBSTRUOIVE CONDITIONS
Obstructi,·e conditions inu·insic to the uretJu-a are rare.
Cicauicial stenosis may follow surge•)' of the bladder neck
for a fistula or lower down in the uretJ1ra for a caruncle.
inflammatory stenosis following gononi10ea is 1-are in
women. Sling ope1-ations for stress incontinence performed
"ith tmdue enthusiasm may occlude tl1e bladder neck and
cause retention of urine, which can only be relieved by
cutting tJ1 e sling. Cancers of the cervix, vagina, bladder
or ure tJua may lead to extensive tissue infilu·ation and
obsu·uction to the flow of urine.
SPACE-OCCUPYING LESIONS IN THE PELVIS
Space-occupying lesions in the pelvis may obstruct the ure-
tllra or bladder neck region. Some of the lesions encoun-
tered are as fo llows:
• 1-laematocolpos in adolescent girls
• Reu·overted gravid uterus at abo ut 14 weeks of gestation
• 1-laematocele complicating an ectopic gestation
• Cervical myomas or a posterior uterine wall myoma
impacted in the pouch of Douglas
• Ovarian neoplasm impacted in tJ1e pelvis
NEUROLOGICAL CAUSES
Spinal cord lesions, disseminated sclerosis, tabes dorsalis
and denen'll.tion oflhe bladderdu•·ing extensive surgery for
a malignant disease in tJ1e peh·is are recogniLed causes.
CHAPTER 30 - DISEASES OF THE URINARY TRACT 373
Amicholinergic and antidepressam drugs may also cause
retention.
CHRONIC RETENTION WITH OVERFLOW
Chronic retention of urine in old women is due tO bladder
neck nan·owing owing to senile changes in urethra.
Treatment of Urinary Retention
ln the presence of an organic lesion, attend to the removal
of the p•·imary cause.
Rdtmtion ofttrine due to lt rdrovt'Yted gmvid ttlenL5 is encoun-
tered relati,•ely frequently. This occurs between the 12th and
14th weeks of p•·egnancy when the retroverted gravid utems
fails to grow out of tJ1e pelvis into tJ1e abdomen. The ante-
rio•· \'llginal wall and tJ1e auached uretJ1ra get unduly
stretched as the reu·ovened gravid uterus sinks low into the
pelvic cavity. Sometimes, the uretJ11-al meatus may be drawn
upwards into tJ1e vagina. A soft rubber catheter can usually
be passed into tJ1e bladder witJ1out difficulty, suggesting that
ratJ1er tJ1an occlusion of the urethra, it is tJ1e distw·bance of
the reflex mec hanism of vo iding wh ich ca uses the retention.
On examination, the fu ll bladder is palpable as an ab-
dominal mass. On pelvic exam ination, tJ1e cervix is lifted up
high behind th e S)•mphysis pubis and the gravid uterus is
palpable as a large mass fi lli ng up tJ1 e po uch of Douglas.
The u·eaunent cons isiS of slow emptying of the bladder
by an indwelling catJ1eter draining into a sterile drainage
bag over 12-14 hours. The patient is encouraged to lie
down on her face so tJ1at poswre and gravity assist t11e
gravid uterus to assume the an tevened position. Digital re-
position of tl1e gra' id uterus is neitJ1er safe nor successful,
hence not recommended.
URETHRAL SYNDROME
A patiem with uretJ1ral S) ndrome is usually a posuneno-
pausal woman \lith complaints of d)Su•·ia, frequency of
micturition and occasional su·ess incominence. Urine is
sterile. The cause of ur·ethral syndrome is oesu·ogen defi-
ciency at menopause causing weakening of t11e intemal
w·ethral sphincter and urethr·a l mucosa l changes. Oestro-
gen cream applied vaginall y improves the blood supply to
the urethral sphincter and uretJHal mucosa a nd improves
the symptoms in about3 montJ1s.
In a yo ung woman, uretJua l S)•ndrome is associated with
sterile urine, but tl1e presence of pus cells indicates proba-
b le infec tion wi tl1 tubercle bacilli o r Chl amyd ia.
DIFFICULT MICTURITION
Difficult)' in emptying the bladder is a symptom present
witJ1 tJ1ose conditions which eventually prod uce retention
of wine. lt also occurs in growth of tJ1e bladder and tuinat)'
caiCLLii. One of t11e mosl common gynaecological caLLSes of
difficulty in micwlition is a severe degree of prolapse of tl1e
anterior vaginal wall and procidentia. When such patients
su-ain to mictuJ-ate, the anterior vaginal wall prolapses
further and me bladder descends so that a large sacculation
of the bladder comes to lie below the level of tl1e imemal
urinary meatus. The more Lhe patient strains, the less likely
is she to empty her bladder, as tJ1e urine is forced down imo
the cystocele instead of tJ1e uretJH-a. The only way the act of
374 SHAW'S TEXTBOOK OF GYN AECOLOGY
mict..utit..io n can be started by the paLiem is by her own digi-
tal manipulation by pushing back the prolapsed anterior
vaginal wall and the uterus this is te rmed "splinLing". Treat-
mem consists of anterior colporrhaphy, combined with a
pelvic floor repair, and vaginal hyste rectomy if indicated
PAINFUL MICTURITION
Pain may be expe ti enced either dut·ing or immediately
following the act of micturition. Pain dut·ing micturition is
usually of ' 'esical odgin due to infection but may be of ure-
thral origin and refet·red LO the urethra itself, whereas an
intrinsic lesion of the bladder gives t·ise LO bladder spasm
felL in the mid-hypogastrium so that, as soon as the paliem
has voided urine, she has an tn·ge tO pass urine again,
t11ough the bladder is empty. Gonococcal uretl1ritis causes
scalding pain, as urine passes over the inflamed mucous
membrane. Othe r causes of painful mi ctu riti o n are tender
caruncles at th e mea tus, prolapse of the ure th ral muco us
me mbrane and d isease of th e vulva such kraurosis and
carcinoma of tl1e urethral mea tus. T he recen tly consum-
ma ted marriage somewhat traum ati zes the urethra and
leads Lo pain and freq uency of micwriLio n. T his has been
called honeymoon cystitis. All operations perfo rmed upon
or near the tli"Ctltra and insu·umen Lation of the can al, even
with a soft catlteter, cause some degree of dysuria. Painful
micturition is a prom ine nt symptom in cystitis; tlte pain is
experienced at the e nd of micturition when tlte inflamed
SLU'faces of the bladder come into apposition. Otlter condi-
tions which cause painful micturition are papilloma, carci-
noma. tuberculosis and stone. One imponam cause of
dysut;a and pain is radiation cysti lis, which in severe
can cause a smalkapacit) irritable bladder. This is seen
after a radium treatment of carcinoma of the and
can be very disu·essing. The ut·ine should be examined in
all cases where tlte S)lnptom is presem and the presence
of infection excluded or confirmed by culture. CysLOure-
Lhroscopy must be perfonned to exclude Lhe presence of
Lhe more sedous ca uses of drsuria. The postradiation blad-
der often shows telangiectasia of the vessels in the •·egion of
tlte trigone.
INCREASED FREQUENCY OF MICTURITION
Void ing urine more than e ight tim es el uting day and more
t11an o nce duling ni ght is co nsidered freq uency of micturi-
ti on . Freq uency of micu uitio n is one of tlte most co mmon
sympLOms comp lained of by gynaeco logical patie ntS, and al-
tlJO ugh man)' causes of freq ue ncy lie in the urin ary tract, a
large number are gynaecological in origin. T he nongynaeco-
logical ca uses are diabetes me llitus, d iabetes ins ip idus
or pol)'ltric phase of renal fa ilure when utinary output
ina·eases. Ft-equency of micturiLion is present when the
patiem passes small amount of urine at short intervals,
and it is often associated with ot11er symptoms of bladder
imtabilit) such as urgenC) of micturition and incontinence.
Common causes of C)Stitis include l'scherichia coli infection,
tuberculous infection, stone or growtll. Frequency of mictu-
tition is a normal S) mptom of earl) pregnancy and develops
again eluting the last few weeks when Lhe presenting pan
emers Lhe peh·is. Pressltl·e upon the bladder by
tumours such as m) omas of the uterus and ovarian cysts can
also cause frequency. PatientS with cystocele often complain
of the symptom because chronic t-esults from incom-
plete empL)-ing of the bladder. InflammatOry swellings
arotllld tlte bladder suclt as parameu·itis and inflamed
appendages can also lead to freque ncy of micwrilion.
Infiltration of the bladde r b) carcinoma of the cervix or of
the vagina can cause frequenC) of micturition. Apart from
the tu-ological causes, tltis S)lnptom also develops in reten-
tion overflow when tl1e bladdet· is O\'erdistended. One very
important.. cause offrequency is bladder neurosis. ln tlte fully
established bladder neul'Osis, the patiem's life is ultimately
dominated by her bladder-though Lhis at first happens only
in the day time. The condition is readil y misdiagnosed as
stress incontinence. The urin e is sterile, \\1th nonnal cystos-
copy, and no local cause is discover-able.
The investigation offt-equency of mictul'ition requi res, in
addition Lo the usual gynaecological examinati o n, a com-
plete examina ti on of the urine, utine culture test, cystoscopy
and in traveno us pyelogt·ap hy, and ultrasound scann ing.
Treatm ent is by sim ple app lied psyc ho t11e rapy, bladde r
d iscip li ne and sedati ves. Jnct-eased freq uency due LO an
organi c lesio n, usuall )' C)'StiLis, occurs equall y at night as
du ring t11e da)', and tlt e nocwri a sco re gives a ro ugh indica-
Lion of the severil)' of the condition.
Other causes of fr-eq uenC)' need pt-ompttreatment.
INCONTINENCE OF URINE
l n true incontinence of urine which is due to a vesicovaginal
or tLreLel'Ovaginal fistula, t11e urine is discharged involun-
tadly and con tinuousl) so that the patient is constantly wet;
tlhe bladder is alwa)S em pt) without residual Lll·ine in tlhe
case of a vesicovaginal fiStula and comains only half Lhe
expected nonnal in the case of an ure tet-ovaginal fistula.
True or complete incontinence of ut·ine is presem besides
urinary fistulae in malfonnations such as ectopia vesicae,
ectopic ureter opening into the ' -agina and in some diseases
of the spinal cord.
False or partial incontinence is much more common. lt
is exemplified b)' the nocturnal enuresis in young girls when
the urine is voided during sleep and when local reflex
caused by tltreadworms may be found. O ne of tl1e most
common types of partial incontinen ce is t11 e stress urinary
inco ntinence witl1 prolapse of the amel'ior vaginal wall. In
this co ndition, the pa tie nt voids very small q uam ilies of
urine invo lun ta ti ly whi le sneezing, co ughing o r laughing.
T he co nditio n also develops d uring pregna ncy and immed i-
a te ly after deliver)' duri ng the ea rly weeks of tlt e p ue rpe-
rium, although the majo tity of symptoms Le nd to d isappear
with ti me. An impo rtant condition that is readily co nfused
with s u·ess incominence is urge inconLinence. ln this condi-
tion, tlte patiem mttSL pass Utine at a moment's no tice and,
LLn less she is quick about it, she is unab le tO conu·o l her
bladder, which empties some of its coments before she can
reach the washroom. As a point of differemial diagnosis
from stress incon tine nee, t11e amount of urine lost in urge
incontinence is al'va)S considerable and sometimes the
bladder is complete!) em ptied involumarily. This cat..asu·o-
phe is preceded b) an exu·e me desire LO pass urine. ln stress
incontinence, Lhe amount of ltline lost is minimal and mea-
sw-able (a few millilitres), and tltere is no pre,·ious desire LO
pass urine. Urge incontinence is more common than true

su·ess incominence. The concliLion is essentially due to
detrusor instability, which overcomes the normal urethral
sphincter. Cystoscopy is normal a pan from a decreased blad-
der capacit). The conclil.ion is largely funcLional, but there
may be an organic base. For example, urge inconLinence is
often associated with tn1e cystitis or urinary infection.
CYSTITIS
The female urethra always contains microorganisms sud1 as
coliform bacilli, streptococci, staph)lococci and OOderlein's
bacilli, which should be regarded as iLS nonnal inhabitantS.
These microo1-ganisms neither cause w·eth1itis unless the ure-
thral tissues are clamaged nor do they spread upwards to the
bladder unless they u-ansported by catheterization. The
catl1eter is undoubtedly tl1e most common cause of lower mi-
nary infection (UTI). However gentl e and meticulous
aseptic the technique is, no mauer of what material tl1e catheter
is made of, once it has been passed, there remains a danger of
infection.
As the catheterilal.ion is a lmost an imegral part of all
de liveries and of all gynaeco logical opemLions, the inci-
dence of C)1Stitis must be accep ted at a figure in th e region
of 80%, understandably highest in those paLiems requiring
frequem catheterizaLion or an indwelling cathetec The
logical answer is to abo lish the use of catheters as a routine
preoperative measure in minor pelvic surgery and only to
use them when su·ictly indicated, in which case a urinary
antiseptic is a prudent prophylacLic precaution.
Anotl1er cause of infecLion of the bladder is by a descend-
ing infection from t11e kidne), such as that may occur with
renal tuberculosis and dll'onic pyelonephritis. Organisms
ma> also reach the bladder from acljacem structures such as
an inflamed ce1"1ix and parameu·itis infections. TI1e bladder
may perhaps be infected by way of the bloodsu·eam and in
other cases by lpnphatic spread from the genitalia or tl1e
bowel. The organisms found in llline in cystitis are £ roli,
streptococci, staphylococci, BacilbL5 proteus, tl1e w-
bercle bacilli and occasionally other organisms sudl as Pseudo-
moiU.u fl)'OC)'<IIUXt. Gonococcal cystitis is relatively rare. The
organism which is found most freq uently is£. coli. This o1·gan-
ism is now supposed to auack the bladder secondarily to an
original infection by other orga nisms and subsequently to
overgrow and replace t11e p1imary infection. On t11e contJ-al) ',
it is well established t11at cysLiLis clue to a primal)'£. coli infec-
tion is occasionall )' encountered. As t11e result of anLibioLic
treaune nt, P. fl)'()(.)'(lltll(t so metimes becomes the dominant
infecting organism beca use of its resistance to antibiotics
relative to tl1e other infec Ling orga nisms.
SYMPTOMS
The symptoms and signs of cys Litis are painful and fre-
quent micwrition, pain in the region of bladder, su·angu ry
and passage of pus in the urine. As the bladder fills up with
urine, its sensitive inflamed mucottS memb1-ane cattSes
pain and a desire to micturate. Pain is also experienced at
the end of the act of micwrition when tl1e adjacem
inflamed surfaces of tl1e bladder come into contact.
In tu·ethritis, pain is felt as the urine is being voided.
Frequenq• of micturition ma)' be exu·eme, as the patient
has to pass ul"ine every 15 minutes. The S)lnptoms of acute
cystitis are severe, and patients are deprived of sleep and
CHAPTER 30- DISEASES OF THE URINARY TRACT 375
soon become exhausted. The temperature is often raised,
but it soon falls if proper u·eaunent is given. A persistent
high temperature usuall) due to infection ascending to tl1e
kidney. causing p)elonephritis when constitutional spnp-
LOins are more marked and rigors may occur. With pyelo-
nephritis. the kidne> is alwa)S tender to palpation in the
costOvertebral angle, and the patient will complain of pain
locali£ed to tl1e loin which 1-adiates down the ureter intO
the lower quadrant of tl1e abdomen. In chronic cystitis,
pain and su-angury are less prominent S)lnpLOms, but
frequency of mictul"ition and P> uria are alwars present.
Chronic C)'Stitis ma)' persist for months or even years
without causing symptoms and signs other than frequency
of micturition and pyuria.
DIAGNOSIS
The diagnosis of acute cystitis is based on the characteristic
symptoms and by an exa mination of t11e urine. Difficulty
may be experienced in distinguishing between acute ure-
thriLis and ac ute cystitis. In ac ute urethriLis, pain is experi-
enced during the ac t of micwril.ion. There is no abdom inal
pain or tenderness, and frequency is not extreme. In both
conditions, tl1 e win e contains pus and microo rganisms. In
acute ure tluitis, harm may be done b)' ca tlle terization or
C)'Stoscop)', becattSe tl1e instnunentaLion may can·y infection
to the bladder. Simila rly, t11e inflamed mucous membrane
is readily damaged and bleeds Urethritis can be
diagnosed by massaging the urethra against the back of
the spnphysis pubis when pus will be expressed from tl1e
external meaws. Anot11er simple met11od of distinguishing
between acute uret11 ritis and C)Stitis is tl1e t11ree-glass test; in
urethriLis. tl1e third specimen will be clear of pttS, but more
contaminated with pus in C)'Stitis.
TREATMENT
Cystitis must be u·eated by giving urinal)' antiseptics along
with the adminisu-ation of large quantities of fluids by
mouth, at least 2.5 L e1·e1)' 24 hours. Plain water, alkaline
drinks, milk and weak tea should be given. Alcohol in any
form is conu-aindicated, as it agg1-avates tl1e sympw1ns. ln
the acute phase, tl1e patient must stay in tl1e bed and some
relief may be obtained by th e application of a hot water
bottle over tl1e bladder region. The pain is best treated with
spasmolyti cs such as codeine and belladonn a. Large quanti-
ties of ciu-ates sho uld be given b)' mo utll , as much as 3 g of
potassitun ciu·ate give n three to four Limes a day.
The organisms which have bee n culwred are as a routine
tested for se nsitiviq• aga inst t11e various anLibioLics, and the
bacteriological report wi ll indicate which dn.ag should be used
for a given patient. Most of t11e lower UTls are due to E. coli,
which is neal'l)' always sensil.ive to niu·ofuramoin, so this drug
is particulal'ly useful as a prop hylac Lic and as specific thempy
for tl1e established infection. Drugs such as norfloxacin, cipro-
floxacin, pefloxacin and sparfloxacin in appropriate doses
have been found to be vel) effective and are amongst tl1e first-
line drugs selected b) clinicians in presem-day practice.
CHRONIC CYSTITIS
Chronic C)'Stit.is catLSed by descending infection fi·om tl1e
kidney is a w·ological problem, and patientS with chronic
cystitis should be seen by a urologist.
376 SHAW'S TEXTBOOK Of GYNAECOLOGY
PYELONEPHRITIS (PYELITIS)
P)elonepht·itis is an infection of the upper lllinat)' u-act
imolving kidneys, mostly a complication of the lower ut·inary
tract infections. T he urinary infections of postoper-ative and
puerperal cystitis often spread to the kidneys to cause pyelo·
nephritis. Pyelo nephritis in pregnancy is no t uncommon,
a nd the infec ti ve organism is us uall y col i. Ascending pyelo·
nep hritis is a common comp lication of adva nced carcinoma
of the cervix a nd vagina, ei tl1eras a resu lt of the g rowtllulcer·
a ting in to the bladder or thro ug h invo lve mem of the ureter
by the growt11 , and a Large number of patients with carcino ma
of the cervix, atleast60%, die of uraemia induced by ureteric
obstruction. Recurrem attacks of p)elonephritis also occur in
patients who have had ureterocolic Lmnsplantation, either
for the relief of incw-able fistula or becatLSe the bladder has
been removed in exememtion opemtion for advanced pelvic
cancer. The signs and symptoms of p)elonephtit.is are pain
and tenderness in tl1e loins, wi tl1 high temperature and
frequent rigot'S, headache, vomiting a nd furrin g of the
Lo ngue. Freque ncy of micturition is prese nt due LO t11e assoc i·
a ted cystitis. In acute pyelonephritis, t11e affec ted kidney
regio n is exq uisitely tender, whereas in c hro nic pye lo nephri·
us, te nde rness a nd tigidi ty a long tl1e co urse of t11e ureter can
often be detected on abdominal examination. The urine is
tumid and contains pus cells and bacteria. In acute pyelone·
ph titis, tOxaemia is well marked. the blood urea level is t-aised
and casts are found in t11e urine.
TREATMENT
Tr·eau11ent consistS in keeping the patient in the bed lying on
tl1e unaffected side tO prevem pressure upo n the tender renal
a ngle. Copio us fluids mus t be admin iste red. S)•Ste mic antibiot·
ics, fo llowed by oral fluid, s ho uld be given for 10-14 clays. It
ofte n needs a referral to a urologist.
Pye lonep htitis wh ich does not respond to the usual
metl1ods of treaunent or which recurs after initial successful
treaunent becomes a urological problem, and the patient
should be transferred to the care of a urologist.
DISEASES OF THE FEMALE URETHRA
URETHRITIS
AETIOLOGY
ln flammatO t)' disorders of the ure thra a re fairly common.
Sex uall y tra ns miued diseases caused by the go nococcus,
CM.am)'dia tmclwm(ltis, Triclwnwn(l.l, Caudida a nd certain
vi ruses may lead to this disorder.
The lower uretl1ra is usually affected, as vulvovaginitis is
a common accompa niment. Freque nt sexual in tercourse
often aggt-avates tl1e problem. Hone) moon cystitis is a
distinct clinical entity following coital injtll)' to the uretl1m
and the bladder base.
Me nopausal women suffer from thinning of the vaginal
epitl1eli um and urethml lini ng due to oestrogen deficiency;
tl1ese women a re more s usceptibl e to u·auma a nd infection,
which may lead LO ureth titis.
Use of c he micals, deodorants, do uc hes, vaginal contracep·
Lives a nd ta mpo ns may lead to alle rgic or c he mical reaction s
causing vulvovagini tis and ure t11ri tis.
SYMPTOMS
The common S) mpwms of urelltritis are frequency of mictu·
•·iLion and dysuria. The patiem complains of pain
dUt·ing micturition and not at the end of mi cttllition as seen
in cystitis. Examination m ay reveal an inflamed uretl1ml
orifice, a nd milking of tl1e uretl1ra m ay yield a purulent
di sc harge. Culture and microscopy of the ure t11ral disc harge
help esta blish t11e diagnosis.
TREATMENT
TreaunenL consistS of ad ministmtion of appropriate antimi-
crobials. Antibiotics such as ampicillin. nitrofurantoin or
cephalospotins may be used as indicated b) the culture. The
patient should be encouraged to maintain an adequate fluid
intake, and menopausal women should be given supplemen-
tary ' oaginal oestrogen cream to impro,·e tl1 e au·ophic SLate of
the vagina and the uretht-a. The patiem should be advised to
avoid all initants such as deodomnts, vaginal conu-aceptives
an d do uches.
URETHRAL CARUNCLE
Urethral caruncle is no t an uncommon co nditio n. It is
frequently e ncountered in posunenopausal women. The
atrophic \ttlva and vagina and introitus leave the urethral
meatus exposed to infection. The posterior ure t11ral mucosa
becomes swolle n, congested and pouts like a c hert) from l11e
postetior wall of the external meatus (Fig<> a nd 30.3).
The patient may presem with postcoital bleeding, dyspa·
reunia, pain and dysu•·ia. Before making a diagnosis of
uretlua l caruncle as a cause ofthese symptoms, it is impor·
tam to exclude genital tract mali gnancy by cytology, e ndo-
me u·ial hi stology a nd sonogmphic evalua ti o n ofthe pelvis.
T he ca runcle is treated by diathetm y excisio n. Simultane-
o us administm uo n of oestrogen he lps in recovery, a nd tl1is is
presa·ibecl on a lo ng-te rm basis; imermiLLent progesLOgens
must also be used to avo id uterine and breast cancer devel-
opment as a result oflong-term use of unopposed oestrogen.
Local oestrogen cream may be prefet-red to oral hormone.
Figure 30.2 A urethral caruncle. (Soutt:e: V N Rosenblum,
B. Brucker, Vaginal Surgery for the Urologist. Benign Vaginal Wall
Masses Md Pwaurethral Lesions. Sal.llders, 2012.)

Figure 30.3 Operation for removal of urethral caruncle by diathermy
excision.
URETHRAL PROLAPSE
This uncommon condition is seen in the very young and the
old. Chronic str·a ining and oestrogen deficiency conu·ibute
to itS occurrence. Surgical excision of the excess of mucosa,
followed by suturing of the urethral mucosa to the circum-
ference of the urethral meatus by interrupted sulllres,
con·eets the condition. Spontaneous prolapse of urethral
mucosa is rarely seen in children.
URETHRAL DIVERTICULUM
TI1e woman complains of nonspecific symptOms such as
urinary freq uenC), d)suria, dyspareunia and dribbling,
urgency or incontinence of urine. A swelling may be noted
in the urethral region. The differential diagnosis includes
t.u·ethrocele, Cartner's duct cyst or a Skene's gland abscess.
Treau11ent comprises antibiotic tl1erapy, followed by surgi-
cal excision or marsup ialization. Urethra l stricture and
fisu.tla are the likely postopera ti ve complications.
URETHRAL STENOSIS
T he comm on sites of nan·owing are tl1e regio n of the blad-
de r nec k and the mea tus. It may be conge ni tal in origin o r
as a result of infection, inj ury, neoplasm or a di verticulum.
T he pa ti ent complains of a poor su·eam, straining at micturi-
tion and repeated UTI.s. Uretlu·oscopy may reveal a narrow-
ing of the passage and trabeculation of tl1e walls of the
bladder. Treatment consistS of control of infection and
sw·gical removal of any existing cyst or tumour. ln termittem
urethral dilatation, u•·et11rotomy and reconstructive urethro-
plasty may be needed in select cases.
URINARY FISTULAE
In women, most urinaq fistulae result either from injLU)'
to the urinar> u·act during ID naecological operations
CHAPTER 30 - DISEASES O F THE URINARY TRACT 377
or fi·om obstetric damage. In India, obstetric fistulae
are more common than the ro·naecological or radiological
fistulae because of difficult home deliveries conducted
by dais when obstructed labour is not recognized.
The most common fonn of fistula is ,•esicovaginal, in
which there is a communication between the bladder
and the upper third of the anterior vaginal wall. Next
in order of frequency is ureterovaginal fistula, which
is LLSually caused b) injuq to the ureter dLUing g)11aeco-
logical operations. U rinaq fistulae can be classified as
follows:
Vesic(l/ fistukur. Vesicovaginal, vesicocervical. vesicouterine,
vesicoabdominal and vesicointestinal
Ureteric fistulrtf: Ureterovaginal and ureteroabdominal
Urinary fistulas have been desa·ibed in detail in th e
chap ter on Uri na ry Fistulas.
IURETERIC OBSTRUCTION
Ure te ric co mpressio n and obs truc ti on occ u r fro m extra-
neo us so urces. Ma ny co nd itions in the fe male pelvis ar e
associated with u reteric obstruction. T hese are disc ussed
as follows:
UTERINE PROLAPSE
In complete procidentia of tl1e uterus, the main supporting
struCtures, namely the Mackenrodt ligamentS, are greatly
elongated, and in their descent with the lllerus, a loop of
the ureter is dmwn do" n on either side to lie outSide tl1e
vaginal o•·ifice. This p•·ocess catLSes an acute angulation of
the ureters. Hence, it is not Slllprising that it gives lise LO
hydroureter and h)dronephrosis. The uterine anelies may
also compress tl1e ureters as t11e) become elongated by the
descent of tl1e utenLS. Man> of these patients have a duonic
urinary infection and this, associated with uretelic obstruc-
tion, may seriously impair the renal functions and render
them in poor surgical•isks for any repair operation. Vaginal
tampons soaked in gtycerin-acriAavine for seveml days
p receding surgical repair of prolapse helps in decreasing
cha nges in ureters.
PELVIC TUMOURS
Pelvic tu mo urs lll CI)' ca use co mpression a nd obstructio n
LO the ure ter, and this is especia ll y tr ue of the myoma
whi ch lies fi rm ly embedded in t he pelvis. Ovarian cysts,
benign and malignant, pelvic endometriosis and inAam-
mawry disease, and b•'oad ligament tumours produce
the same picwre. Such patientS should have thorough
urological investigations befo•·e operation because
roughly half of them would show some ureteric obstruc-
tion and this may well account for postoperative urin:u·y
infection. Removal of these wmours will reswre the
urinar>' tract tO normal in 70% of cases. The worst offend-
ers are those in whom the obsu·uction is due to pelvic
inAammator> disease or advanced cancer of the
where permanent stricture fonnation may have occun·ed
in a segment of the ureter.
378 SHAW'S TEXTBOOK OF GYNAECOLOOY
CARCINOMA OF THE CERVIX
Although the ureter is guarded by a tough sheath in the
ureteric canal against acwal malignant infiltration, itS sima-
Lion in this wnnel is a gr·m e danger because it is particularly
subject to compression. It is an absolute dictum that no case
of cancer of the CCI'\ ix should e'er be treated b)' surgery or
radiation therapy until a preliminary urographic study has
been conducted. Those patients who show LU'etelic obstruc-
tion have a de fin itel) poorer prognosis. and it must be re-
membered that in 70% of cases, patients with carcinoma of
the cervix die not of their plimaq disease but of bilateral
ureteric obstnaction. In these patientS, the surgeon's knife
has been regarded in the past as a great menace to the ure-
b ut effective irradiation of an infiltrated parametria.un is
an eq ual if not greater menace, because the resulting
fibrosis eve nLUally strangles l11 e ure ter. This posu·adiation
is not immed iate but ma)' develop over months or
even )'ears, and the patient may we ll be cured of l11 e local
d isease to succu mb at a later date to l11 e ure tetic obstruction
(see l11e chapter o n Cervical lnu·aepi ll1elial Neop lasia,
Ca rcinoma of Cervix).
OBSTRUCTION AT THE SITE OF FISTULA
Many ureteric fistulae heal spon Laneously and, alll\Ough this
is a gratifying pa"Ocess to the sw-geon and l11e patient, the net
result of such a cicau·ix may be disastrous to the affected
kidney. By llle same token, ureterouretetic anastomosis of a
ureter it'\iured too high to be implanted into the bladder is
unfortunately often followed by stricture formation at l11e
site of the junction. uch a patient should be carefully
followed up b)• a competent urologisL A periodic dilatation
may well save the kidne), but man) of l11ese patientS end up
with a nephrectOm).
PREGNANCY AND URINARY PROBLEMS
Al l gynaecologists are conversant with the fact l11at preg-
nancy has a profound effect on the ureter and kidney.
Th is is cl ue to the specific action of progesterone on a ll
smoo th muscles throughout th e bod)'· The gasu·ointesti-
na l tract and the ga ll b ladder, l11e muscu la tu re of the
ve ins, and the liga ments of the spine and the pelvis are a ll
affec ted. T he changes are most remarkab le, however, in
l11 e urin ary tract a nd appear by the fo unh month to reach
a maximum at term. After pregnancy, this process of
hyd rourete r slowly resolves an d returns to normal by
l11e end of the puerperium, certainly by the lllircl month.
lf, h owever, a severe infection occu rs, such as in pyelon e-
phritis of pregnancy, the process of involution may never
be completed and permanent damage may result in
chronic pyelonephritis. The cause of this ureteric dilata-
tion is not the compt·ession from the growing utems
because it occurs before such an obstruction can operate.
It is more frequently noticed on the right than on l11e left
side and is probably due to some distortion of the uretelic
canal by dextrorotation and dextroposition of the preg-
nant uterus, which is so ft·equent a finding at caesarean
section.
KEY POINTS
• IJ•·inaq S)lnptoms a•·e commonl) encoumered in
g) naecological practice. The g) naecological diseases,
peh'ic operations and difficult vaginal delivelies
con tribute towards most of the lllinat') complaints.
• Neurological disorder ma> also be t11e underlying
cause, so the mnaecologist must excl ude the neuro-
logical cause before undertaking surgery for Ltlinary
complaints.
• Apan from postoperative and puerperal retention of
tHine, other obsu·uctive co nditions are haematocol·
pos, retroverted gravid uterus, fibroids, and an ovatian
wm our and bladder neck obstmc ti on in o ld women.
• Ure t11ra l syndrome is noticed in posunenopausal
women d ue to oesu"Ogen de ficiency and is effec tive!)'
u·eated witl1 s hort-te rm oesu·ogen vaginal cream.
• Urinary fistu la in deve loping co unu·ies is mostl y obstet-
ric in origin. In developed counuies, urinal')' fistula
follows u·auma to t11 e bladdet· during difficult surget')'·
SELF·ASSESSMENT
I. How would )Oll investigate and u·eat acute UJinary t-eten-
tion in a woman?
2. Oesctibe llle u•-ethral S)ndrome. How would )Outreat it?
3. Oesctibe the management of dysuria.
4. OiscLLSS llle management of u.-inar) incontinence in
middle-aged women.
5. What are the clinical manifestations of infection of the
female auinary system? OiscLLSS itS managemenL
SUGGESTED READING
Allen R£, tloskcr CL, Smith ARB, cl al. Pchic floor damage and
childbinh: A neurophysiological .tudy. Br J Ob.tcl Cynaccol 1990;
97: 770-9.
American Collcb'C of Obslclrician• and Gync-cologi>J.>. Ccniwurinary
Fistulas. ACOC Technical Bulletin 83. Wa>hingwn, DC, ACOC,
1985.
Bhatia NN, Bergman A. Cystomcu-y: Unstable bladder and urinary tract
infection. Br.J Urol 1986; 58: 134-7.
Burgio KL, Mauhcws r<A, Engel BT. Prcvalcncc, incidcncc and corre-
lates of urinary incontinence in hcahhy womcn. J Urol
1991; 146: I
Elia C, Bergman A. Estrogen clfccJs on d1c urcthrd: lkndicial effects
in "··omen wi1h genuine urinary incon1int:nce. Obs1c1 GynecoJ
Surv 1993; 48:509-17.
Preminger CM. Acute urinary retention in female patients: Diagnosis
and treatment.J l:rol 1983;130: 112-3.
Urinary Incontinence Guideline P·.md. Urinary lncominence in
Aduhs: Clinical Pmctire Guideline. Rock,ille. MD. Agency for llealth
Care Polk)•and Rese-.trch. Public llcahh Senice, l:.S. Departmem of
lleahh and lluman Sen i=, 1992. All CPR publication no. 92.()()38.
Wall LL Diab"'osis and manab'Cmcnt of urinary incontinence due LO
detniSQr instability. Ob>tet C)11L'C Surv 1990: 45(Suppl): I 5-4 iS.
 Urinary Fistula and Stress
Urinary Incontinence
Urinary Fistulae 379 Key Points 395
Stress Urinary Incontinence 384 Self-Assessment 395
T he urinary syste m a nd th e fema le ge nit.a l system are closel)'
re lated e mbryologicall y, anato mi cally and functionally. It is
therefore not surprising t11a t urinar")' fis wlae resu lt from
obste u·ic and gynaeco logical o perations and gynaecological
diseases. A uri nary fis tu la is o ne of tlt e most distressing
conditions for a woman , fo r her family members and
equally for a gy naecologist who looks after such a patient
URINARY FISTULAE
ur;naJ] fistulae are abnormal epithelialiLed corrumutication
u-acts between tlte genital u-act and t11 e urinary u-act (Fig. 31.1).
Injur-i es tO the urethra, bladder and ureter can occur
during childbirtl1 or during pelvic surge ry. Genital u-act
malignancy in its ach>ancecl form is known to involve t.hese
pelvic organs and catLSe fistulae. Finally, radiat.io n tlterapy
ca n cause tissue necrosis and may result. in fistula formation.
Vesicouterine fistula
Figure 31.1 Diagrammatic representations of urethrovaginal, vesi-
covaginal and vesicouterine fistulae.
In developing co unu·ies, the vast of genit.al fistu-
lae cominue to be obste u·ic in origin. Even in tlte present
times in rur-al Indi a, it is not uncommon to enco unter obstet-
ric emergency cases of prolonged, neglec ted and obsLructed
labo w·. These potentially infected and dehydrated patients
may often nan·ate the history of attempted manipulation or
vaginal insu·ume ntatio n which has failed to accomp lish child-
birtlt or resulted in a difficult u·auma tic delivery witl1 poor
perinatal o utco me. In such women, the bladder and vaginal
walls which have undergo ne prolonged ischaemic changes
ultimately e nd up witl1 tissue necrosis and fistula fonnation.
ln developed countries, o n t11e co nt.rary, ope rative
u-alltna dw·ing pelvic surge r1 constitutes t.he most com mo n
cause of genital fisw lae.
AETIOLOGY
The common causes of geni tal fistulae are as follO\\S:
OBSTETRIC CAUSES
Prolonged obsu·ucted labour; difficult insu·ument.al or
manipulative delivel'ies such as forceps delivery or forceps
rot.ation can cause injury to t11 e bladder neck and tl1 e
ure tJ1 ra. T he surgeon must ta ke ca re to avoid injury LO me
urinary bladder during caesa rea n seCLion. The bladder is
most vttl ne r-able (pa rti cul arl)' if it is not empty) during its
mobi li zati on from tl1e front of t11e lower segme m before
making a u·ansverse incision o n t11e su·etched lower segment
to deliver tl1e fetal head. Bladde r injury ma)' follow as a resul t
of ex tension of tlte lowe r segment incision amerio rly to the
bladder during de livery of a deep ly im pacted fetal head in
tl1e pelvis. The bladder o r urete r may be inadvertently
included in tlte suture li ne whi le suutrin g the lower uterine
segment. Wo me n undergoing repeat caesarean sections are
at a higher risk for bladder injury. The tL5e of cranial perfora-
tOrs and spicules of bone during craniotomy and symphysi-
otOmy also cause Rupture ofuLenLS is anotl1e rcause of
urinary fistulae if tl1e bladder is invo lved
OPERATIVE INJURIES
The bladder and tl1e pelvic ureter are vulne r-able tO
during g)naecological surgery. These may result from poor
379
380 SHAW'S TEXTBOOK Of GYNAECOLOGY

exposure of the organs, faulL) technique or due to dis- RADIOTHERAPY

toned anatOm)' caused b)' LUmour or fibrosis, or
surgery. In Western countries, operathe inju•·ies during a
gynaecological operation accoum for most of the unnllr)•
fistulae.
Bladder injury may ensue during its dissection from the
cervix in abdom inal or vaginal hysterecto my and during
caesarean secti on when the bladder needs to be d issected
from tJ1e lower uterine segment. The inj ury is most like ly to
occur in a woman with previous caesarean section. Other
causes are pelvic adhesions, cervical fibroid and sli ng opera-
Lions for su·ess urinary incontinence (SU I).
Ureteric injuries. Most of the ureteric injuries occur
dUiing ID naecological surge•")\ especiall) cancer surgery.
rete•ic inju•·ies can be serious if not recogniLed at opera-
Lion. Only a third of the ureteric i•'\iuries are detected dur-
ing surgery and repaired. Others are discovered only in the
postoper·ative period.
The ca uses of ureteric fistula are as follows:
• Congenital fistula is rare and occurs in double ureters.
• Direct injury such as cutting (partial or complete),
clamp ing, ligaturing or including it in a suture to obtain
haemostasis.
• Devascularization of ureter. The ureter receives rich vas-
cular supply on the lateral aspect of the ureter below the
pelvic brim, and the dissection on the lateral aspect can
cause avascula 1ity. Devasculariation follows denuding of
the ureter and stripping it off its blood supply during
cancer sw·gery.
• Thermal injury (camery or laser cautery during laparo-
scopic surgery).
The bladder cannot tolerate tl1e same dose of i•·radiation as
the cervix. Hence, genital fistulae may follow in the course
of Lime if due precautions :u·e not taken to protect the
bladder during r-adiotherapy.
LAPAROSCOPIC INJURIES
Direct u·ocar iJ!juries to the urinary bladde r have been
reported, along with the inju ry to the ureter, bowel, sigmoid
colon and rectum. Their time ly idemification and prompt
repair prevent lo ng-term sequelae.
ANATOMICAL CLASSIFICATION OF URINARY
FISTULAE
It is importam to group bladder fistulae according to
their anatomical location. This has an important bearing
on the selection of approach for su•'gical repair, the tech-
nique of repa ir, complications to be a nti cipated and
prognosis (Fig. 3 1.1 and Table 3 1.1 ).
CUNICAL FEATURES (Table 31 .2)
Women with urinary fistula complain of contin uous leakage
of urine in dothes. In case ohesicovaginaJ fJSlllla (WF), the
woman is not able to pass urine whereas. in case of ureteric
fistula, the woman complain s of lllina•1 incontinence in addi-
tion to, be able to pass urine. ln urethrovaginal fistula, the
woman notices incontinence only when she uies to pass w·ine.
Table 31.1 Classification of Urinary Fistulae

• Bladder: Vesicovaginal fistula

Sites of Ureteric Injury are as Follows Vesicocervical
• At the infundibulopelvic ligament. Vesicouterine
• In ureteric tunnel. Wertl1eim hysterectomy while dissect- • Ureter: Ureterovaginal fistula
ing the ureter in the parametrium. Ureteroabdominal fistula
Urethra: Urethrovaginal fistula
• Near the cervix and vaginal vault, as tl1e ureter is close to
it and the ute•·ine vessel also is proximal to it dUJing
hysterectomy. Clamping the utel'ine ,·esse! may indude
the ureter anteriorly. Table 31 .2 Clinical Featwes of Fistulae
• Near entry of the ureter in the bladder during bladder
Bladder Rstula Ureteric Fistula
dissection.
• Near the pelvic brim, during ligation of the internal iliac Aetiology Mostly obstetric causes Mostly foll owing
arte ry. Prolonged labour - gynaecological
• Near the uterosacral ligament. During laparoscop ic operative - vag inal surgi cal proce-
uterosacra l nerve ablation, vau lt closure d win g hysterec- caesarean section. dures, sometimes
tomy and in endometriosis. Sometimes gynaecologi- following caesar-
cal causes such as ean section
sling operations for
The risk of injury is high when the surgery is undertaken stress incontinence,
for endomemosis, pelvic in Aammatory disease, cen<i- hysterectomy
cal and broad ligament fibroid, as well as during Wenheim
hyste•·ectOm)' when the anatomy of ureter is distorted. The Clinical Continuous cribbling of Continuous dribbling
left ureter is closer to the cervix and is liable to injury, but, urine - no micturition of urine but can
also micturate
overall, it depends upon the position of the ureter.
Other nonsurgical i•'\iuries to the bladder occur due to Methylene Swab stains w ith Swab stains with
c1iminal abortion, bladder stone, tuberculosis of the blad- swab methylene blue urin e but not with
der, ca nce r of the bladder and cervix, radiotherapy for test methylene blue
cancer of cervix and, rarely, in infec tions such as tuberc ulo- IVP Normal Hydronephrosis on
sis, lymphogranu loma venerewn, sc histoso miasis and acti· the affected side
no mycosis.
 CHAPTER 3 1 - URINARY FISTULA AND STRESS URINARY INCONTINENCE 38 1

The fis tulous tract is lined by epithelium, fibrous and

granulation Lissues, or malignant tissue depending upon
t11e cause.
VESICOVAGINAL FISTULA
ln lndia. 80%-90% oflhe bladder fiswlae are a result of the
obsteu·ical causes. The patient presen LS witll complaintS of
constant dribbling of tuine {true incontinence ). The con-
staJll wemess in the genita l areas leads to exco•·iation of Lhe
vagina, ' 'ulva, pe.-ineum and thighs. These women are de-
pressed and often treated as social outcasLS. Some develop
amenorrhoea a nd may develop bladder stones as weU.
The most common type of fistula in our cow1U)' is VVF
(Figs 3 1.2 and :H.:l) at the bladder neck region following
difficult d 1ildbirth. The woma n with an obsteu·ic fistula is
in variably shonstawrcd with a con u-acted pelvis and suffers
from secondary a meno rrhoea. Whenever a fistula is sus-
pected, it is a good practi ce LO examine t11 e patient in the
kn ee-c hest position unde r a good light. A speculum
inu·oduced to retrac t the posterior vaginal wall exposes the
fistul a, a nd w·ine is seen collec tin g in t11e vagina. It also

Figure 31.2 Vesicovaginal fistula.

Figure 31.4 (A) Repair of a fistula. A c irc ular Incision is made

t hrough the vag ina around t he fistula (B) Repair of a vesicovaginal
fistula The vag inal wall Is now dissected away from t he bladder
wit h utmost care to obtain a maximum degree of mobi lization of the
bladder. (Source: M Walters and M Barber. Hysterectomy for Benign
Disease: Female Pelvic Surgery VIdeo Atlas Series, Saunders: 2010.)
lnterureteli c
bar

Opening of the e nab les clinical assessme nt of iLS size, locatio n and number;
ureter a bimanual examination provides info rmatio n abo ut the
size of fiswla, iLS fix ity and ex tent of scarring in the
SLLrro unding tissue. A positive methylene blue teSt confirms
t11e diagnosis in case the fiswla is not visible d ue to scarring
in t11e vagina and helps the surgeo n tO plan a repair opera-
- =-;..:...__ Internal urethral Lion (Fig. :H .I).
orifice
URETERIC FISTULA (Figs 31.5-3 1.8)
Urete.-ic fiswlae result from direct ir\iury or devasculariza-
Lion of me peh·ic ureters during g) naecological surge•y.
especially during We•·tJ1eim ope•-ation for carcinoma of t11e
Rgure 31.3 Transveslcal view of vesicovaginal fistula cervix.
382 SHAW'S TEXTBOOK OF GYNAECOLOGY
Uterine artel)'
Pubic bone I
Rgure 31.5 Relations of the pelvic ureter. It crosses the bifurcation
of common iliac vessels, lies close to ovarian vessels and t hen
crosses the uterine artel)' to enter the ureteri c tunnel.
Uterine vein
Uterus
Rgure 31.6 Uterine artery and ureter. The ureter crosses under the
uterine artery.
ln case of u·ansec tion of the Lhe woman develops
Lttinary leak into the peritoneal cavity immediately. Because
of failure to recognize and repair the u·auma at the time of
operation, these women have a stom1y postoperative course
and presem with nausea and vomiting, abdominal disten-
sion and ileus, associated with the rise of tempera[ure and
leuCOC) tosis. and loin pain.
l n case of obstruction as a result of ligating o ne or both
Lu-etet'S. the din ical feawres differ. If both ureters have been
Lied (5%-l 0%), there is no passage of lll·ine and the paliem
complains of pain in the flanks; palpation in the renal
angles t'e\eals tender enlarged kidn eys.
Figure 31.7 (A) Cystoscopic view showing relation of vesicovaginal
fistula to the trigone. (B) Small midline vesicovaginal fistula (Soun::e
for (A): AJ Wain, LR Kavoussl, MF Campbel, PC Walsh. Campbei-Walsh
Urology: Urinary Tract Astulae. Saunders: 2012)
The woman develops fever, haematuria, loin tenderness
and oliguria.
ln case of nec rosis of tJ1 c ureter fo llowing denudation,
the urinary leak is dela)•ed. IL ge nera ll y sta ns 2 weeks or
later after s urge ry whe n tJ1 e woman startS dtibbli ng urine
from tJ1 e vagina a pan from passing urin e from the ure tJua.
Uni lateral causes oliguria, fever and pain in tJ1 e rena l
angle on that side, apa rt from dribbling.
Late complications of ut-eteric it'titll)' includes stricture
with hydronephrosis and infectio n.
INVESTIGATIONS FOR A CASE OF URINARY ASTULA
Investigations for urinaq ftSLUlae include the following:
Besides the LLSual tesiS of urine examination, complete
blood cell coum. renal function testS and serum elecm>-
l)'les, the following special teSIS are useful in planning surgi-
cal procedures: .-ine cultut·e is mandatOt')' before surgery,
and infection should be treated. The lll·ine is collected by
 CHAPTER 3 1 - URINARY FISTULA AND STRESS URINARY INCONTINENCE
catlleLerization in case of VVF or by us ing urine which
collecLS in tl1e well of a sterile Sim's spec uh.un.
CystoscOp) witl1 indigo carmine excretion test
(5 mL intravenous!)) enables visualiLation of the dye from
each uretedc orifice (Fig. 3 1.7A and B) and
identifies which ureter is damaged. It helps in Lhe
site and number of fiswlae. During sonography of Lhe kid-
ne>•s, ureter and bladder, a C)Stic mass (tu;noma) due LO
collection of urine can be identified.
• Descending intratH'IIOtL! jt)Y'logmphy (IVP): f\IP may reveal
h)dronephrosis and h)droureter and indicates tl1e exact
site of ureteric obstruction.
• Ureteric catheteriuttion will detect the side and site of ureter
damage.
• ln case the fistula is small and not clearly visible, methy-
lene blue test is applied.
• Methylene blue - 'f'ltlf!N,uah left. A ca tlleter is introduced
into the bladder thro ugh the urel11ra. T he vaginal cavity
is packed wi tl1 three steri le swabs; 50-100 mL of d ilu te
me tl1 ylene blue d)•e is injected intO tl1 e bladder through
tl1e catl1 eter. lf tJ1ere is a WF present, tl1 e me tl1ylene blue
d)•e stains tl1 e midd le swab. If the lowermost swabs geL
stained, tl1e leak is from tJ1e ure tJ1ra. lf the swabs do not
take up the stain b ut geL wet wi tJ1 urin e, the leak is from
tl1e ureter. Oral Pyridium (p henazopyrid ine) (100 mg)
stains urine orange and is easily recognized in the vagina;
however, iL does not identify tl1e site of fistula.
• Metal catheter not onl) identifies a fistula but also
confi nns the patenq of the uret11ra.
MANAGEMENT
VESICOVAGINAL FISTULA
ln case bladder damage is suspected following a difficult
childbirth, an indwelling catheter for 3-4 weeks is
recommended for prolonged draining of the bladder, and
antibiotics and supportive tllerapy are recommended.
Spontaneous healing of small fistulae is known to occur.
However, in case of an established fistula, it is beuer LO wait
for about 3 montl1s for all tissue inflammation to subside,
tissue vasculalization to improve and local infection to be
cleared before su r'gery is undertaken.
ln case of a fiswla following ca ncer, a biopsy sho uld be
taken from tl1e edge of tJ1e fiswla and tl1e presence of can-
cer ru led out prio r tO surgery.
• Most VVF can be repaired vagina ll )'· T he Latzko proce-
dw·e involving den ud ing of the vaginal epitl1eliu m
all around tl1e fisu.do us edge, fres hening the edge
and approximating the wide raw surfaces witll rows of
absorbable suwres is often successful. This techn iq ue is
suitable for post- hysterectomy fistulae. It, however, leads
to narrowing of the upper vagina or atresia.
• ll1e Chassar Moir technique of widely separating L11e
vaginal and bladder mucosa all around by tl1e flap-
splitting metl\Od and suturing tl1e bladder and vagina
separate!) in two la)ers is the most commonly used
metllod. Absence of tension on the suture line promotes
healing. IL is preferable to see that tlle suture lines on tl1e
bladder and vagina do not o'·erlap. Haemostasis should be
meticulous to ensure success. In cases of extensive fibrosis,
383
omental grafts, interposil.ioning of Marti us graft or gracilis
muscle graft between the bladder and vaginal walls im-
proves the blood supply aL t11e site of repair and promotes
healing. Flap-splitting surgery has L11e advamage of
tension-free sutures. If one attempt fails to heal tl1e fistula,
a second vaginal repair can be undertaken after a pe,;ocl
of 3 montllS. In case of a large fiswla dose to or
the uretelic orifice, vaginal repair ma) be difficult; also in
cases of failure of previous surgical attempts to repair L11e
fistula by the vaginal route, transabdominal approach is
recommended LO achieve successful closure.
• ln case of exLensh e loss of bladder tissue, previous re-
petitive faillli"CS to close t11e fistula or radiation fistula
which fails Lo heal, the sur-geon must consider procedures
for uti nary dive1-sion such as implantation of tl1e urete•-s
imo the sigmoid colon, creating an ileal loop bladder
imo which tl1e ureters arc implanted, or a rectal bladder-
an operation in which the term inal sigmoid colon is
brought out as a colostOm)'· The d istal end of the recto-
sigmoid is sulltred and closed and the ureters im planted
into tl1e term inal rec tal po uch, which ac ts as a ulin ary
receptac le. T he da nger-s of ureteric implantation into tl1 e
large bowel include a high incidence of ascend ing infec-
tion to tl1e kidn eys and the risk of elec trOI)•te imbalance
leading to hyperchloraemic acidosis as well as su·icture at
the s ite of implantation.
• lf tl1e fiStula r-epair fai ls, one sho uld wait for at least
3 montl1s before auernpting a second repair. A fistula
located at the vaginal vault following hysterectOlll)' is tl1e
most difficult LO repair.
• Fistula caused b) cancer cervix may require ame.;or
exenteration.
Postoperative management after VVF •-epai•·:
• Continuous bladder drainage for 14-21 days. Some
prefer suprapubic drainage.
• Antibiotics - Urine infection should be treated
adequately. After removal of t11e catheter, the woman is
advised Lo pass udne f•-equently as the bladder capacity
may have been r·educed.
No vagina l o r· speculum examination or imercoUJ-se is
allowed for 2 months after the surgery. In the nex t preg-
nancy, a caesarean sec tio n is ind icated following successful
fistu la repair. Stress inco nLin cnce fo llowing VVF repair may
be noted, and it results from ligid ure t11ra, loss ofvesico ure-
thral angle, small bladde r and short ure tl1ra.
URETERIC FISTULA (Fig. 31.3)
Most t.u-e teric fistulae are traumatic; rare ly, ectopic ureter
cmJSes dlibbli ng of urine apart from passing urine from me
otl1er kidney.
Only one-third cases of ureteric trauma are recog-
nized intraoperative!). In case of total obstruction follow-
ing bilateral ureteric ligation, anuria will ens ue; sonogra-
phy will reveal bilateral h)dronephrosis and dilated
ureters up Lo the site of the block. The renal function
tesLS reveal a rise in creatinine levels. If tl1e obsu·uction
is detected early, the offending ligatures removed and
the urete•-s sLemed, recovery is possible. However, if L11e
ureters are damaged, tl1ese should be implanted imo L11e
384 SHAW'S TEXTBOOK OF GYN AECOLOGY
bladder. In case the diagnosis is delayed, as happens
in cases of unilateral ureteric block, the symptoms of
loin pain and fever gradually subside and the kidney
on the affected site undergoes atrophy. A procedure of
percutaneous nephrostOm) (PCN) can save the kidney
functions before reimplamation of ureters is undenaken
at a later date.
In case of urete•·ic transection, partial or complete, a
p)elography fails to show pan or whole of the ureter on the
transected site and there may be pooling of the urine in the
peritoneal cavity. The immediate u·eaunem is percutane-
ous nephrostomy and reu·ograde d)e iryection under fluo-
roscopy to help identify the site of transection. If the injury
is partial transection, cystoscopic catheterization and stem-
ing of the ureter at the site of inju•)' may be attempted. ln
case of complete u-ansection, urina•)' diversion by nephros-
tom y is advisable to tide over the crisis, followed later with
repair surgery. In case the transec tion is recognized during
surgery itse lf, the surgeon must eithe r undertake anasto-
mosis at th e site of inj uq• o r implant the cut end of the
ureter into the b ladde r o r perform a Boari flap ureteroneo-
cystostomy. Ure terourete ri c anastomosis is also so metimes
possible, but tl1 e risk of stricwre sho uld be re membered.
Fixing the dom e of tl1 e b ladde r to the psoas muscle re lieves
tension on tl1 e im plan ted ureter. Urete•ic sui cture a nd in-
fection are the sequ e lae of urete ric implantation and need
to be observed.
When ureteric damage goes unnoticed, following the
hectic postoperative period, fever settles down, but patient
starts dribbling urine from t11e vagina around the 10tll-14tll
day. Urine collects in the vagina, but tl1e woman also micrur-
ates and oliguria is noticed. It is difficult to visualize the
fisttLlous opening. Melll) lene blue test recognizes the ure-
teric fistula. Cystoscopy with retrog•-ade catheterization
shows the absence of urine coming from the affected side
and the site of blockage, respectively. IVP will be required
to detect hydroureter/ h)dronephrosis. U•·ine culture and
kidney function tests are also required.
One should not wait for t11e kidney damage to occur and
perform laparotomy; it sh ould be performed at tl1e eadiest,
once tl1 e inflammation and infection subside.
The surge•)' for urete•ic if!jtuies comprises tl1e following:
• Ure teroureteral anastomosis with tl1e ure teric stent
inserted
• Imp lanta ti on of tl1 e ureter into the bladde r
• Psoas muscle stitched to tJ1e dome of the bladde r to avo id
su·etchin g a nd te nsion on tJ1e ureter
• Boali operation
• Ileal bladder
Prophylaxis
In a difficult gynaecological su•-ge•)' where inju ry tO ureters
is likely, it is prudent to trace the ureter from tl1e pelvic
brim downwards before damping any vessel or cutting tl1e
tissues. ll1e ureter is identified by its position (may be dis-
LOrLed or abnonnall) placed in pelvic diseases), pale glisten-
ing appearance and peristaltic movement when su·oked.
In a difficult case, some mnaeco logists prefer to insen
the ureteric stem befo•·e sta•·ting the stu-ge•)'. but tl1is does
not always p•-e,·ent tn·ete.-ic clamage if devascularization
occurs during its dissection.
Blood supply to the pelvic ureter co mes from the latera l
side, so dissection of the ureter should be done on itS
medial side and devasculalization and isc haemia should be
avoided.
VESICOUTERINE FISTULA
Vesicouterine fiswla is a 1-are variet) of fistulae where there
is a communication between utentS and bladder, usually
caused during caesarean section or ute•·ine mpture or
placenta acueta. The patient's S) mpLOms are unlike those
of lower u•·inary u-act fistula. The patient remains continent,
as urine does not d.-ibble into the lllerine cavity. The
patient, however, complains of crclical haematu•·ia -
mensuual blood trickling through t11e fistula imo the blad-
der (Youssef synd•·ome). The other cause of crclical h aema-
turia ru·e bladder endomeu·iosis and rarely an intrauteri ne
contraceptive device (I UC D) perfo•-atio n into tl1e bladder.
Cystoscopy wi ll reveal tl1 e true pathology. Methyle ne blue
injec ted in tO the uterine cavity wi ll s how a lea k imo the blad-
der. Occasional prolonged b ladder ca the te rizati o n may
close tl1e fisw la; o tl1erwi se, t11 e treaunent is by abdom inal
repair. Ome ntal or graci lis graft is so metimes req uired.
URETHROVAGINAL FISTULA
T he patient is continent and dry b ut dribb les t.LJine onl)'
during the act of micturition. A speculum examination will
show tl1e fistulous opening clea rly. Vaginal repair is often
Sttccessful, but urethral su·icture may fo llow. A big fisu.tla
may need a graft technique. The ure tiH-al fistula is encoun-
tered following surgel') for paravaginal cyst and uretl1ral
diverticttlum. Penetrating iryul') following a fall or during
criminal abonion can cause uretl11"al fistula. Urethral recon-
structive sttrge•) is required.
STRESS URINARY INCONTINENCE
SUI is a fairly common condition affecti ng 25o/o-40% of
women. It is more commonly seen among women older
than 40 years. The conditi on may be seen in association
with genital p•·olapse or may occur as an isolated con-
dition. It is a very disu·essing problem, especially among
working women, limiting their social activities. T he u·eat-
ment, often a surgical repair, may fail to provide relieffrom
symptOms. T he exact ae ti oiOg)' of SUI remains unknown;
a number of hypotheses have been put forward.
Urina ry incontine nce ma)' be stress inco m inence, urge
inco ntin ence or true inco ntinence. The co mm on type of
stress incon tinence is assoc iated witl1 cystocele and ge nita l
prolapse when tl1 e woman voids a small quantity of urine
invoh.tn tari l)' wh ile sneezing, coughin g o r laughing. The
condition also develops during pregnancy and soon after
delivery.
Stress incontinence is confused witl1 urge incontinence.
In ttrge incontinence, the woman wants to pass urine at a
moment's notice, and unless she is quick abo ut it, she passes
u.-ine in lru·ge quantit) before reaching tl1e washroom. The
amoum of urine passed is considerable. In stress inconti-
nence, tl1ere is no desire to pass u•ine, but escape of a small
quru1tity of u.-ine occurs during coughing, sneeLing, lifting
heavy weight or change of postu•-e. Both are bothersome
symptoms and affect tl1e quality of life.
 CHAPTER 3 1 - URINARY FISTULA AND STRESS URINARY INCONTINENCE 385

Uti nary incontinence may indicate a symptom, a sign or
a condition. The patient complains of invo luntary leakage
of ttrine, which is socially and hygienically unacceptable.
The sign is the objective demonstration of urin e loss, and
the condition is the underlying pathophysiologic mecha-
nism responsible for the urine leak.
The S) mptom of involunta•") urine loss may be associated
with stressful aCLi' it) such as coughing, sneeLing, su<lining
or other ph)'Sical acth·ity (su·ess incontinence). The involun-
ta•")' w·ine loss may follow a su·ong desire and need to void
(urge incontinence), or there may be continuous uri nat')'
leak (true incontinence) as in a fiswla.
MECHANISM OF FEMALE URINARY CONTINENCE
Most women remain continent. It is as a result of normal
mechanism of micturition and supportS to the urethra
provided by s un·ou nding tissues. Ultrasonograph y and
MRl have recen tl y im proved our knowledge abo ut the
anatomy of the lower urinary tract and validated some of
tl1e urodynamic investiga tions of stress inco min ence.
ln normal conditions, inte rna l urinal')' meau1s lies above
tl1e level of levato r an i muscles. Upper half of tl1 e urethra
lies above and tl1e lower half below the levmor an i muscles
(Fig. :H .8).
Norma l mechanism of con tin ence mainly re lies on the
internal sphincter at the neck of th e bladder and is main-
tained by the urethral closure pressure. The urethral
closure pressure is the intraurethral pressure minus the
intravesical pressure (closure pressure is tl1e difference
between the vesical pressure and the urethral pressure).
onnal uretl1 ral closure pressure is more tl1an 20 em of
water (em when the upper urethra and the bladder
neck remain abO\ e t11e levator muscles and the urethrovesi-
cal angle is more than 100". Under this condition, the
alxlominal pressure is u-ansmitted equally 1.0 t11e bladder
and the uret11ra, maintaining the closure pressure.
Because of atony of pelvic floor muscles or datnage to
the pudendal nerve during vaginal delivery, the bladder
neck descends below the level of levator ani muscles and
the urethrovesical angle is lost, Lillis the abdominal pres-
Sttre is transmitted only to the bladder, resulting in urina ry
incontinence. The vascular plexus and l11e longitudinal
fibres of the urethra maintain the tone during me filling
phase (Figs :H.9-:H. ll ). Extrinsic control of the bladder
neck is provided b) striated smoot11 muscles. Internal
sphincter consistS of two loops of smooth muscle fibres:
one loop pulls me sphincte•· ante•·iorl)• and me other loop
posteriorly and maintains t11e urethrovesical angle.
The tone of the levator ani muscles, pudendal nerve a nd
pubovesical fascia also contribute to urinary continence.
Lateral attachment of the urethra to the arcus tendineus
and pubococc)•geus muscles limi tS urethral mobility and
maintains continence.
GENUINE STRESS INCONTINENCE OF URINE (SUI/GSI}
Genuine stress inco ntin ence (GSI) of urine occurs when
the bladder pressure exceeds uretJnal pressure during
physical su·ess in the absence of detrusor comrac tio n. lt is
defined as a small in volu ntary lea kage of urine with
increased abdom inal pressure in the absence of detrusor
contraction.
Aetiology
lt is generally due to anatom ical cha nges in the urinary tract
such as hypermobi lity of uret11ra (80%), loss of posterior
ttretJwal angle or sphincteric dysfunction.
• Age: Older menopausal women wit11 loss of pelvic muscle
wne are liable to develop GSI (oestrogen deficiency).
• Multiparous women after repeated childbirtl1s are prone
to loss of tone of tl1e pelvic floor muscles.
• Obesity, smoking, prolapse and constipation.
• P regnancy and puerperium - du•·ing pregnancy, su-ess
incontinence is due to the progesterone honnonal effect
and the pressure of the gJ'avid uterus on t11e bladder
neck. During puerperium, the su·ess incontinence is
caused by the descent of t11e bladder neck, the loss of

loops of internal Involuntary sphincter

_ _ Liidinghausen pubo-sphincter ligament
+ -+-- - - - Annulus urethrolis
/ -...;t.;__.,.L- - - - -- Urelhra showing Anlerior curvalure
Anterior vag inal wall
ani

_ _ _ _ _ _ Sphincter membranaceae urethrae

- - - - - - - Urogenital diaphragm

Tendon connecting bulbospongiosus muscles

Figure 31.8 Normal support of internal sphincter.

386 SHAW'S TEXTBOOK OF GYN AECOLOGY
Inferior mesenteric
Brain
r ganglion
Brain stem
ll
[
reg10n
Thoracic [
region
Spinal oord
Lumbar [
region
Sacral
region l sphincter
Figure 31.9 Normal control of micturition.
urethrovesical angle due LO pudendal nerve denervation,
and diminished tone and su·e tching of levatOr ani
muscles during vaginal delivery.
• Hereditary - loss of collagen tissue
• Repair of VVF and urethral fibrosis may also cause GSI
GSI is the onl) t)pe which can be cured by surgical
procedures, hence the imponance of making a correCL
diagnosis before planning any surgical repair.
URGE INCONTINENCE
Urge incontinence of urine is involuntary escape of a
large amount of urine following a desire LO pass u1·ine un-
less the woman immediately goes to the wash,·oom. Urge
incontinence (motor) is comm onl y the result of deu·usor
muscle overactivity (detruso r instability, Dl) . Sensory ur-
gency is an intense desire to void tha t is no t assoc iated
with deu·usor pressure . Unconsc io us inco ntinen ce is of-
te n the res ult of a ne uropathi c b ladde r; th e underlying
cause of the invo htnll\l")' urin e loss may be re te ntion of
urine with overflow.
PRIMARY CLINICAL EVALUATION IN A CASE
OF URINARY INCONTINENCE
HISTORY
A carefully taken his tory can he lp diagnose urge inconti-
nence and avoid making a wrong diagnosis of SUI. Meno-
pausal obese women with previous vaginal deliveries are at
risk of urinal") stress incontinence. PatientS with GSI usually
complain of the passage of a single spun of Lll·ine at the
height of ph)sical exertion such as sneeLing or coughing
the urge to ul·inate. PatientS with motor urge incon-
tinence admit to a su·ong desire to void, which if not com-
plied with immediately, leads to a considerable invo luntary
Sympathetic
Detrusor muscle
Trigone
Urethra
External urethral
Muscles of the
pelvic floor
passage of urine. A hisLOry of diabetes and pulmonary dis-
ease is relevant.
Local patholog) in tJ1e bladder and urethra may lead to
frequency of micturition, i.e. infection,lowered capacity of
the bladder. lowered compliance of tJ1e bladder because of
chronic fibrosis of the bladder interfering with itS conu-ac-
tion pattem following mdiotherap), tuberculosis or diabe-
tes. O rganic neurological diseases ma)' adversely affect
bladder function. These include multiple sclerosis, tabes
dorsalis and subacute combined degenemtion of tJ1e cord.
Major pelvic dissection dtll·ing 1-adical ope1-ations on tJ1e
uterus and rectum causes widespread damage to tJ1e
splanchnic nerves in tJ1e deeper partS of the cardinal liga-
mentS. The nervi erigentes carr y the pamsympatJ1etic mo-
LOr supply to the detrusor muscle of the bladder, and inter-
ference with this pa th way ca n ca use disturbances of
bladder function. £xu·auretJ1ral ca uses of urinary inco nti-
ne nce include u·ue co nLin ence of ge ni to urinary fis tulae
disc ussed earlier and rare co nd itio ns such an ec top ic
ure tec
PHYSICAL EXAMINATION
A clinical examinaLi on, includ ing pelvic and spec ulum ex-
amina tion, and a tJ10rough ne uro logical assessment sho uld
be undenaken. An attempt sho uld be made tO assess the
anatOmical defects of pelvic supports and the LOne of the
levatOr muscles. Note the increase in ure thral and uretJlro-
vesical jtmction mobil it). Assess vaginal wall prolapse and
senile vaginal changes. Elderl) posunenopausal women
benefit from oestrogen therap) when follow-up examina-
tion reveals a health) pliable "aginal wall.
GSI is gJ<tded as follows:
• Gmde I. Incontinence "ith on I)' severe stress, such as
coughing, snee1.ing and jogging
 CHAPTER 3 1 - URINARY FISTULA AND STRESS URINARY INCONTINENCE 387

Cough Strain
100

lntraurethral 50
pressure

- -- - - - - - - l - 0

100

50

100

50

Patient with genuine

stress incontinenoe
Figure 31.10 Comparison of urethral and vesical pressure in a normal subject and in one suffering from genuine stress urinary Incont inence.

.
Continent woman Women wllh s ire .. lnconllnence

Rgure 31.11 SUI mechanism.

388 SHAW'S TEXTBOOK OF GYNAECOLOGY
• Grade II. lncominence with moderate stress, such as fast
walk, go ing up and down the smirs
• Grade Ill. Incontinence with mild stress such as
standing
From the surgical proced ure point of view, lhree types of
GSI have been described:
• ' l)'pe I. GSI occ urs due to loss of posterior ure tJuovesical
angle alone.
• Type II. Loss of poste•ior urethrovcsical angle as well as
urethral hypermobility.
• Type Ill. This resuiLS from intrinsic sphincter deficiency.
INVESTIGATIONS
Prior to sur.gical managemem of GSI and in urge inconti-
nence, dem•led uwesugauons such as uline analysis, urine
culwre and urod)'llamic studies should be undertaken to avoid
making a \Wong diagnosis and ac hieve approp ti ate results.
Urine culture.
I nvesligatio ns such as (i) stress test, ( ii) co tton swab
test, (iii) Marshall 's and Bonney's test, (iv) urelhroscopy
and (v) urodynam ic studies.
STRESS TEST
test is an excellent method of demonstrating objec-
uvel) the presence of GSI. ll1e palien t is asked w void
urine. ·n1 e patiem is t.hen caL11eteriLed under aseptic con-
ditions, taking precautions to determine the voi Ltme of
resid ual urin e present. Ultraso und scan is done a nd re-
sidua l urin e is measured. The urine sample is se nt for
culture. T he reafter, 250 mL of s te ri le sa li ne is instilled into
b ladder. T he patient is the n made to sq ua t on a pre-
we tghed absorbent pad placed o n the floor. She is asked to
co ugh and strain. Objective evidence of urine leak is
noted. The leak can be g•·ossly quantitated as mild, moder-
ate or severe. The patiem is then placed supine in lhe li-
th?tomy position and as ked LO strain or cough for furL11er
e-.tdence of stress incontinence. The absorbe nt pad is
weighed at the end of t.he test. A net weight gain of 2 g o•·
more is indica live of GSL
Uri1111 culture before invasive investigation.\ 11Utrulatory. It is
necessary to rule out utin ary infection by culture before
undertaking invasive investigations because of lhe following
reasons:
• The sympto ms may be due LO urinary infec ti on.
• Invasive procedures sho uld not be undertaken in the
presence of infection.
• Urinary infection may imerfere with interpremtions of
im'liShe procedures.
These tesLS are also required if the CSI rectu-s following
surgel'):
Normal cystometric findings
Parameter Norma l fincUngs
Residua l mine <50 mL
Fi t"St desire to vo id urine 150-250 mL
Bladder capacity 500-600 mL
Detrusor pressure
During filling < 15 cm 1-120
During voiding <70cm 1-120
Urine flow > 15 mL
COTTON SWAB STICK TEST
A QLip couo n swab s lick dipped in Xyloca ine j e lly (lido-
caine) is placed in t11 e urethra. T he patie nt is asked tos u·ain
a nd cough. Initiall y, the cotton swab sLick wi ll be parallel to
the floor. In paLienLS with no GSI, the cotton swab slick wi ll
nonn all y •·each an angle not exceeding 10-15° above the
horiLonml. This angle increases by 20° or more, commonly
50-70° in most positive cases. A posith·e test indicates
sufficient degree ofbladde•· neck descent. Unfon.unately, all
pa1ients with GSI may not have a positive tesL A positive
test obviates tl1e need for a meml bead chain cystouretJuo-
gram. However, L11is test is not ve t)' specific and does not
indicate the severit)' and type of surge t)' th e wo man requires
(Fig. 3 1. 12).
MARSHAll:$ AND BONNEY'S TEST
In patie nts with a positive stress test, the abse nce of leakage
of u.-ine following bladder neck elevation is indicative of
beneficial outcome following surgical repair. In Bonne)"s
test, two fingers are placed in t11e vagina at the urethrovesi-
cal junction on either side of t11e uretJ1ra and t11e bladder
neck region is elevated. O n straining o r coughing, t.he
absence of leakage of llline indicates a positive test. ln
Marshall 's test, tl1e vagina in L11e region of the bladder neck
is infil trated with local anaesthetic and the area is elevated
with an open Allis clamp. Failt.u·e to demonstrate leakage of
urine on coughing is indicative of a posiLive test. Instead of
fingers, I lodge pessa ry may be used to e levme the b ladder
nec k. A positive Lest incUcates t11 at woman wi ll benefit from
a s urgical procedure where elevatio n of th e bladder neck is
ad1ie-.•ed.
URETHROSCOPY
The Robe•·tson urethroscope using a gas medium permits
satisfactO•') visual evaluation of L11e urethra, trigone and
bladder neck regions. Urethroscopy provides information
about the opening pressure, presence or absence of uretJui-
tis, presence of diverticu lu m or a rigid uretJH·a. Th e
uret11rovesical junction can be observed d uring b ladder
fi lli ng with a hold command, during co ughing or d uling
Va lsalva manoeuvre.
URODYNAMIC EVALUATION
These arc a group of tests tO study the pauen1 of storage
and evacuation of urine. These teSL5 aw reqrdml when clinical
diagnosis is IWI dear prior to surgery.
Cystometry
Meas ureme nt of pressttres wiL11in the bladder and Ltre-
thra during artificial filling of the bladder witJ1 saline
C02 or fl uid he lps differentiate tru e su·ess incon tinence,
Dl , urgency i ns tab ili t:y and o the r t)' pes of ineon Li ne nce.
T he re la ti o nship between the b ladde r and ure th ra l
press ures ca n be mos t helpful in planning t11e correc t
treatme nt.
 CHAPTER 3 1 - URINARY FISTULA AND STRESS URINARY INCONTINENCE 389

Nonnal

Resting

Stress urinary
incontinence

0>30°

Resling Valsalva
Rgure 31.12 Diagrammatic representation of Q-tip cotton swab test. fSouroe: Hacker NF, Ga11bone JC, Hobel CJ, Hacker Md Moore's Essen-
lials of Obstetrics and Gyneoology, 5th ed. Phladelphia: Elsevier, 201 0.)

UrethrocystometTy in doubt or lhe patient continues LO have symptoms despite

o.-.nal findings are as follows: At rest, 150 mL of urine
causes 2-8 em pressure, which •ises to 15 em H 2 0 at
filling. Urethral pressure averages 40 em H2 0 , and less t.han
20 em H 2 0 pressure leads to incontinence.
UroflowmetTy
Measmement of u.-ine flow rate and volwne provides an
objective, noninvasive measure of voiding function .
Micturition Cystourethrography
Normall y, a contine nt woman demonstrates a well-marked
posterior urethrovesical angle of about 100•. Loss of poste-
lior ureth rovesical angle ca uses stress incon ti nence in many
women. Colposuspension and s li ng operations are based on
restoring tl1is angle s urgically.
Uroprofilometry
Uroprofilomeu'Y measures the dynamic urethral pressures
and diagnoses urethral instability and uretJ1ral diverticu-
lLtm. It is a gold standard in the diagnosis of GSL
The normal flow is 15-25 mL/ s. Flow below 10 mL/s
occLu·s in atonic bladder and during obst.ruction, which is
confi1med b) C)StomeU). Increased bladder pressw·e of
more than 50 em H 2 0 and low flow suggest obsu·uctio n.
Urod)namic study may not be needed in all cases of uri-
11M)' incontinence; however, it is desirable when diagnosis is
surgical intervention.
UltTasonography
Ultrasonography is useful in measuring the bladder volume
and residual urine. A bladder wall tJ1ickness of more tl1at1
6 mm suggests Dl. Bladder stone can be seen.
Videocystourethrography
Videocystourethrography is th e new gold standard urody-
namic in vestigation to s tudy the lowe r urinary t.ract dys-
function. It combines the pressure studies wi tJ1 th e video
position of the bladder nec k and ure tJ1rovesical a ngle.
MRI Studies
MR! studies tl1e defects in the pelvic floor muscles and the
supporting fasciae. Appropriate surge•)' to b uttress the blad-
der neck wi ll cure incontinence.
Sophisticated testing is requi red when
the neurologica l component for stress incontinence is
suspected.
ResidLtal urine on ult.rasound scan shows incomplete
voiding.
TREATMENT
It is impo•·tam to rule out Dl before any smgery for SUI is
undertaken; otherwise, tJ1e S)lnpLOms will worsen.
390 SHAW'S TEXTBOOK Of GYNAECOLOGY

Drugs
Table 31.3 Management of Stress Incontinence
a -Adrenergic drugs may help to constdctthe bladde r neck
Conservative Drugs Surgery and •·educe the frequency of stress incontinen ce. Oesu·o-
First line of treatment • Oestrogen If others fail
gen cream is useful in menopausal women. Phenylpropa-
• Young women cream in • Vaginal (Kell y) n olamine enh an ces uretl1ral pressure. Ven lafa.xine 75 mg
• Frail, old women menopausal • Abdominal dai ly is a se rotonin (5-hydroxytt}'ptamine [5-HT]) and
• Postpartum, previ· women Marshaii- noradre na line re up take inhibitor and is th e lates t drug of
ous fail ed surgery • Venlafaxine Marchetti- Krantz choice. It ca n cause mild u·ans ient nausea and mi ld
Kegel pelvic floor 75 mg daily and Pereyra cardiac effect. Imipramine at a close of 10-20 mg b.cl. is
exercises x 4-6 • Imipramine Burch a lso effective.
months 1D-20 mg b .d. Combined
Electric/magnetic vaginal and lntraurethral and Vaginal Devices
stimulation for abdominal
These have been tried with some success. A ring pessary in
nerve damage, suspension
magnetic Slings
ge nital prolapse may reduce stress incontinence in so me
stimulation Tension-free women. Contifonn is a silastic vaginal cone ava ilable in
Artificial urinary s ling India. It is placed du•·ing the day and rem01•ed and cleaned
sphincter in Transobturator at nighL The con e needs changing eve•}' 6 weeks. It is suc-
neurolog leal tape cessful in 85% oft11e cases. Vaginal cones weighing 20-100 g
condit ion Laparoscoplc are ava ilable. A small cone is used initially, with larger ones
I Vaginal cones suspension of used later. The co ne is inserted in tl1e vagina and held in
the bladder neck positio n by co ntraction of the levator ani muscles long
as possible, the reb)' to ning up these muscles. The)' are not
useful in menopausal women with weak levator ani muscles
or in the presence of vaginal scar. Toxic shoc k S)'ndrome
Treaunemcomprises t11e followin g (Table 3 1.3): can occur if retained for a long period.
• Conse•vative t11erapy Electric Stimulation
• Surgical repair Electl"ic stimulation ofthe pelvic floor muscles has also been
tried dul'ing physiomerapy if the stress incontinence is
The main aim ofu·eaunem is to imp•·c:>Ve the quali ty oflife. caused by clenervation of the pudendal nerve during
CONSERVATIVE TREATMENT delive•"Y· Magn etic stimulation is lately empl oyed. It is espe-
cially useful in old women witl1 weak pelvic floor muscles.
treatment should be the .fin.t li11e of espe-
in younger women. It is cheap, has fewer co mplications Artificial Urinary Sphincter
and does no t co mpromise future surgery if so required. Artificial urin al)• sp hincter (AUS) (Fig. :31. I:1) model-800 is
Conse rvative therapy is also app lied to the e lderly and used in Lhose with ne urological conditions and in th ose with
frail women unfit for surgery and during the 6 mont11s after previous surgical failure and sphincteric dysfunction.
tl1e delivery. It is also applicable in tl1ose with previo us failed AILhough an 80% success rate is reported, equipment is
surge') a nd in women desirous of child bearing.
The trea unen t complises me following:

• Physioth erapy
• Drugs
• lntraurethral and vaginal devi ces
• Elec u·ic stimulation
• Artificial urinary sphincter
• We igh exercises
• Red uced caffeine in take and smoking cessmion
• Bladder u·a ining and timed voiding
Physiotherapy
Suited for Grade I GSL Pelvic floor exercises for 4-6 monms
with or witho ut elecmcal stimulation make patient's life
tolerable in 60% of cases. Bom weight loss and exercise
are beneficial. It takes 8-12 weeks before any improvemem
is seen.
Kegel pelvic floor exercises work best in younger women
and in those witl1 mild stress incontine nce associated wim
ure thral hype •mobility with no da mage to imernal sph inc·
te 1: It is also effective in th ose wi tl1 urge inco minence, as
tl1ese exercises wne up t11 e leva to r ani muscles a nd in ternal Figure 31.13 Artificial urinary sphincter. (Source: R Gonzalez, L Piaggo.
sp hincter. Pediatric l.Xology. Artificial umary sphi'lcter. Sau1ders: 2010.)
 CHAPTER 3 1 - URINARY FISTULA AND STRESS URINARY INCONTINENCE
expensive, can cause infec tion and mechan ical fai lu re can
occur.
Genuine Stress Incontinence
Posune nopau.s.'\1 women with senile changes in the vagina,
hypoto nic urethra and mild stress incontinence may benefit
immense!) with oesu·ogen replacement therapy, preferably
a ·eam applied locall). Women with chronic cough, COilSti-
pation and alle1-gic rhinitis or excessive ph) sica! activity may
benefit with medical measures. Avoiding aggravating fucwrs
such as smoki ng, straining or undue physical exertion also
plays a complementary role. Successful surgery for GSI
restores the relationship between the bladder, urethra and
t11e urogenital diaphragm.
The goals of su•-gi cal repair of GS I include tl1e following:
• Repositioning the proximal ureth ra tO a high retropubic
position to maximize proper ureth ral compression.
• Preserving vesico ure thral angle tO facili tate ureth ral
compression.
• Preserving comp ressibili t)' and pliability of the ure th ra.
• Preserving integrit)' ofLhe sp hi nc teri c mec han ism.
SURGICAL REPAIR OF STRESS URINARY INCONTINENCE
Various sur-gical proced ures (> 100) have been designed over
tl1e )'ears; some of Lhese existing proced ures are discussed
here. lt is, however, recomme nded that any sur(.,rery should be
defemd in a )'OIIrtg tuonum and C01lSI'TVtttive method employed ini-
tiall)'. Future pregnane) ma) mar t11e good result of surgery.
Primal') stu-gel) offers the best resultS; tl1erefore, selection
of cases and tl1e procedure should be most appropriate.
Vaginal Operations
These include a nte •·io•· colpon·haph) with plication of the
bladder neck (Kelly's repair) or apposing the medial fibres
of the puborectalis mttSCies in the midline under tl1e blad-
der neck region to ele-.'l\te the same (Pacey's repair).
Abdominal Operations
These operatiOilS a•·e of reu·opubic colposuspension such as
the Marshaii-Mar·chcui-Kr·anu operation, in which the
bladder neck and \'llginal vault are suwred tO the perios-
teum of the back of the pubic symphysis, or tl1e Burch
colposuspension, whi ch aims at vaginal suspension using
t11e iliopectineal ligame nts rather t11an tl1e perioste um of
tl1e back of tl1e S)' mp h)•Sis p ubis. Osteitis may follow the
Marshaii- Marchetti - Kra n tz opera ti on . Beca use of this and a
low cure rate, tl1is operation has been more or less replaced
b)' the s li ng operation.
Combined Abdominal and Vaginal Operations
The Pereyra operation is performed by the vaginal route. A
Foley catheter is insened and its bul b distended with 5 mL
of saline. Traction on the bulb helps idemiry the bladder
neck and urethra. Two parallel incisions are made on either
side of tl1e uret11ra in the regio n of t11e bladder neck.
Paraurethral spaces are created by blum dissection. A heli-
cal suwre is passed tluough the paraurethral tissues and itS
ends threaded into a needle, which is advanced tllrough
t11e endopeh·ic fascia into the retropubic space. The needle
is now ach'l\nced close to the back of the pubic bones tO
penetrate the rectus abdominis muscle where it can be
391
palpated and guided into a sma ll mid line transverse supra-
pubic incision in tl1e abdominal wall. A similar paraurethral
tissue sling can be pulled up on th e other side with a helical
sutLLre. After appropriate traction which ele\'lltes the blad-
der neck adequate!), t11e he lical sutures are fixed to tl1e
aponeurosis of the anterior abdomina l \\'<Ill. As an extellSion
of this principle, fascial slings o r n) IOn mesh slings placed
under the bladder neck regio n vaginall)' can be made tO
sling up the bladder neck like a ' hammock' (Rau and
Stamey modifications are becoming increasingly more
popular) with a 50% success rate.
Immediate complications of sling operations are as
follows:
• Bleeding
• Trauma
• Urinary infection
Late complications are as follows:
• Bladder dysfuncti on
• Erosion of the s li ng
• Prolapse of the poste rior vagina l wa ll and e nterocele as
the in u·aabdominal pressure is exerted on tl1e posterior
vaginal wall
Burch Colposuspension (Figs 31 14 ond 31 16)
After tl1e retropubic space is reached, nonabsorbable
sutures of (3-'1) polygi)COiic ac id are placed in tl1e lateral
fornices (paravaginal tissue) lateral to t11e bladder base
and the bladder neck is fixed to t11 e ipsilateral iliopectineal
ligament. An 85% success rate has been reponed witll
this procedure. It is to be balanced agai11SL tl1e •·isk of
development of enterocele and rectocele postoperatively
due to u-ansmission of inuaabclominal pressure. Burch
operation, though popular until recently, has now been
superseded by tellSion-free \'llginal T-tape. Burch operation
causes bleeding in 3% of cases, bladder u-awna in 6%,
venous tluombosis in I% and voiding difficulties in as much
as 25% of cases.
Laparascopic Colposuspension
Burch colposuspension has been successfull y accomplish ed
laparoscopicall y through the extra peritoneal or transperito-
neal ro ute. Expertise and fac ili ties for laparoscop ic Burch
operation may not be ava ilab le at all t11e cenu·es.
Intravesical Bladder Neck Plication
T h is operati on is used only cxceptionall)'·
Tension-Free Vaginal Tape (TVT)
The tape does not e levate the urethra b ut provides a resis-
tam platform in the mid-ure thra that maintains continence
against intraabdominal pressure. It was designed by PetrOs
( 1993) and Ulmstem ( 1996). This tec hnique is good for
obese women. as it does not causes de1n•sor dysfunction.
TVT (Figs :H .15 a nd :H . Hi) has been designed from
nontissue reacti'e S) nthetic material (Prolene). After
exposing the region of the bladder neck on \'llginal dissec-
tion, the hammock of the tape is placed underneath it tO
support at tl1e micl-u•·ethrallevel, the lateral exten-
siollS are brought out pa•-aureth•-ally onto the skin at tl1e
392 SHAW'S TEXTBOOK OF GYN AECOLOGY

Symphysis
pubis

A White line of pelvic fascia

Rgure 3 1.14 (A) Colposuspension (Burch operation). (a) Burch colposuspension; {b) colposuspenslon using t he w hite line of pelvic fascia;
(c) MMK procedure. (B) Modified Stamey method of endoscopic colposuspension .

Transobturator Tape (TOT) (Fig. 31.17)

Designed by Delorme (200 I), iJ1is mid-uretJual tape avo ids
passing iJ1 ro ugh the reu·op ubic space. Instead, a hammock is
inserted mid-uretJu·a by passing iJ1e u·ocar from iJ1e thigh
through Lhe obuu·ator canal. This red uces tJ1e risk of b ladder
perforation and cystoscopy is not req uired. This techn ique is
good for obese women.
Mid-urethral sling is good for uretJ1ral hypennobilit:y,
whereas otJ1er slings are for internal sphincter dysfunction.
Lately. TOT has become more popular tJ1an 1Vf.
Rgure 31.15 Transobturator tape.
Periurethral Collagen Injection
Glutara ldeh)de cross-linked bovine collagen (Conuge n,
Bard) is commercia II) available for pe•·iurethral injection. A
dose of 2.5 m L is injec1.ed at 3 and 9 o'clock positions into
the submucosa of iJ1e proximal uretJ1ra near Lhe bladder
base w1der C)Stoscopic vision. It can be unde•·mken as an
office procedure for mild cases but is often reserved for
cases of surgical fuilures. Objective relief is achieved in
about 50% of cases. However, allergic reactions to tJ1e col-
lagen have been reponed. The procedure raises
the urethra l pressure by external compression and is useful
TVT TVT in sphincteric dysfun ction. It is used in imernal sphin cter
Figure 31.16 Tension-free vaginal tape device.

level of the pubic S)•mphysis and the vaginal tnCJSJOn is

closed. After aclj usting the proper elevmio n of the b ladder
TOT
neck region, the ex u·a le ngth of the lateral arms oflhe tape
is cuL The operation can be performed under local anaes-
thesia. Under local anaesthesia, te nsion can be checked by Urethra
asking th e woman to co ugh. Cystoscopy avo ids inadvertent
bladder enu·y. Success rate of 88%-90% has been claimed --"---- - - - Obtu rator
at the end of 3 years. This procedure also does not require membrane
catheterization postoperatively. Two percent of procedures
require removal, and 5% have voiding problem.
This surge!') is emplo)ed in Lhe following cases:

• Previous I) fui led surge '1 Figure 31.17 Transobturalor tape (T01) procedure. The tape is
• lntemal sphincter d) function placed under the mid-urethra, taken through the obturator membrane
• Mobile ure1.hra to be fixed to the thigh.
 CHAPTER 3 1 - URINARY FISTULA AND STRESS URINARY INCONTINENCE
dysfunction. It can cause t·etention of urine and may require
reit'\iection.
Recently, microni£ed silicon rubber particles suspended
in nonsilicon gel known as ut·oplasty has been used witl1
success. Local reaction with fibrosis is less seen with
w·oplasty t11an with collagen. Durasphere is nondegradable,
nonallergic and longer aCLing. Bulkamid is a type of
h)drogel.
Complications. The following complications can occur
with t11 ese operations:
• Injury to t11e bladder, urethra
• Haematoma in the retropubic space
• Infection
• Breakdown of SULures
• Voiding d iffic ulties, re te ntio n of urine
• Incomple te b ladder emptying and repeated urinary
infec tions
• Late proble ms include e rosion of nonabsorbab le s utures
into t11 e b ladder, ure tlua or vagina, resu ltin g in infectio n,
fistula o r sto ne forma Li o n
• Dl follows stu·gct) ' for GSI in I %-10% of cases
• Failure
Outwme foUowing repair of GSL
Initial success r·a tcs noted with various oper-ations for SUI
are foll owed by fai lut·es over a period of time.
Potemial reasons for failure include the following:
• Surgical failure - suttu·es cut out because of poor place-
ment of sutures, inadequate mobiliation of me bladder
neck and proximal uremm, postoperative haemaLOma
fonnation / infection.
• Incon·ect choice of operation - mainly the result of in-
complete or incorrect preoperative assessment of the
cause of urinar> incontinence.
• Developmen l of incontinence due to otl1er causes such as
fiswla formation, DI or pipe-stem uret11ra previously not
present
With the pass;1ge ofLime, the resu lts of all kinds of incon-
tinence surge ry Lend to deteriora te. Long-term follow-up
data s uggest (Tab le :H.tJ ) cure rates of different surgical
procedures.
Table 31.4 Cure Rate of Different Surgical
Long-Term
Operation for Repair of GSI Cure(%)
Bladder buttress operation 67.8
< Ma-shaii- Marchetti-Krantz operation 89.5
Colposuspension 89.8
Endoscopic suspension 86.7
" Vaginal sling operations 93.9
Source: Modfied from Jatvis (1994) and Lea::h (1997).
393
DETRUSOR INSTABILITY
Incontin ence occurs when t11e detrusor muscle comracLS
spontaneously or on provocation during me filling phase
while auempting inhibition of micturition. It is more com-
mon in older women "itl1 decreasecl bladder capacity, de-
creasecl sensation and central nen·ouss)Stem (CNS) diseases.
It is often by O\ eracti,·ity of paras> mpametic nen·es.
AETIOLOGY OF DETRUSOR INSTABIUTY
DI may be:
• Functio nal and pS)Chosomatic.
• Deu·usor hyperreflexia (neuropatl1y) in certain medical
conditions such as diabetic neuropatl1y, a cerebrovascular
accident, multiple sclerosis, spinal ir'\iut)' and Parkinsonism.
• It occ urs following s urge ry fo r GSI if Lhe b ladder neck is
placed LOO high and LightJysuw red. IL is seen in 1% of th e
cases following anteri o r vaginal wa ll repair, 5.8% afLer
e ndoscopic bladde r nec k suspensio n and 10% fo llowing
colposuspension and sling operati on.
• ld iopa t11i c. l e n pe r cent of men and 30% wo men older
Lhan 40 yea rs have Dl.
• Uti nat)' infectio n.
PATHOPHYSIOLOGY
lnneased a-adrenergic and cholinergic activit)' is responsible
for this condition.
SYMPTOMS
A woman develops imoluntary escape of urine with urge to
ut·inate. This urge is accompanied by frequency more t11an
seven times dut·ing the day and at least once during me
nighL There could also be bedweLting during sleep. Dl also
occtu-s during sexual intercourse and wim me sound of
flowing water and handwashing.
INVESTIGATIONS
• Neurological examination, especially in o lder women.
• Blood sugar estimaLio n.
• Urine cui Lure wi ll indicaLe whether tl1e urinary infection
is the cause of freq uency a nd urge.
• CystomeU) '·The no nn al pressure of 15 em H20 aL200 mL
exceeds in Dl. CysLoscopy is norm al. Bladder capacity may
be red uced.
• Othe r in vesti ga tio ns ma>' be required LO ru le ouL other
causes of assoc ia Led b ladder nec k instability.
• Ultraso und sca n shows a tl1i ck b ladder wall more than
6 mm in Dl a nd residua l urine, apart from ureLhrovesical
angle posteriorly.
Differential diagnosis - inter-stitial C)'Stitis, it has urge but
no dt·ibbling.
TREATMENT
• Low caffeine intake and avoid smoking
• Bladder training
• Resu·ictecl fluid intake and weight
TreaLment of DI is medical. Amicholinergic drugs are
mosL tLSeful. Some of Lhem are mentioned in (Table 3 1.5).
394 SHAW'S TEXTBOOK OF GYNAECOLOGY
Tab le 3 1.5 Dosage and Side Effects of Anticholinergic Drugs
Drugs Dosage
Urispas (flavoxate) 200 mg t.i.d.
Antispasmodic action on the
detrusor muscle, an analgesic
Dicydomine HCI 100 mg q.i.d.
Pro-Banthine 15-90 mg q.i.d.
Oxybutynin HCI 5-1 0 mg t.i.d.
Imipramine SQ-100 mg at night x 3 months
Tolterodine (Roliten, Terol) 2 mg b.d.
• Ouloxetine 4Q-80 mg b.d. x 3 mont hs
• Solifenacin (Soliten) 5 mg dally x 12 months
• Darifenacln (antidepressant [Depsol)) 7.5- 15 mg daily
• Flavoxate (U rispas) is musc ulotropic and has a direct
ac tion on the smooth muscle when given at a dose of
200 mg Li.d. It has antispasmodic and analgesic action.
Side effects include headac he, nausea, constipation, dry
moutJ1 and blurred vision. It is conu·aindicated in the
presence of glaucoma and cognitive impairmenL
• Dicyclomine HCI: 10 mg four times daily
• Pro-BantJ1ine (propantJ1eline): 15-90 mg four Limes daily
• Ox)bUt)nin 1-lCl: 5- 10 mg t.i.d or extended release o.d.
tablets
• Imipramine (u·ic)clic anr..idepressam): 50-100 mg at night
for 3 months has a 70% success rate. It causes sedation,
constipation and blun-ed vision in 10% of cases. It is not
suitable for elderly women.
The ch-ugs may cur·e incontinence in 60% of cases. New
dn1gs are toltet·odine tartrate 2 mg b.i.d. (extended release
o.d. 4 mg) and propiverine. T hese drugs cause less dry
moutJ1 t11an Aavoxate. Darife nacin and trospium chloride
are curren tJ y under u·ial.
OuJoxetine is a serotonin-norepinep hrine reuptake in-
hibitor (SN RI). Dose of 40-80 mg b. d. orally for 3 mo nths
improves th e b ladde r ca pacity. Nausea a nd dry mo uth
are its side effects. IL inc reases t11 e b ladde r capacity b ut
decreases libido.
If the drugs fail, posterior tibial nerve sr..im ular..i on (PTNS)
sho uld be tried. IYJ'NS - ne uromod ulation is indirectly
app lied on t11e third sact·a l ne rve via a needle electrode and
connected to a stimulator. Thirty minu tes of stim ulation
3 monthly is pracr..ised.
If the dntgs fail, trans vesical injectjon of phenol is tried.
A 10-mL voltune of 6% phenol is injected imo t11e uigone;
60% get benefit for a short period, but at the end of I year,
onl) 2% get relief. Sloughing and fistula can occur. Acu-
pLmcture ma) be useful in some cases; urethral dilatar..ion is
successful in a few cases when the drugs fail. Augmentar..ion
'Clam· C)'SlOplasty invoh·ing augmemar..ion of bladder capacity
"itll a (25-cm lengt-h) segmemofileum gives a 95% cw·e rate.
Side Effects
Headache, nausea, dry mouth, blurred vision
Headache, nausea, dry mouth, blurred vision
Headache, nausea, dry mouth, blurred vision
Cognitive impairment, not to be given to e4der1y women.
Outflow obstruction, glaucoma. myasthenia gravis
Sedation, constipation, blurred vision
Fewer side effects
Headache, nausea, dry mouth, blurred vision
Decreased libido
Under trial
It is a major sw·gical procedure that requires repeated catlle-
terization to empt)' the bladder; excessive mucus secrer..i on
from ileal mucosa can be tro ub lesome. Twenty-five per cent
complain of otJ1er ulinal)' problems, and 5% deve lop adeno-
carcinoma of t.he ileal segme nL Augmentar..ion cystoplasty re-
q uiresself-catlleteritation and causes sto ne formation, urinary
infecr..ion. as well as elecu·olyte imbalance and malignancr
Botox (Botulinum toxin A). lnjecr..ion of Bo u.tlinum toxin
A (neurotoxjn) produced b) anaerobic bacteria Clnstridium
botuli11um imo t11e detrusor muscle inhibits acetyldlOiine re-
lease at tlle neuromt.LScular juncr..ion and increases bladder
compliance and capacit); tlte effect lastS for 9-12 momhs.
Side effects: Retenti on of urine and requires self-
catheteritation, not·mally in t11e first 6 weeks. It is recom-
mended in resistant cases of Dl and may supersede surge1)'
in future, but more trials are required. Done via C)Stoscopy,
15-30 diffe1·em detnLSor muscle sites are injected under
di1·ect visualitation. Though side effects of anticholinergic
t.her-apy ;u·e avoided, this technique has a higher rate of
urinary retention and tll'inal)' infection.
• Detrusor m)•ectomy crea tes a diven.ic ulum and improves
bladder capacity.
• Oestrogen crea m alleviates S)•mpto ms of inco m inence in
postmenopausal wome n.
• Resuicting fluid inta ke, especiall y a t night, psychotherapy
and treatin g the cause arc also of help.
• Bladder drills or u·aini ng disc iplines the b ladder to ho ld
the LUine for a longer period.
1-Deanuno-8-0-;u·ginine vasopressin (DDAVP) is a syn-
ther..ic antidiuret.ic hormone (AOH ) analogue. Peptide or
intranasal 20-40 meg at night cures nocturnal enuresis.
Nausea. hyponau-aemia and Auid retention may occur witJ1
t11is drug. It is contraindicated in coro nary heart disease,
hypertension and epileps) in e lder!) women. O ral tabletS
are now available.
Medical thempy should be the maillSta)' of treaunem;
nerve stimulation and surge•) ' should be emplo)ed only if
medicalthempy fails.
 CHAPTER 3 1 - URINARY FISTULA AND STRESS URINARY INCONTINENCE
Biofeedback uses visual and auditory signals to demon-
strate tl1e strength of detrusor activity. Hypnotl1erapy helps
in women with ps)chological disorders.
NeuromodulatOI) - Sacral ne rve stimulation is reserved
for refractol) urge inco ntine nce. It comprises surgical im-
plantation of a ge neraLOr to provide stimulation to tl1e sacral
nerve. It is \CI) expensive, a nd 60% relief is re-
porte<l Pain at tl1e insertion is complained by 40% of women.
PT S is also attempted.
KEY POINTS
• Incidence of gen ita I fistulae of obsteu·ic ongm is
decreasing as a result of improved obsteu·ic care.
However; they still contribute LO a major share of all
genital fiswlae seen in cli nica l practice in India.
• Genital fistulae occur following p ro longed uns uper-
vised obstructed labour, foll owing d iffic ult vagin al
instru men ta l de li veries and occasio nall y as a compli-
cation of caesarean sec ti on.
• Gen ita l u·act Fistul ae have been repo n e d fo llowing
gynaeco logica l operatio ns. T he bladde r o r ure ter may
be invo lved.
• Investigal.ions inc lud ing methylene b lue dye test,
descending pyelography, cystoscopy and u reteric
cathetelizal.ion may be required to make a correct
diagnosis. Surgical con·ection is possible in most cases.
• Besides obsteu·ic and surgical u-auma, advanced geni-
tal cancers and radiation if1iuries can cause fistulae.
To allC\ iate S) mptoms, the surgeon may have to reson
to palliathe proced ures such as surgical diversion of
tl1e urinaq u-act in th ese cases.
• GSI requires to be differentiated from urge inconti-
nence, O I and a ne uro logical bladder. Surgical repair
in selected cases ghes g.-auf} ing results, but t.he
long-tenn results are not sat.isfactory Primat)'
ment should be conservati,e.
• Burch operation is recommended for hypermobility
of the ur·ethr-a but is now superseded by Tvr and
TOT in some countries.
• TOT is considered super·ior to Tvr, as it avoids
retropubic space, osteitis and bladder ir"!j u ry.
Dl caused by an overactive de u·uso r m uscle is treated
with various drugs. Surgery is rarely resorted.
• Bo tox injec li on tntl)' rep lace s urge ry b ut requires a
lo nger u·ia l in 01.
• Vario us d rugs ava il able (ex tended re lease) s ho uld be
u·ied first, a long witJ1 p hys io tllerap)', before s u rgery is
u ndertaken for 0 I.
395
SELF-ASSESSMENT
I. Discuss tl1 e causes of vesicovaginal fistula.
2. How will )O U invesl.igate, diagnose a nd manage a case of
vesicovaginal fiswla?
3. What are the causes of ureteric fistula?
4. Discuss ilie mana gem e n t of uretelic fistulae.
5. What are the causes of genu ine su·ess incontinence?
6. H ow will you manage a case of genuine su·ess inconti-
nence in a woman 40 )Cars of age?
7. Discuss the causes and management of deLnJSOr instability.
SUGGESTED READING
Absu"'.tCLS of rhe American College of Ol)."lrerricians and Gynecolo-
gistS 53rd Annual Clinical Mccring. May 7-11,200.3, San Francisco,
California, USA. Ob>lel Gynccol 2005; 105: IS.
American College and Gynecologist>. Urinary inconti-
nence in women. Obsrcr Gyncml 2005; 105:1533.
American Ur<J!,'ynccologic Socicry and American College ofOI:t;r.erridans
and Commirrcc opinion: c"aluarion of uncomplicat.ed
st.rt:ss urinary incontinence in \'I'Oinc n before surgical treatment.
Female Pelvic Med Recon srr Surg 2014; 20:248.
Bonnar J. RL-ccnl Advances in Obsrcrrics and Cynaccoi<:>!.'Y· Vol. 15,
Elsevier, 1987.
Bonnar J. Re-cent Ad,·,ancc> in Obsrctrics >uld Gynaccology. Vol. 19,
Elsc,ier, 1996.
FOGS I. Urodyn.an1ic <:L hUm en wilh urinary incontinence, 2009.
Scngupra ct al. Textbook of for Post Graduares and Prac-
titioncn. El>e\ier, 2007.
Shulman Lee P. Year Book of Obstetric., Gp1e<:ology and Women's
llcahh . Moob)' Ebc,icr, 2010.
Studd ct al Progra. in Oh.tcuic. •md G)ne<.'Olog), Vol. 18, Elsc:."ier; 2008.
Srudd J. Mechanical dc\iCL'> in >trcs. inconrinence. In Progress in
Obstetrics and G)nat:colog). Vol. 13: 325, Omrchill Lhingstone:
Else\ier. 1998.
Sruddj. Sul),<ery for genuine >Ire,.. incontinence. In Progress in Obster-
rics and Gynaecology. Vol. 14, Onarchill U\in!,'SIOne: Else,ier; 2000.
Sruddj. Treauncnr ofdcrna>or in>rabiliry and urge incontinence. Prog-
ress in Obsrerrics and Gynaecol<>j.,'Y· Vol. 14, Churchill U\ingsrone:
Else,ier. 2000.
Srudd J. f.Jrereric il1juric;,. Progres;, in Obsrerrics and Gynaecology.
Vol. 16, Churchill Lhinl!'rone: Elsevier, 2005.
 lniuries of the Genital Tract
and Intestinal Tract

Obstetric Injuries 396 Perforation of the Uterus 402

Injuries due to Coitus 397 Injuries of the Intestinal Trod 402
Direct Trauma and Vulval Haemotomo 398 Vaginal Delivery 403
Injuries Due lo Foreign Bodies and Instruments 398 Faecal Incontinence 403
Chemical and Other Burns of the Vagina 399 Redovagino l Fistula 404
Perineal lacerations 399 BOVolel lnjury 405
Old, longstanding Complete Perineal Tears 400 Key Points 405
Rupture of the Uterus 402 Self-Assessment 406

Most of tl1e injuries of female genital u·act are obstetrical,
gynaecological and u·aumatic injuries are rare. They need
to be recognized and repaired immediately to avoid bleed-
ing. infection. painful scar and symptoms related to tl1e as-
sociated it"\iul) to the neighbouring strucwre.
OBSTETRIC INJURIES
Most it"\iuries of the female genital tract occur during child-
birth. ln a normal delivery, the circular fibres which sur-
round the external cervical os are tOm laterally on each side
so that an anter·ior and a posterior lip of the cervix become
differentiated. As a t·esult of stretching, the vagi n a becomes
more patulous, and as a result of laceratio n tl1e h ymen is
s ubsequen tl y represented by irregul ar tags of skin termed as
tl1e carunculae myrtiformes. A s upe rficial fi rst-degree lac-
erati on of tl1e pe ri neal s kin is comm o n eve n in uncompli·
cate d d e li veties.
In abnormal labo ur a nd whe n obste tri ca l ma nip ula tio ns
have been carried o u t, o r as a resu lt of in acc u rate tec h·
niq ue, injuries of tJ1e b irtJ1 canal a re freq ue nt. Severe lac-
era tions of tJ1e perine u m are pe rh aps the mos t co mmon
form of b irtJ1 inj u ry. "Jears of the vagina may be caused by
rotation of the head witJ1 forceps or may take the form of
extension of tears eitJ1er from tJ1e perineu m or the cervix.
Severe lacerations of the cervix are usually caused by strong
uterine contractions at tJ1e end of tl1e first stage of laboLtr;
others result from the deliver> of a baby in an occiput pos-
terior position and some from dystocia. A vesico-
vaginal fistula ma> result from ischaemic necrosis or a
difficult forceps deliver> in cases of cephalopelvic dispro-
portion, whereas a rectO\<aginal fiswla is a result of a com-
plete tear of the perineum or a suwre which pet·forates the
rectal \\<all. Extenshe vaginal laceration causes fibrosis and
narrowing of vagina, which may lead to dyspare u nia and
even apareunia.
Majority of obstetric it"\i uries are theoretically prevent-
able. A case of cephalopelvic disproportion should be rec-
ogniLed antenatal I) and u·eated in time b)' a caesarean sec-
tion. Lacerations of the cervix and extensive tears of the
petineLUn, tJ1ough a'oidable, should be u·eatecl by immedi-
ate sututing. One of tJ1e worst it"\ittt·ies in obsteu·ic practice
in lndia is rupture o f the uterus. It occurs mostly in delivery
cases conducted at home when obstructed labour is not di-
agnosed by the midwife. Uterine rupture catTies a very high
maternal mortality and subse<1uem morbidity among tl1e
survivors.
Obsteu·ic trauma dudng chi ldbirth can involve more
than one T he perineum and the vaginal walls are
most vulnerable; o n occasions, chil dbirth traum a
is known to badly injure the cervix, vagin al fornix, causes
colporrhex is and eve n ex tends in to tJ1e ute rus resulting in
uterine rup tu re.
PERINEAL TEARS
T hese are not u ncommon; a thoroug h inspec tio n of th e
perine u m and lower gen ita l tract u nder a good lig h t is
mandatory after any instrumenta l or assisted vaginal de liv·
ery and after spontaneous labour whenever u·au matic
postpartum haemorrhage is diagnosed. Small lacerations
that are not bleeding may be left alone. All other injuries
must be surgical!) repaired, preferably in an operation
theau·e. The presence of a competent assisLant and avail-
ability of an anaesthesiologist during the procedure are of
immense help. All bleeders should be meticulously tied.
The tear should be repaired in la)ers. Sometimes, a small
bleeder may be O\'erlooked; Lhis may lead to a vuh<al hae-
matoma. ln such an e\enL, it is important to e\<acuate the

396
 CHAPTER 32 - INJURIES OF THE GENITAL TRACT AND INTESTINAL TRACT
haematoma at the ea rliest, ensure haemostasis and repair
t11e wound promptly. At times blood u·ansfusion may be
needed to correct shock.
The common risk factors predisposing to perineal floor
injttries are listed below:
I. Overstretching of the perineum:
• bab)
• Prolonged labou•· (d) stocia)
• Occipitoposterior malposition
• Vaginal instrumental delivery
• After-coming head in breech presentations
• Midline episiotomy
2. Rapid stretching of the perineum:
• Breech presentation
• Precipitate labour
3. Rigid p erineum:
• Elderly primigravida
• Vulva l oedema
• Scan·ed perine um following previous surgery
• Repair of previous co mp lete perineal tear
PREVENTION OF PERINEAL TEARS
Perineal tears can be avoided b)' tim el)' adop tion of the fo l-
lowing measw·es:
I. Supporting t11e pe tineum and permitting gradual egress
of the presenting part during delivery.
2. Timely episiotom) if the stretched perineum seems likely
to tear.
3. It is advisable to perform an episiotomy while undertak·
ing an) instrumemal-assisted vaginal delivery.
4. It is advisable to perform an episiotomy while conduct-
ing assisted vaginal b•·eech delivery.
5. In patients having history of successful repair of com-
plete pe•inealtear, difficult genital u-act prolapse. It will
be advisable to go for a caesarean section as t11e route
for delivery in women with previous repair of urinary
fistulas.
VAGINAL TEARS
Isolated vaginal teat'S or lace•·ations without in volvement
of the perineum are usua ll y found following instrumental
or manipu la tive vagina l deli ver ies. T hese sho uld be
promp tl y repa ired after de li ve ry to prevent undue blood
loss. Sometim es, it is advisable to pack the vagina with ster-
ile ro ller gauze soa ked in glycerin e acriflav ine/ Betadine to
provide local comp ressio n ; the pac k sho uld be removed
in 24 hours.
CERVICAL TEARS
These may follow instrumental vaginal delivery, in shoulder
dystocia or manipulations during vaginal breech delivery.
The faCLthatthere is excessive vaginal bleeding in t11e pres-
ence of a well-conu-acted uterus, should raise StLSpicion of
genital u-acttrauma. Speculum examination and packing of
Ll1e cervix against t11e vaginal vault penn itS satisfaCLory visu·
ali.t.ation of the vaginal walls. Thereafter, t11e entire rim of
tlle cervix should be inspected between •·ing forceps to iden-
tify any cen ical tear and repair the same.
397
COLPORRHEXIS
Rupture of t11e vaginal vault is called colporrhexis. There
may be concomitant tear of the cervix. If this iqj ury is ex-
tensive. it ma) lead to formation of broad ligament haema-
toma requiring laparotom). Suwring of t11e rent shottld
suffice. There is danger to the uterine vessels and urete•·
during repair. Great care should be exercised to avoid
complications.
INJURIES DUE TO COITUS
A slight amount of bleeding from the tom edges of the
ruptured hymen is no•·mal after defloration, but the
haemoni1age can sometimes be severe, particularly when
the tear has spread forward to the region oftl1e vestib ul e.
The haemorrhage can usuall y be co mrolled by t11e appli-
cation of gauze pressure, butoccasionall ysuwr ing under
anaesth esia is req uired and b lood transfusion may be
necessary.
Bruising of Ll1e vagi nat wa ll is not uncommon in the early
days of married life, and a urc tJHitis may resu lt from bruis-
ing of the ure tJ1r-a. Such cases (hone)•moon cystitis) are seen
freq uen tl)' and it is not uncommo n for ascend ing pyelone-
phri tis to resul L
Lacerations of the vagina caused by coitus are occasion-
ally seen. Violem coiLUs or rape in yo ung girls, forcefi.tl
peneu-ation in posunenopausal women with atrophy of t11e
vagina or in t11e presence of malformations such as u-ans-
verse vaginal sepwm, extensive and serio tLS injuries are
known to occur. These lacet-ations may be of variotLS types.
It often takes the fonn of a longitudinal tear of the anterior
vaginal "all. Cases are on l'ecord where the posterior vagi-
nal wall has been tom through and tlle peritOneal cavity
opened up. Both bladder and recwm may be involved
in serious coital Similar injuries may occur in
patients who ha,•e undergone vaginal ope•-ations in t11e
past, especially if coiLUs takes place soon after the opera-
tion. All patientS who have had a vaginal ope•-ation should
be advised to avoid coitus for initial 2 mont11s. A similar
injury can ocnu· after the ope ration of total h ysterectomy
when t11 e recently stitch ed vaginal vault may be disrupted
by coitus. Large or small bowel and omentum can prolapse
into Ll1e vagina with res ulting shock and perito nitis. Severe
haemorrhage follows inj uri es of this kind. When Ll1e inj u-
ries are small, treaun e nL co nsists in plugging Ll1e vagina,
provided thorough inspecti o n has excluded Ll1e possibility
of ex tensive or interna l In more severe cases, it is
necessary to sutme Ll1e laceration under anaesthesia. If the
bowel has prolapsed, it is imperative to open the abdomen
so that a complete inspection of Ll1e gut from the jejunum
to t11e recwm can be undertaken. Damage to bowel or
mesentery can then be assessed and the correct treaunent
performed under direct vision. It is imeresting 1.0 note that
quite apart from the coiltLS or direct injury, a spontaneotLS
rupttu·e of Ll1e '-agina can occur in Ll1e upper posterior one-
tllircl. The patien LS are LLSuall) elderl) and the vagina is
atrophic. The catLSe is LLSuall) a violent bout of coughing or
some severe strain associated "ith a sudden rise in inu-aab-
clominal p•·essure. The u·eaunent is tlle same as for coital
398 SHAW'S TEXTBOOK OF GYN AECOLOGY

PElVIC HAEMATOMA
DIRECT TRAUMA AND VULVAL HAEMATOMA
Pelvic haematomas are of two types. lnfrale,oator haema-
wma following a perineal tear or episiotomy, these have
lnj Ltries to the \lllva as the result of direct Lrauma are not
been described abo,e.
tmc.ommon. AccidenlS such as falling astride gates and
Suprale,oator haematoma resullS in the fonnauon of broad
';lre frequent a nd usuall) produce bruising of the la-
ligrunent haematoma. It follows ce rvical tear the
b.a maJora. In more seve re cases, large haematoma devel-
ute1ine vessels. uterine rupture (spontaneotLS or caesareru1
o!;>s in . the labia majora a nd the effused blood spreads
scru· and uterine anel)' tear dlll·ing uterine surgery.
m the lax. tissues. This is specially seen The chagnos1s may be dela)ed, if it is small. A large haema-
when the lacerauo n mvolves the region of the cliwris and
wma causes h)potension, taCh)Cardia and pallor. A tender
the erectile tissue around the ' oaginal orifice. Compressible
swelling is felton one side of the in t11e broad ligrunenL
haematom.as of vulva are sometimes caused by the rup-
Management depends upon the siLe of the haematoma.
ture of \'<lncose of the labia m;yora du•·ing pregnru1cy,
and the swellmg may obsu·uctthe delive•)' of t11e head
• Conservative treaun ent with observation: A small haema-
(Fig. 32.1 ).
toma gets gradually absorbed. Antibiotics should be given.
. most common ca use of the vulvovaginal haematoma • Laparotomy: If t11e bleeder can not be identi fied as is
IS the haemostasis d uring sutu1ing of an episi-
the usual case, t he broad li gamen t shoul d be packed for
owmy or a penneal tear. T he im po n ant com plicatio ns of
24 hours and one end of t11c pack brough t o ut of the
hae mato ma of t11e vul va are haemorrhage with s ubsequen t
abdo min al wo und to be re moved later. Blood tra nsfusion
and loca l infection. A vulva l hae ma to ma prese nts
may be req ui red .
as a pa•.nful tender swell ing, bluish b lac k in appearan ce.
• Hysterec tomy for ute rine ru pture.
T he pauen t ma>' look pale and she may be in a co nditio n of
• Internal iliac li gatio n to comrol bleeding.
shock. A s ma ll haernatoma respo nds we ll lO bed rest sitz
• Embolization of internal iliac arte ry.
ba tl1 and magnesiu m sul phate fomemauon. are
given to prevent infection. With large haematoma, it is nec-
It is important to idenLify the ureter and avo id trauma to
essary to incise t11e swelling under anaesthesia and to re-
tu·eters d llling hysterectomy.
move the cl_oL If hae mostas_is is diffic ul t to sec ure, pack-
mg IS e mployecl. l he deep penetrating injuries
req LLLI'e umned1aLe operation, suwre and repair of t11e in- GENITAL MUTILATION
JLLred structure. lf t11 ere is a suspicion of visceral injury or if
This practice of genital mutilation is sLill prevalent in African
t11e pouch of Douglas has been opened, laparoLOmy must be
counu;es, pru·ts of Asia and amongst Arabs. It involves partial
perfonned and perforation of the bowel and bladder su-
or total removal of exte mal genital organs in girls, for non-
lllred A temporal) colostOm) ma> be necessa•)'. if the rec-
medical reasons. It imolves partial or total remo,'<ll of the
has i•1iured. Road u-affic i•1iu•·ies may involve in-
clitoris prepuce (L) pe 1), clito•·is "it11 labia minora (type
Jury to peh·•c bones, ' >agi na and pe •ineum.
U_), apposing labia minora (t) pe Ill ) or pricking,
p1ercmg, mc1S10n and cauteri£ation (t) pe IV) .
Immediate complications a re as follows:

• Bleeding- haematoma
• Pain
• Infection

Long-term adver-se effeclS arc as follows:

• Severe pe r-sistent pain d ue to unprotected ne rve e ndings.

• Dyspare uni a, apare un ia.
• Haemawma dming fo rceful interco mse.
• Infec tion wit11 sca rin g.
• Transmission of I-I IV, tetan us.
• Reten tion of mine, haernatocolpos.
• Diffic ul t c!li ldb irtll and need for caesarean delive•y
• Psycholog•cal trauma of m utilation and distorted anatomy
ofthe external genitalia.

INJURIES DUE TO FOREIGN BODIES

AND INSTRUMENTS

VAGINA
An extraordinary variety of bi£a•·re fo reign bodies have been
Figure 32.1 Vulval haematoma. recovered from the ' oagi na including safety pins, hair g•ips,
 CHAPTER 32 - INJURIES OF THE GENITAL TRACT AND INTESTINAL TRACT
pencils and small jam jars. The pal.iem is often men rally re-
tarded or a young ch ild, and in both these cases a persistent
and a malodorous discharge should always suggest the pres-
ence of a foreign bod).
Neglectetl or forgottm objerts empluyed therapeutiwll)' The
most frequent!) found is the ring pessary used in prolapse.
Some of these have remained in the vagina for many years
and have become encrust.ed with phosphal.ic depositS.
These neglected pessaries can cause severe ulceral.ion oft.he
poste•·ior fornix and lat.er even vaginal carcinoma. Less trau·
matic are forgouen swabs and tampons which cause a foul
purulent discharge.
Con tracepl.i' e devices such as cervical caps and dia-
phragms, e,•en a mislaid condom when retained, can cause
discharge and ulce1-ation.
instrumental damage is ca used during auempted criminal
aborl.ion. Sound, gums, clastic bougies, knitting needles and
the like have ca used perforation of th e vagina into the blad-
de•; recLUm, the pouc h of Douglas and the parametrium.
CERVIX
Obstetric cervical tea rs occ ur d urin g precipitate labo ur or
insu·umen tal de li very.
The commonest cause of ce rvical tear is cervical di lata-
Lion witl1 the metal di lators and this causes b leeding and
later an incompetent os. Cervical stenosis fo llows conization
and amputation as in Fothergill's operation for prolapse
and cauterual.ion of cervix for cervical erosio n. This can
lead to haematometra and infertility.
liTERUS
Foreign bodies in the uterus are almost a lways inu-auterine
contracepth·e de,·ices such as copper-T. These may be ne-
glected or forgotten by the patient. They can cause ulcer-
ation of the endometrium and give rise to a se•·ious ascend-
ing infection with inflammatory tubo-ovarian masses. These
foreign bodies may also be a cause of meno.-rhagia.
The other fo•·eign body met within the uterus has usually
been introduced to procure abortion. Se•·ious intrauterine
infections often result in pelvic abscess from acute salpingo-
oophoritis.
Perforation of the uterus may occur during dilatation
and curettage (D&C) and medical termination of preg-
nancy (MT P). Pe •foration d uring hysteroscopic operative
procedures, such as u·a nscervical resec tio n of e ndometrium
(TCR£) or division of the ute rin e septum, is known. T hese
sho uld not be trea ted lightly; the possibility of inj ury to ho l-
low viscera, or vessels, must always be borne in mind and
necessar)' surgical measures immediate ly taken to ensure
patient safety.
Sometimes Asherma n syndrome with uterine synechiae
follows vigorous cureuage or uterine packing to control
haemorrhage, manual removal of the placenta and uterine
infection.
TREATMENT
Treaunem for vaginal foreign bodies is to remove tl1em, if
necessaq•, under anaesthesia. Simple local antiseptic
douches are sufficient thereafte•: If, however, the vagina has
399
been perforated, anL.ibioL.ics are indicated, and if there are
signs of peritonitis or bowel damage, laparotomy should be
Llllde rta ken.
Uterine foreign bodies should be removed under anaes-
thesia and. if infecl.ion is present, a swab taken and tl1e
appmp•;ate antibiol.ics given. Adnexal involvement if resis-
tam to chemotherap), e.g. large persistent masses witl1 re-
cun·ent fever and constitutional upset, calls for laparowmy
and their surgical remo"al. In )Oung women, it is some-
times possible to conserve the uterus and pan of one ovary.
'Nhen the pelvic organs are grossly damaged by the pelvic
inflammatory disease (PID), total h)'Sterectomy and bilat-
eral salpingo-oophorectomy is the only logical answer. For-
tunate I)', tl1ese seve•·e infections due to ute•·ine foreign
bodies are •-a•-e now.
CHEMICAL AND OTHER BURNS
OF THE VAGINA
T he most common ca use of t11 ese is t11e use of strong ch em-
icals such as L)•Sol, pe•manganate o r co n·osive sublim ate to
induce aborti ons b)' un tra ined persons. T he dangero us
complication of tl1 is type of b um is that d uring heali ng,
extensive vaginal adhesions and fibrosis will obli terate the
canal and prevent coitus, and even cause retention of men-
strual discharge with haematometra and pyometra. Plastic
reconstruction is tJ1e only answer LO tl1 i.s problem.
Douches administered at a very high temperature can
also cause bum. This is a culpable ermr on pan of tl1e
ope1-ator.
DLU;ng tl1e operation of cauteriLation of tl1e cervix by
cautery or diathenn), it is quite eas> to bum the vagina eli-
recti)' or b)• conduction. Fortunat.el), CI)OSurgery has nowa-
da)S replaced cauteri1.ation oflhe cen·ix, and bum injuries
of this natu•·e a•-e rare. Laser the•-apy for cervical lesions and
vaginal cancer in situ can also result in bun1s ohagina.
Lt must be remembered that the 1-adium inserted into
the vagina for carcinoma of t11e cervix alwa)S causes •-adia-
tion burn. DLII·ing the process of healing, the vaginal vault
frequent!)' becomes oblitCI-ated by adhesive vagini tis and
fibrosis.
TREATMENT
Most vagina l bums, unl ess severe, heal with expectant treat-
men L T hose resulting in ex te nsive sca rring a nd atresia will
requi re p lasti c surge•)'·
PERINEAL INJURIES
A minor degree of laceration of t11e perineal body often oc-
curs during childbirtl1. Some degree of perineal laceration
occurs in nearly all nonnal deliveries, whereas t11e incidence
is greater if instrumental deliveries have been perfonned.
LacemL.ions are fi,e to six times more frequem in primipa-
me than witl1 mull.iparae.
It is customal") to gmde lacemtions of the perineum into
four degrees. ln the first degree, the laceration is resu;cted
w the skin of the fourchette. In t11e second degree, tl1e
muscles of the pelineal body are wrn through, whereas in
400 SHAW'S TEXTBOOK OF GYN AECOLOGY
tl1e third degree the tear extends partially backwards
tlwough tl1e external sphincter o f the an us. In the fourth
degree. tl1e sphincter is torn and a nal mucosa is also in-
volved. A rare type of Lear is the cen u-al tear o f the perinettm
whe n tl1 e head peneu-ates llrst tl1rough tl1 e posterior vagi-
nal wal l. tl1en through the perineal body and appears
tlu·ough the skin of the perineum. It tLSually occurs in pa-
tients with a con u-acted outlet of pelvis.
PERINEAL LACERATIONS
An occult injury to the perineum without noticeable sign
occurs in 0.5%-2% of women following vaginal delivery.
Studies have shown that as much as 35% of p•imiparae sus-
tain occult sphincter i•'\itll)' as shown by ano-endosonogram.
The first-degree lacerations, resu·icted to tl1e skin ofthe
fourchette, have no influence o n the integrity of tl1 e pelvic
floor, but if the lacerations are not sutured after delive•) ',
tl1e vagi nal orillce beco mes patulous. In practice, small lac-
erations of the fourcheue are no t sutured unless tl1ey ex-
Le nd to tl1e skin of the perine um, whe re tl1 ey a re more likely
LO become infec ted and to ca use pain.
T he second-degree lacerations sho uld always be sutured
carefully immediate ly after de liveq•. T he pelvic floor is
weakened unless the il'\i ury to the muscles of tll e perineal
bod)' is efllciently repaired. If the deC t.LSsating fibres of the
levator ani muscles are torn through, tl1 e hia tt.LS urogenital is
becomes pawlous predisposing LO prolapse of the vagina
and the utenLS subseque ntly.
With the extensive seco nd-d eg ree tea rs, the patient
should be g ive n a local, regional pudendal block or gen-
eml anaesthesia, placed in the lithotomy position and the
torn muscles of the perineum ide ntified a nd sutured to-
ge tller with catguL The torn edges of the vagina and the
skin of the pe.-ineum should tl1en be sutured togetl1er
with an absorbable suwre material. The essentia l pan of
the after treatment of perineal lace•-ations consistS in
keeping the perineum clean. Frequent swabbing is tl!ere-
fore impe•-ath•e during the puerperium. The wound
should be cleaned with an antiseptic solution such as
Betadine after mi cturition and defecation. Antibiotics
are requir·ed.
The third- and fourth-degree tears are much more im-
portant, because un less L11 e)' are efficiently repaired imme-
dia tely after deli ve•y, the patie nt develops incontinence of
faeces and flatus. Amongst the predisposing causes of com-
p le te tea r of Ll1e pe rin eum are forceps deli ve•)' in the persis-
te nt occipitoposte ri or positions, and ex trac tio n of the after-
coming head in a breec h prese matio n. Large head and
precipitate labo ur are also co ntrib utOI)' factors, b ut the
most common ca use is vigoro us pulling in L11e wrong direc-
tion during forceps delive t)', especially witl1 Kie lland's for-
ceps. A properly performed wi ll ve•)' largely
eliminate tl1e risk of the third- and fourtl1-degree tear. This
t)'Pe of tear is more commo n with median episiotomy than
mediolateml episiotom).
Complete tear of the perineum should be repaired as
soo n as possible after the delivery. A pmctitione•· should
not lllldertake the repair of a complete tear of the
perineum single-handed ly. The ope•-atio n should be un-
d ertaken under anaesthesia with tl1e patient lying in the
lithotomy position in good light and with good assistance.
The operation should be regarded as a surgical emergency
and tl1ere is no excuse for dela). As fac iliues may not be
available in tl1 e paLient's home, she sho uld be u-ansferred
to a hospital.
The immediate repair of a complete Learoftl1e perineum
is a relative!) simple procedure, becatLSe the mtLScles of the
pe.-ineal bod), though torn, can be distinguished witl10ut
much difficulty. The su t-rounding skin is first cleaned and
the opemtion area isolated with sterile towels. A ste•·ile pack
is placed in the 'oagina and the limi ts of tl1e lace•-ation de-
fined with tissue fo•·ceps. The rectum and tl1e anal canal are
first repaired with ViCL)'I '30' sutures insened witl1 an au-au-
maLic needl e. A few Lembert sutures are then inu·oduced to
invaginate the torn edges of the •-ectal wa ll. The muscles of
the perineal body ar·e now sutured togeth er, and every effort
should be made to obtai n exa ct anatomical repositio n. Par-
ti cul ar attention must be paid to tl1 e sp hincter ani muscle,
a nd at leas t two Vic1yl s utures sho uld be used to draw the
cut edges wge tl1er. The tea rs in the vaginal wall and in tl1e
s kin of th e pe rine um are now repaired witl1 ime rrupted
s utures. Cat-e sho uld be ta ken LO avo id tying tl1 e suu.tres too
tightly; otherwise, oedema of the pe rineum will lead LO se-
vere pain and ca use tl1 e s titches to cut through. If a com-
p le te tear of the perineum is u·eated b)' immediate sutt.u·e,
the end result issatisfacLOt)' if co rrec t anatomical reposition
has been attained. Lf primary union of the 'oagina and tl1e
perineal skin is not obtained, the wound sho uld be kept
clean and encouraged to gmnulate by frequem sitz batl1s.
The end resultS are often functionally good in spite of tl1e
initial breakdown of the suwre line. The bowels should be
confined for at least 5 da)S, solid foods withheld and imes-
tinal antiseptics given, along witl1 stool softe ners. Systemic
antibiotics are necessat).
Late ly, instead of end-to-(:nd sutu•·ing of the tom sphinc-
ter muscles, an o,·erlap technique is recommended LO yield
a stronger sphinctelic control.
OLD, LONGSTANDING COMPLETE PERINEAL
TEARS
Vatious degrees of co mplete perineal tears, usually resulting
from careless a ttempts at immediate suturing, are no t un-
usual. T he rectal wa ll may be torn through as h igh as 5 em
or mot-e along Ll1e posterior vagina l wall, but in most cases
only the ana l canal is involved. The ap pea rance of the
perineum in cases of old co mp le te Lea r is charac te ris tic. T he
red glistening muco us membrane of t11e anal canal and
rectum protrudes and fuse d irec t!)' with the vagina l wall
without an)' of the pe rin eal tissues intervenin g. Laterally, o n
eac h side, on a level with the an us, is the depression in the
skin which cotTesponds LO the position of tl1e severed edge
of tl1e tom external sphin cter (Fig. 32.2). Behind the amLS
are the radial folds in tl1 e skin which are corrugated b)' the
tmderlying con u-acted subcuta neOlLS sphincter. The exter-
nal sphincter is on I) present posteriorly a nd tl1e absence of
the sphincte tic g1ip is appreciated b) inserting a finger imo
the anus.
One of the most inte1-esting features of the complete tear
of the pe•ineum is that it is vety rarely, if ever, associated "itl1
 CHAPTER 32 - INJURIES OF THE GENITAL TRACT AND INTESTINAL TRACT
Figure 32.2 Complete tear of the perineum.
ute tine prolapse, altJ1ough tJ1e fibres of the le\'<1·
tor an i muscles have been torn through. T he reason is that
the patient con tinuously dmws togethe r Lhe two levator an i
muscles in an effon to close the so Lhat by constant use
t11e tone of the muscles becomes excep tionally good. This
finnness and good development of tl1e levator muscles is
found on clinical examination when tl1e levator muscles are
palpated.
SYMPTOMS
The patient complains of incontinence of faeces and fla[US.
A few patients develop the tone of the levator muscles so
well that they only suffer incontinence of flatus. These
"omen will complain of incontinence of faeces only if tl1ey
develop dianiwea.
Apart fi·om clinical examination, a gap in me sphincter
can be identified by perineal ultrasound or magnetic reso-
nance imaging (MRJ ).
TREATMENT
The treatment of old co mplete tea r of tl1e perineum is op·
erative. The tec hni cal d ifficulties are much greater in old
cases than in tl1ose operated upon immed iately after deliv-
et)'. T he op timum time for operatio n in the case of old tears
is 3-6 months after de li very. If the operation is atte mpted
earlier tl1an tl1 is, healing by first inten tion is exception,
whereas if tl1 e operation is furt11 er delayed, a dense scar
tissue forms which adds LO tJ1 e operative d iffic ulties. Preop-
erative preparation is of importance, and the patient should
be kept in the hospital for a co uple of days before the op-
eration during which time the bowels sho uld be emptied by
aperients and enemas, and the vagina disinfected by douch-
ing and b) insertion of packs soaked in flavine ( 1 in
1000) or Betadine lotion. The bacterial flora of tl1e bowel
should be controlled b) ampicillin or neomycin, given in
large doses for 3 da) S before the operation. The patiem
should be put on a nom·esidual diet such as milk and fluid
for 2 days before slll·gery. Various techniques have been
401
described in the operative treatment of complete tears of
the perineum, but tl1e underlying principles are the same in
all. The rectum must be dissected from t11e vagina b)' incis-
ing tl1e intervening scar tissue and by dissecting upwards in
tl1e rectovaginal septum.
Perhaps tl1e most important step in t11e operation is to
dissect me rectum clear of scar tissue and 1.0 mobilize it so
that it can be brought down, without tension to tl1e anal
region. The tear in the t-ectum and anal canal is now re-
paired by excising scar tissue, freshening me cut edges and
suturing mem togetl1er with fine Viet") I suwres moumed on
an auaumatic needle and tied wimin t11e lumen of bowel.
The needles, forceps and scissors used during tl1is step are
discarded. The wound in the bowel is now invaginated with
a layer of interrupted Lemben sutures. Next, tl1e deep
muscles of the perineal body and the leva LOr ani are identi-
fied and sutured together with no. 0 or I Vicryl. It is im por-
tant to ensure tl1at t11e muscles a t-e dissected clear of scar
tissue and are mobilized. The nex t impo rtant s tep in the
operati on is to sulltre toge the r the torn edges of the exter-
na l sp hin cter: T hese must be ca refull y defined, dissected
clear of scar tissue and sutured toge tll er with three or four
separate Vict"')d suwres. T he remains of the superficial mus-
cles of tl1e perineum are now s uLLLred toge tJ1er with catgut/
Vict)•l and then tl1e Clll edges of th e vagina and the
perineum are repaired, inte rrupted catgut/ ViCt)'l sutures
being used. These principles are uniformly followed in tl1e
various metl1ods described for the treatment of a complete
tear of tl1e perineum. The modifications depend solei)' on
tl1e position of tl1e incisions made in t11e vaginal walls and
in me skin of tl1e perineum, and t11ese, in tl1eir tum, de-
pend not on an) particular technique, but on the type of
complete tear which is to be repaired (Fig. 32.3).
Latel)\ man> ronaecologists believe in me overlap of
sphinctetic sutw·es to su·engthen the tone and function of
the sphincter, tl1ough others feel this overlap technique has
no advantage on tl1e surgical outcome. This remains a con-
troversial point as of today.
AFTER TREATMENT
The most important part of the after u·eaunem is to keep the
wound dry. The perineum should be swabbed after micturi-
tion and defeca tion with an antiseptic solutio n and subse-
quently powder-ed. Betadinc is th e antisep ti c solution of
choice, and it is effec ti ve. The bowels sho uld be co nfined
until at least the fiftl1 cia)' of the operati on. To ac hi eve this,
tl1e patient is given on I)' imravenous fluids for the first2 days
and oral flu ids tl1e next 2 days. From tJ1ird da)' she gets
a small dose of la.xative so Lhat when she stool on
fifm da)' tl1e)' are not hard. As in all operations on the
perineum, retention of urine is a common complication; it
may be advisable to leave a Fo ley's cat11eter for a few days in
tl1e immediate postoperative period. Antibiotics adminis-
tered preoperative!)' should be con tinuecl for at least a week
postoperative!). S)Stemic chemotherapy is necessary to pre-
vem infection and it should be given for a week. The end
result is tLSuall) good. Another complication tl1at may de-
velop is a rectovaginal fLStula which is tt$ually tl1e result of
faulty technique but also may be due to infection and break-
down of SUtw·es.
402 SHAW'S TEXTBOOK OF GYN AECOLOGY

intrauterine conu·aceptive devices. The intrau terine device

may perforate tJ1e wa ll of th e llle i'LL5, but remains with in t11e
myometrium. At times it perforates through tJ1e entire
thickness of tJ1e m) ometrium a nd e itJ1er lies free!)' in the
pe.-iLOneal cavit) or more often gets e mbedded in the ab-
dominal viscera.
lf ilie uterus is e mpl) and not malignan 1, laparowmy
may not be necessa•1· Simple obse rvatio n is all tJ1at is re-
quire<!. I n tJ1e presen ce of p)Ometra and malignanc)', im-
mediate lapa•·otomy and h) sterectomy is strongly advised. lf
the abdominal viscera, i.e. the intestine, prolapses
the perforation and is seen protruding in the vagina, im-
mediate laparotomy becom es mandatory. The repair of the
intestinal iryury b y resection and e nd-to-end anastomosis
wi ll be •·equired depe nding on the e xtent of the damage LO
th e intestine. If the uterus contains produ cts of conception,
repair of tJ1 e rent after evacuation of u terus u nder guidan ce
will s uffice. Lf the perforation is large o r if th e pati e nt h as
co mp le ted her fam il y, h ysterecto m)' is the opera tio n o f
c h o ice. Ute li ne inj ury h as been rece ntl)' rep011.ed dllling
h yste roscopi c excisio n of t11e u terine septum . Excisio n un-
d er laparoscop ic s upervis io n ca n avoid t11i s injUI)'- T he uter-
ine perforati on ca n a lso occ ur d u ring abla tio n of e ndo me-
trium th rough a h )'Steroscope in cases of d)•Sfunc tio na l
uterine b leed ing ( DUB).

Rgure 32.3 Operation for repair of a complete perineal tear. An area INJURIES OF THE INTESTINAL TRACT
of scarred skin is excised and the mucous membrane of the anal
canal freshened at the edge. The rectum is then mobilized and pulled A close anatomical relation of the lower female genital tract
down. Three structures must be defined, freed of tissue and to the rectum and anal ca nal so me times results in injury LO
mobilized, namely (a) the mucous membrane of the anal canal, (b) the these su·uctures. This is reported during vaginal delivery
external sphincter and (c) the levator ani muscles. First the edges of and vaginal surgeq. Similar!), abdominal gynaecological
the anal canal mucosa must be sutured together, then the cut edge surge•)' ma)' inach enentl) inju•·e t11e bowel. The LLSC of cau-
of the sphincter and lastly the levator muscles. Afterwards the cut teq• in mnaecology may inOi cta bum to the gasu·oin-
edges of the posterior vaginal wall and the skln of the perineum are
testinal uact (GIT), a nd tJ1is becomes noticeable a few days
sutured.
after ilie procedure.
It is important tJ1 erefore to realiLe the •·isk of to
the small and large bowels in obstetrics and g)'naecology.
ro the lxJwel in ob:,lelriCIJ are <JJ follmvs:
RUPTURE OF THE UTERUS
I. Vaginal delivery
Ruptu re of th e ute rus is th e most d readed com p li cati on • T h e third- and fourth -degree perinea l tear
in obstetrics, a lmost entirely a compli ca tio n of d iffi c ul t • Rec tovaginal fistula
labo u r. It is common in multi pa rae, us u ally foll owin g a • Faecal incon tin ence
neglec te d , obs u·uc ted de li ve r)'. Mi suse of o xytoc ics, o r • Stric ture of the ana l ca na l a n d rec tum
d e hi sce nce of a p rev io us u terin e sca r (caesa rea n sec tio n), 2. Caesarean d e li ve ry
rare ly a hae ma tome u·a o r p)•Ome tra, may lead to ruptu re • Lmesti nal inj u•)'
spontaneo us !)' as a resul t of d is tensio n a n d thinning of 3 . Du ring MT P
th e a troph ic tn )'Ometriu m. Depend ing on the ca use an d 4. Other causes of bowe l in obste u·ics a nd gy naeco-
extension of tear, re pa ir or h ysterec tomy is performed at IOg)'
laparotom)'· • Congenital rectovagi nal fistula
• Peneu·ating injury - accidents
• I nfective- sexually transmitted infections, septic
PERFORATION OF THE UTERUS abortions
• Rectal abscess, pe lvic abscess
ln tJ1e nonpregnant state, perforation of tJ1e uterus ma)' oc- 5. Dttdng surge•1
cur dw·ing tJ1 e operatio n of D&...C. The perforation is more • Abdominal h) SterectOm)
common if tJ1 e ute rus is soft as in pregnancy and in malig- • Vaginal surge I") - postvaginal re pair and vaginoplast)'
nancy. The au·ophic ute rus of a menopausal woman can • Endoscopic- laparoscopy and h yste roscopy
easily be pe rfora ted du.-ing c ureuage for posunenopausal 6. Genital cancers
bleeding. Spontaneous perforation may also occur witJ1 7. Radiothempy for cancer of the female genital organs
 CHAPTER 32 - INJURIES OF THE GENITAL TRACT AND INTESTINAL TRACT
VAGINAL DELMRY
The i•1jury to the anal sphincter, anal canal and sometimes
the rectum dut·ing vaginal delivet)' is more common in a
A big baby, prolonged labour, occipiLOposterior
presentation, breech a nd forceps deli very are fucLOrs lead-
ing to higher incidence of bowel inj ury.
T he may be a direc t muscle traum a, injury to the
pelvic floo r muscles or to th e nerve supp l)' of the anal canal
(p udendal nerve).
The symptoms appear soon after the delivery if a tear
occurs, or may appear years later due to stretching when a
woman develops anal wall prolapse or faecal incontinence.
The it'!jury LO the pelvic floor mttscles will cause both
stress incontinence of urine and faecal incontinence be-
sides genital prolapse.
FAECAL INCONTINENCE
Normal anaLOmy of the anal canal and maintenance of con-
tinence offaeces:
The anal canal is 3-4 em in length and is surrounded by
the internal sphincter above and external sphincter below.
The internal sphincter represents the expanded distal por-
tion of the circular smooth mttscle of the rectum and is in-
nervated b)• autonomic nerves. The external sphincter is a
su·iated muscle and is innen'<!ted by the pudendal nen·e
(sacral 2-4). The anal pressure remains above the rectal
preSSlli"C and imemal sphincter remains conu-acted in a con-
tinent woman, and opens only when the rectum distends
aided b)' inu·aabdominal pressure. T he ex te m al sphincter
muscle is supplemented by the puborectalis muscle of the
levaLO r ani and this prevents or defe rs defeca tion when the
suitable situation does not prevail. In add ition, the rectum
forms an angle of 60-130° with the anal canal, and this also
helps to keep the internal sphincter closed, and preventS
stool from entering the anal canal. During defecation, the
angle straightens out and allows the faecal matter to enter
the anal canal. The le\'<ltor ani muscles relax, so also the ex-
ternal sphinctet: The pelvic floor descends by 2 em. The anal
canal widens and shortens during defecation.
Faecal incontinence is defined as a loss of normal conu·ol
leading to involuntary leakage of faeca l co ntentS. Depend·
ing on the degree of incontinence, flaws, loose motion
(diarrh oea) o r solid stool leaks o uL
Faeca l incontinence is reponed in 0.5%-2% of women fol-
lowing vaginal delivety Women at-e mo re prone to faecal in-
continence than men, and elderly women suffer more than
)'Ounger "-omen. Faecal incontinence may follow some years
after the delivery, but many develop it within 6 months of de-
liver). Primiparae are more inclined than the multiparae. The
occult damage to the internal sphincter occurs in 35% of
women following first vaginal deJi,ery, t11ough t11e petineum
appears imacL This is revealed b)' anal endosonogJ-aph)(
AETIOLOGY
Several causes a re known to cause faeca l inco ntine nce, but
t11e most im portant factor in women is obsteu·ic u·auma dur-
ing vaginal delive ty
403
Obstetric trauma during vaginal delivery:
• Prolonged labour which can oversu·etch t11e le\'<ltOr ani
muscle or damage the pudendal nene.
• Difficult forceps del ivery.
• Occipitoposterior presentation of t11 e fews, big baby.
• Rigid perine um.
• Episiotomy does not always safegua rd aga inst sp hincter
damage. Mid line episiotomy increases tisk to t11 e
sp hin cter, compared to mediolateral episiotom)'·
• The Lh ircl- and fourth-degree perineal tears, by tearing
the external sphincter, lead to faecal incontinence.
on obstetric catLSes are as follows:
• eurogenic, dementia, cerebrO\'<ISCular accident, spinal
cord lesion.
• Bowel diseases such as inflammatory disease, cancer and
rectal prolapse.
• RadioLherapy for ca ncer of the genital u·acL
Urge incontinence of faeces resu lts from to t11 e
external sp hincter when the woman is unab le to ho ld on
until she can reach the to ilet
HISTORY
The woman may develop faecal incontinence soon after t11e
delh·ery (tLSuall)' first \'<lginal delivet·y) or some) ears later if
the damage is mild. Fun.her weakening of t11e pelvic floor
muscle support and sphincteric conu-ol with an advancing
age is t11c cause of delay for the onset of symptoms. Many a
tim es, t11e woman is reluctant to reveal this h istOt)' due 10
shyness, un less directly questioned.
On exa minatio n, perineal tears are obvious, but damage
to t11e interna l sp hincter shows no ex ternal ir'!j ury and certain
investigations are required.
Occasionally, faecal incontinence may follow pelvic surgety
INVESTIGATIONS
• Proctoscop) and sigmoidoscopy for a rectal disease.
• Manomeu·y to measure the anal canal p•·essure. onnal
pressure is 45-100 mm
• Elecu--omyelogt-aphy to detect a nerve injut)' to the mus-
cle (pudendal neuropathy).
• Ten herll. ( I 0 H z) ul trasound scanning of t11e anal canal
has now replaced elec u--omyelograp hy. UlLraso und scan-
ning de tec ts a defect in the sp hincter (Fig. 32.'1).
• MRI.
TREATMENT
Managementoffaecal incontinence comprises t11e following:
• Medical - Loperamide and codeine phosphate increase
the resting tone of the anal sphincters and also cure urge
incontinence.
• Fibre-rich diet makes the stool finn.
• Antidiani1oeal treaunem in inflammatory diseases of the
bowel.
• Physiotherapy and biofeedback u·aining are useful
tho ugh time consuming, but nerve injury recovers in
2 weeks in 60% of early cases.
• Sacral nerve stimulation with a probe im proves pudendal
nerve stimulation and tones up the Je,'<!tor a ni muscles.
404 SHAW'S TEXTBOOK OF GYN AECOLOGY
Rgure 32.4 Transrectal ultrasonography (TRUS) showing a defect
in external anal sphincter.
• Surgery - surgery is requ ired for ex te nsive perineal tears,
fistula and anal prolapse. Rec topexy for rectal prolapse
cures incon tine nce. The woman sho uld be de livered by
caesarean section following a successful repair in subse-
quent pregnancy.
RECTOVAGINAL FISTULA
The majorit) of rectovaginal flswlas result from obstetric
injLLries. usuall) a complete tear of the perineum which
has been imperfeCLl) sutured immediately after delive•·y
(Fig. :32.5). It has ah·ead) been pointed out that the repair
of a complete tear of the perineum should be undenaken
carefully, with the patient in the lithoLOmy position and
under anaesthesia. If, fo•· instance, a few suwres are placed
through the lower part of the anal canal and the upper
pan of the tear in the rectum is not accurately sutured, a
fistulous opening may form between the recwm and va-
gina. Rectovaginal fiswla may occur after opera tion for old
complete tears of the perineum if the wound breaks down,
Rgure 32.5 Examining finger passed through rectum seen to
emerge into the vagina through a recto vaginal fistula. (Source: Benjamil
Person <l1d Juan J . Nogueras. The Management of Rect01aginal FIStulas
il Patients wdh lrllammatory Bowel Disease. Semila-s il Colm ard
Rectal Surgery, 17(2):2006.)
or if tl1e recLUm is not properly mob ilized before the re-
pair of tl1 e wound in t11e rectal wall. These fistulas also
occLll' after the operation of perineorrhaphy in tl1in, el-
derly patients when the anterior wall of tl1 e recwm is ac-
cidentally opened.
Other causes are LUberculosis, wh ich is not uncommon
in India, and l)mphogranuloma inguinale. In adva nced
carcinoma of the cervix, when the growth has spread down
the posterior vaginal wall, a •·ecwvaginal fiswla eventually
resuhs. Such fiswlas also occur following radiation u·eat-
ment of carcinoma of tl1e cervix or vagina, or following
Wertheim's operation for the same condition. A fiswla fol-
lowing radiotherapy may occur 3 months to several years
after radiotherapy and such a fiswla is surrounded b)' exten-
sive fibrosis. It is difficult to cure a malignant fistula and it
can only be treated by some fonn of posterior pelvic exen-
teration or a palliative colostomy. Primary carcinoma of tl1 e
rectum can also ex te nd forward and involve tl1e vagina to
cause a reCLovagina l fistula. A co nge nita l rec tovaginal fistula
is rare ly seen and is the res ult of maldevelop me nt of tl1 e
lower pa11. of the rec wm and anal ca na l. In such cases, it is
cuswmary to perform pre limi nary colosto my before p lastic
operation. Di veniculitis, rectal abscess and d irect u·auma
are other rare causes of a fisu da.
In case of a pelvic abscess whe n the re is collec tion of p us
in me po uch of Do uglas, the abscess sometimes bursts in to
the rectum and a rectovaginal fistu la develops, particularly
if tl1e abscess is surgically opened up through the posterior
fornix. There is a fonn of a rectovaginal fistula which fol-
lows infection in an anal Cl') pt with a resultant abscess for-
mation. which bursts in to the vagina. These cases are diffi-
cult to u·eat surgicall). and good results can not be expected
until the e ntire fiswlous tract into tl1e ana l canal has been
excised. This necessitates eli' ision of t11e extemal sphincter
and follows tl1e pl'inciples laid do" n in the u·eaunem of
fistula-in-ano. The patient complains incontinence offaeces
and flatus. A large fistula can easily be identified, but a small
one is very difficult to detect, especially if it is su•-rounded
by dense fibrosis. Proctoscopy, sigmoidoscopy and ir!jeCLion
of radiopaque dre will be needed to u-ace t11e fistulous u-act.
TREATMENT
T he ll'aumatic form of a rectovaginal fistula is treated by
opera ti on. Preopera ti ve trea un ent is im portant and the
bowel sho uld be emp ti ed with e nema, and tl1 e vagina disin-
fec ted by do uches and ga uze packs soa ked in antiseptic
solutio ns such as flavine o r Bet.ad ine. J>hthalylsulphathia-
zole or neom)'Cin sho ul d be given for a few da)'S before op-
eration to s terilize tl1 e bowe l conte nts. Other dn.•gs such as
Ampicillin, Tinidazo le can be used for bowel preparation.
With a small rectovaginal fisw la above an in tact perineal
body, an unusual even 1, it is sometimes feasible to excise the
fistulous l!'ack and close t11e defect successfully by a local
operation. It will, however, be more commonly found tl1at
the perineal bod) below tl1e fiStula is inadequate and tl1at
the levators are not approximated. In fact, in many recto-
vaginal fistulas. there is merel) a thin skin bridge below the
fistula and often the ana l sphincter itself is incompetent.
When, in addition to tl1ese pe•·ineal defectS, the fistula is
very large, the best u·eatment is to cut the skin bridge in the
midline and come1·t the fistula into a complete perineal
 CHAPTER 32 - INJURIES OF THE GENITAL TRACT AND INTESTINAL TRACT
tear. This is then repaired like a complete perineal tear. A
high rectovaginal fistula may require a preliminary colos-
tomy. The fistula due to cancer of the cervix or rectum re-
quires an exenteration operation. A fistula following radio-
therapy for cancer may be successfully closed by colpocleisis.
This operation consists of obliteration of the vaginal cavity
after denud ing the entire vaginal mucosa. However, resul ts
are not good.
The surgeo n may be invo lved in complicated recta l
surger)'.
Optimal mode of future delivery is not defined; and the
decision is individualized. However, most grnaecologists
believe in perfonning elective caesarean section to avoid
furtl1er damage LO the sphincter.
BOWEL INJURY
AETIOLOGY
• While entering the peritonll(d cavil)', th e risk factors are obe-
sit)', previo us surgery, gynaecological pathology such as
pelvic endometriosis, PLD, cancer surget)' and previous
irradiation.
• Utfwroscof'J· lt is not t.mcommon to perforate the bowel
with the Veress needle or tJ1e trocar. The use of cautery or
laser during laparoscopic surgel') can cause burns to the
intestine. This will be detected about 5-7 days later, when
t11e woman returns with peritonitis and ileus.
• Hylferv¥opic resection of a uterine 5eptum, or TCRE in DUB,
can cause uterine perforation and therma l heat can cause
intestinal burn.
• D&C. IL is rare to damage the intestine during gynaeco-
logical D&C, t110ugh some cases have been reported.
Types of injury- perforation, laceration and cms h it1ju·
ties are likely to occtu· in grnaecological surge ry
DIAGNOSIS
Most of the above U1Juries can be recogniLed at surget)'·
Bum it1jUties, however, may take about a week to present as
pel'itonitis and a fistula.
SURGICAL TREATMENT
Thorough exploration of bowel wi tJ1 t11 e he lp of a surgical
colleague is needed for appropriate u·eaunent. Caesarean
section performed following a prolonged second stage can
also cause injury to the anal sphincter and anal wa ll. More
commonly, howevet; it is t11e small bowel t11at gets injured
during caesarean section, more so if t11e intestine is adher-
ern to tl1e parietal peritOneum tl1rough previorLS surgery.
MEDICAL TERMINATION OF PREGNANCY
Apart from criminal abortion, the bowel can be it1jured dur-
ing MTP if t11e uterine perforation goes unnoticed and a
loop of in testine is pulled tluough the perforation. Immedi-
ate laparotOmy is requi red and bowel injury dealt with.
Criminal abo rtions are responsib le for most of t11e injuries.
Sexual!)' u·ansmiued infec tions can cause ex tensive stric-
ture aro und the anus (i.e. cond)•loma venere um ).
405
SURGERY
lt is rare to injure tl1e bowel during ronaecological surgery
and the incidence quoted varies between 0.3% and 0.8%.
I. A small ir!jlH)' less t11an 5 mm in t11e small bowel can be
effectively closed by a purse-suing or transverse sutures
in two la)•ers.
2. A larger laceration may need resection and end-to-end
anastomosis.
3. Colonic injut)' needs proximal colostom)'.
Rectal ir1j ut)' occurs mainly dul'ing vaginal surgery such
as posterior vaginal repair for prolapse, repair of perineal
tear, exenteration operation and vaginoplaSt).
A small tear can be sutured immediately, but a large hole
needs proximal colostomy.
Radiation causes a fistula or strictut·e. Colpocleisis can
cure the fistula.
The ro•naecologist should not hesitate to ask for a gen-
eral surgeon's assistance. ln case of doubt or a major ir1jul')',
surgical assistance is necessary.
PREVENTION
Obsteuic it1i uries to intestine can be a\oided by proper ob-
stetric managemenL
DLU·ing ronaecological surgel'), the high-risk factOrs
should be remembered. A sharp dissection in endomeu·io-
sis and PIO can avoid laceration. The surgeon should be
careful while using cautery or laser dur·ing laparoscopic
surger)'.
KEY POINTS
• Most gen it.al tract injuries originate from an obstetric
caLLSe. Difficult vaginal instrumental-assisted dlild-
birtl1 can catLSe traumatic injuries.
• Coital it1iuries may caLLSe alarming haemorrhage.
Se-.ere lacerations and penetrating injut) enter·ing t.he
pouch of Douglas require emergenC) surgical auen-
tion.
• In )Oung girls with perineal vaginal it')jUl)', alwa)S keep
a possibili t.y of sexual offence (rape) in mind. Follow
t11e steps outlined for examination of a rape victim.
• Vulval haemawmas: Small hae matomas ma)' be ob-
served. Large haematomas need s urgical evac uati on.
• Foreign bodies in t11 e vagina cause inAamma tion and
ulceration and rare I)' lead LOa fistu la format.ion.
• Chemical burns generally occur due to use of corro-
si'e substances. SLrictLtres ma) follow as a sequelae.
Laser burn is now tl1e common cause of a vaginal
burn.
• Old, healed perineal tears cause faecal incontinence.
Timely detection and surgical con·ection prevem
morbidit.y.
• Cer·vical Lear may cause incompetent os and repeated
pregnancy losses. Cervical sten osis can ca use haema-
tomeu-a or infertili t.y.
• Uterine rupture occ urs during labour and ca r1'ies a
high morbid iL)' and risk of maternal rnortaliL)'·
406 SHAW'S TEXTBOOK Of GYNAECOLOGY
• Bowel injut·ies are observed in 0.3%-0.8% of g) naeco-
logical cases.
• Anal canal and rect.al injuries are mostly obsteu·ical,
inflicted during a difficult or opet-ative vaginal deliv·
e t)'. It is mrely encountered dudng an opera tion on
the posterior vaginal wall.
• Intestina l and rectal iruuri es can occur during
co logica l ope ra tions on PLD and endometriosis cases,
when ex tensive pelvic adhesions have to be d issec ted.
• Intestina l iruuries are increasing ly reported fo llowing
laparoscopic surgery when cauter) or laser are used.
• H)Steroscopic utedne perfomLion leading to intesti-
nal burn and petiLOniLis is reported witlt
e ndo meuial resection and excision o f the utet·ine
se ptum.
• The endoscop ic burn injuries are, however, not im-
m e diately recognized and symptoms may develop
5-7 days later.
• Trcaunent of intestinal injury is s urgical suturin g or
resection a nd end-to-end anastomos is. Bowel injury
may re qu ire proximal co lostom)'·
• The he lp of the genera l or gastrointestina l s urgeon
sho uld be so ught in major bowe l injury.
• Obste uic trauma during vaginal deli,er) with immedi-
ate diagnosis and surgical repair can pre,ent or mini-
miLe the disu·essful symptom of faecal incontinence.
SELF-ASSESSMENT
I. Describe t11e common types of pelvic floor injUiies en-
counte red in practice.
2. I low wo uld you manage a case of vu lva l hae matoma?
3. How wo uld yo u manage a case of co mp le te perineal tear?
4. Desc ribe the causes and manage me nt o f c hemical burns
o f t11e vagina.
5. Desc ribe Lit e practice of genital mutila tio n. What compli-
cations may follow this proce dure?
6. Describe the o utcome of long-retain ed foreign bodies in
Lite vagina of children.
7. Describe Lite genital irtiuries following coitus.
8. How would you manage a pati ent of faecal incontinence?
9. How would yo u manage a patie nt witlt a reetovaginal
fislllla?
10. \<\That a re the common causes of bowel injut)' dllling
obste u·ic/gynaecologic surgery? How would )OU recog-
nit.e the sam e? What precautiot1S he lp to avoid intesti-
nal injuries?
ll . What arc Lit e ca uses of intestinal injury during laparos-
copy? I low wo uld you safeguard aga inst the sa me?
12. £numerate the s itua tions leading to bowel inj ut)' in
obstetric pmctice.
SUGGESTED READING
Bo)d ME. l:bter Rll , cLean fH, ct a!. Ob>tet Crnecol
1986: 68: 779-86.
llandl VL. llarri> TA, Ostergard TR. ProtL>cting the pehic floor: 01>-
s.teuic m.uugement tO pre\'ent incontinence:: ..uul pel\ ic ofbran pnr
lap>e. Ol»tet Cpwcol 1996; BB: 47(}...78.
Leung AS, fanner R.\f, Leung EK, et al. Ri.>k factors associated "ith
uterine rupture during I rial of labour afh:r delivery: A case
control st udy. Am.J ObSif:t Gynecol 1993; 168: 13!\8-63.
Pokorn y SF. Long-term intr.tvaginal presence of foreign bodit"> in chil·
A prelimin ary siUd y.J Reprod Med 1994; !\9: 931-35.
Robcruon I' A, Laros RKJr., Zhao RL. Neonatal mate mal Ot.llcorne
in IOI•'pclvic and midpclvk oper.1th'e dcli,·cries. Am .J Obstct Gynccol
1880; 162: 14!\f>-42.
Smith NC, Van Coc,·erde n d e Groot JIA, Gun.>ton KO. Coital ityurie;;
of the \".tgina in nomirginal paticnl.>. S Afr J.ft'<l J 1983; 64 ( 19) :
74&-47.
Bims lmtd\erten t instmmemal perfor.ttion of the colon during
laparO>Copy. repair. GaslJ'Ointe>t Endo.c 1989; 35:
54-56.
Krebs liB. Intestinal hyury in gynecologic surgery. A ten }ear experi·
ence. Am j OI>Stet Cynecoll985; 155:509.
'icholl.> 0 11 (ed). Oinkal Problems, Injurie• an d Complicativns of
Gynecologic Surgery Baltimore, Williams & Wilkins, 1983.
Pasnlka PS, Bistrian BR, Benou.i PN, ct al. 1l1e rbks ofsul){ery in obese
patients. Ann lnt Mcd 1986; 104: 540.
Reich I I. Laparoscopic bowel injury. Surg Laparosc En dose 1992; 2:
74-78.
RU»ell TR. Gallaghar Low rect.ovaginal fistula. Am .J Surg 1977;
134: 13.
Schaefer G, Graber EA (eds) . Complication• in ob>tctric and grneccr
logic •urge'). I lagersiO\\n, llarper & Row, Publishers, 1981.
Shellj ll Jr, RCJr. Small bowel inju') after laparo.copic steriliza-
tion. Am J Ob>tet Crnecol 1973; 115: 285.
Thomp:.on 811, Wheeless C RJr. Gastrointestinal complications oflapa·
roSCOJ>)' >terilil.ation. Obstet C tnecol 1973:41:669-76.
Whedc» CR. Thennal gastroin testinal In Phillips (ed) .
LaparO>COJ>)', Bahomore, Williams & Wilkin;. 1977,231-35.
 GYNAECOLOGICAL
MALIGNANCIES

33 Preinvasive and Invasive Carcinoma 37 Vulval and Vaginal Cancer

of Cervix
34 Cancer of the Body of the Uterus
35 Pathology of Ovarian Tumours
and Benign Ovarian Tumours
36 Ovarian Malignancies
38 Gestational Trophoblastic Diseases
39 Radiation Therapy, Chemotherapy
and Palliative Care for Gynaecological
Cancers

407
 Preinvasive and Invasive
Carcinoma of Cervix

Epidemiology 408 Carcinoma in Pregnancy 429

Cervical lnlroepilheliol Neoplasia (ON) 409 Endocervical Adenocarcinoma of Cervix 430
Cryosurgery 4 18 Key Points 430
Invasive Cancer of the Cervix 420 Self-Assessment 431

Carcinoma of tl1e is t11e t11ird most common cancer

among women worlcl"1dc and is now awibutable LO infection Tabl e 33.1 Predisposing Factors for Cancer
human (HPV). it is the most of the Cervix
common genital cancer among wo men in Ind ia. In certain parts • Coitus before the age of 18 years
of tl1e COLUlU")', it remains even more common than carcinoma • Multiple sexual partners
breast; however, in most oftJ1e large meu'Opoli tan cities in India, • Delivery of the first baby before the age of 20 years
it now ranks second to carcinoma of tl1e breast amongst cancers Multiparity with poor spacing between pregnancies
in women. The median age at diagnosis is 48 years, and Poor personal hygiene
tl1e majorit) of cases are diagnosed betwee n 35 and 55 years. Sexually transmitted diseases
1l1e universal application of Pap smears in Western communi- Poor socioeconomic status
ties has led to a drastic decline in t11 e number of invasive Circumcision: ExposU'e to smegma from uncircumcised p..-1·
cancers of th e cervi x and a higher detection o f preinvasive ners was considered an Important factor, accounting for tower
incidence of cancer of the cervix; now It Is realized that the inci·
lesions. Howe, er, tl1is has not happened in India because of
dence of human papillomavirus (HPV) is low in circumcised men,
lack o f uni,•ersal screening; a chive agai11SL this preventable and that is the reason for tow Incidence of cancer in their wives
cancer must continue to keep tl1e d isease under control. Smoking and drug abuse, including alcohol
Every year 530,000 new cases and 275,000 deatl1s are re- \Nomen with STD, HIV infection, herpes simplex virus 2 infection
poned annuall y worldwide. In India alone, 130,000 new Immunosuppressed individuals (following transplant surgery),
cases occur witl1 a dea tlltoll of 70,000 cases every year. Can- viral infections and HIV
cer of tl1 e cer vix accounts for 15% of all ca ncers in women. \Nomen with preinvasive lesions of cervix
Prevalence I-ate is 2.3 milli on annual ly globally. In India, • \Nomen who never had screening for cancer cervix
it is 13-24 lakh per year and at diagnosis more tl1an 75% are • Use of oral contraceptive pills
in tl1e adva need stages.
- - Cervical intraepithelial neoplasia
- - Invasive cervical carcinoma
EPIDEMIOLOGY (Table 33.1 )

T here are man)' conditiOI1S wh ich predispose a woman to

development ce rvi cal ca nccc Most im portan Lamong these is
earl)' age at start of sexual ac tivit)'· Multi ple sex parUlers, low
socio-economic st.alllS, m ulti parit)', sexua lly transm itted dis-
eases and poo r pe rsonal hygiene are some of these factors.
Average age of development of cancer cervix is 35-45 years
in India. However, disease can be seen any time between 21-
65 years of age. The precancero us lesio n of cervix usually oc·
mrs I0-15 years earlie r. There is a pe1iod of 10 years or larger 16-20 26-30 36-40 46-00 5fHIO 66-70 7fHIO
whe n a precancerous lesion can p1'0gress LO imasive cancer. Age (years)
ow a definiti\ e relationship has bee n established between Figure 33.1 Al;}e incidence of cervical carcinoma in situ and invasive
HPV infection and developmem of cancer ce rvix. (Fig. 33.1 ). cervical carcinoma.

\iew the k-cturc noJe> :.can th e >pnbol or log in to rour accoun t o n

408
 CHAPTER 33 - PREINVASIVE AND INVASIVE CARCINOMA OF CERVIX 409

SQUAMOCOLUMNAR JUNCTION
Table 33.2 Course of CIN Disease
Most cancers of cervix begin in the region ofsq uamocolum-
nar junction. This junction has a variable position on cervix Regression Persist ence Prog ression
dLLring long life phase of a woman. (%) (%) (%) Years
CIN-1 80-90 1(}-20 1-4 2-10
ORIGINAL SQUAMOCOLUMNAR JUNCTION CIN-11 30-40 40 20 1-5
• IL is a junction in between the columnar epitheliwn of CIN-111 2(}-30 50-60 Almost all 6m-2yrs
the endocen·ical canal and the su-atifiecl squamous epi-
theliwn of eClocer,•ix.
• The position of the original squamocolomnar junction
replaced b)' cells showing varying degrees of dysplasia;
determines the extent of cervical squamous metaplasia
however, the basement membrane is intact. D)'splasia rep-
resents a change in which there is an alteration of cell
NEW SQUAMOCOLUMNAR JUNCTION mor·phology and disorderly an-angemen t of tl1e cells of the
su-atified squamous epithelium. The cells vary in size,
• Witl1 increased oesu·ogen secretion following p uberty,
shape and polarity. There is a n alteration in the nuclear
eversion of e ndoce rv ical columnar epithelium occ urs
cytoplasmi c ratio, and the cells reveal large, irregular, h y-
onto ec tocer"\•ix; this evened columnar epit11elium be-
perchromatic nuc lei with marginal conde nsa tio n of chro-
comes metaplas ti c beca use of vaginal acidity. matin ma teri a l and mitotic figures. Some of these lesions
• T his new j unctio n between t11 e squamous metaplastic
progress witl1 Lime a nd ul timate ly e nd up as frank invasive
epitl1elium and the endoce n•ical columnar epithelium is
cancers. While 4 % nmch tiU! inva5ive stoge iJy the end of 1 year
called new squamocolumnarjun cti on.
and 11 % by the end of 3 ;•ear:,; a.-, much flS 22% become invasive
by 5 yea/"$ mul 30% II)• 10 year:, (Table 33.2).
THE TRANSFORMATION ZONE
lt is t11e area be tween the original and the new sqt!amoco- DYSPLASIA (Figs 33.2-33.9)
lumnarjunction. Cervical almost invariably origi· Dysplasias are graded as fo llows:
nates witl1in t11e u-ansformation zone. → LSIL
I. Mild dysplasia (CIN-1): The undifferentiated cells are
confined to the lower o ne-third of the epithelium. The
CERVICAL INTRAEPITHELIAL NEOPLASIA cells are more differentiated tOwards t11e surface. Mild
(CIN) dysplasia is often due to infectio ns such as HPV infec-
tion, Trichomona:. vaginitis. Cl -1 is lately descr;bed
Before actual developmem of ca ncer cenix, there are as low-grade squamous inu-aepithelial lesions (l.SlL)
changes in the epithelium in the region of transformation according to t11e Bethesda classification. 'ASCUS' is
wne; these changes can be picked up on cytology. These a term descdbed in the Bethesda system as atypical
changes ha'e been named cervical dysplasia, cervical in- squamous cells of undetermined significance. The
u-aepithelial n eoplasia (CIN) and lately as squamous in- intermediate cells mostly display mild d)Splasia with
u-aepitheliallesions. Cen•ical dysplasia is a cytOlogical ter·m enlarged nuclei and irregular outline. One per cent
used to descdbe cells resembli ng ca ncer cells. CLN refers progress to ca ncer over the years.
to t11e histopat110logical description in which a part or 2. Moderate (CIN-11): Undifferentiated cells oc-
t11 e full thickness of the stratified sq uamous epithelium is cupy the lower 50%-75% of t11 e epitl1elial tl1i ckness.

Invasive squamous cell carcinoma

Mild dysplasia Severe dysplasia

Modemle dysplasia Carcinoma in situ Adenocarcinoma

A B c
Rgure 33.2 Dysplaslas. (A) Mild and moderate dysplasias. (B) Severe dysplasia and carcinoma In situ. (C) Invasive cell - carcinoma and
adenocarcinoma
41 0 SHAW'S TEXTBOOK OF GYNAECOLOGY
Rgure 33.3 CIN -111: cervical smear showing cell s with ooarse chro-
matin and increased nuclear to cytoplasmic ratio. (Courtesy: Dr Sand-
eep Mathur, AIIMS.)
Figure 33.4 Cervical lntraepithelial neoplasia 1 (mild dysplasia).
Atypical cells are present In the lower one-third of t he epithelium (H&E
stain, X250). (Source: Vljaya Reddy, Paolo Gattuso, Odile Dal.id Daniel
Spitz, Meryl Haber. Differential DiagnOSis in Surgical Pathology, Female
Reproductive System. Saunders, 2010.)
T he cells are mostJy in termed ia te with moderate nu -
clear en largement, hyperc hromasia, irregular chro ma-
Lin and multiple nucleation. T hirL)' per cem of CIN-ll
regress, 40% persist and the res t progress to in vasive
cancer.
3. Severe dysplasia and carcinoma in (CIN-lll): ln this
grade of dysplasia, tJ1e entire thickness of tJ1e epithelium
is replaced by abnormal cells. There is no cornification
and stratification is lost. The basement membrane, how-
ever. is intaCL and tJ1ere is no stromal infiltration. Often,
an abrupt change in histological appearance from nor-
mal to abnonnal is apparem (Figs 33.2-33.7). O n cytOl-
ogy, cells are mostJy parabasal witJ1 increased nuclear-
cytoplasmic ratio. The nuclei are irregular, coarse
chromatin matel"ial; mitosis and multinucleation are
Figure 33.5 Cervical intraeplthellal neoplasia 3 (severe dysplasia, car-
c inoma in situ). There Is a lack of squamous maturation t hro ughout the
thickness of the epithelium. Almost all the cells have enlarged nuclei with
granular chromatin. Note that the basement membrane Is Intact, show-
ing that this process Is oonflned to the epithelial layer only. (Source: Vijaya
Reddy, Pado Gattuso, Odile David Daniel Spitz, Meryl Haber. Differential
Diagnosis in Surgcal Pathology. Female Reproductive Saunders,
2010.)
Rgure 33.6 CIN -1: cervical smear showing nucleomegaly and
mil d hyperchromasla w it h perinuclear c learing (kollocytlc change).
(Courtesy: Dr Sandeep Mathur, AllMS.)
common. A great m;Uotity of these lesions progress to
invasive cancer.
4. High-grade squamous intmepithelial (HSIL): ClN-ll
and ClN-111 are described as HSI L acco rding to the latest
Betl1esda classification. HSIL have a propensity to prog-
ress and become invasive, a nd tJ1erefore need investiga-
tions and treatment.
The tenn 'CIN' denotes a continuum of disorders from mild
through moderate to se,ere d)splasia and carcinoma in situ.
Mild is often seen "itl1 inflammatory conditions sucl1
as uicl1omoniasis and I-IPV, and is reversible follo"ing u-eat-
mem, whereas tllesevere 'a•·ieties progress tO imasive cancer in
aboutl0%-30% of cases in 5-10 years' time. This
time may be shorter in immunocompromised persons.
 CHAPTER 33 - PREINVASIVE AND INVASIVE CARCINOMA OF CERVIX
• Table 33.3 Pap Smear Screening (www.health.ny.gov.)
• A ge Group
A tive cytologic tests or two consecutive
, •
;
.·• ..
•.
:
..
r
• '
..
. l
..•B
.. ..J· •
,. I 1
.. . .
•
Rgure 33.7 (A) Cervical cytology smear In CIN. This cytology prepa-
ration shows a clump of cervical epithelial cells demonstrating moder·
ate and severe clyskaryosis. (B) Cervical squamous dysplasia, Pap
smeo:w 4So!Jn:;e (A). From Agure 1g 10. Alan Stevens, James Lowe and
1<11 Scott: Core Pathology, 3rd Ed Bsevier, 2009. Source (B): From
FIQire 13-25. Edwa-d C Klan Robbins and Cotran Atlas of Pathology,
2nd Ed. Saunders: Bsevier, 2010.)
A number of studi es in Indi a including Indian Council
of Medical Resea rch ( ICMR) have reponed the incidence
of cervical dysplasia to be 15: I 000 women among cytologi·
call y sc reened wo men. The incidence of severe dysplasia is
reponed to be abo ut 5: I000.
Koilocytes. These cells a re often seen in yo ung women
suffering from IIPV infec ti on, and a re cells with perinuclear
halo in the cyto plasm. Ko ilocytes disappear as dysplas ia
advances.
DIAGNOSIS
Diagnosis of ce rvical d)•Splasia is mainly based on cyto logi-
cal screening o f the po pulatio n. The peak inc idence of
occurre nce o f dysplasias appears to be I 0 yea rs earlier than
tl1at of frank invasive ca nce r. Ma ny of tl1ese wo men are as-
)'lnpto matic. Some wome n co mplain o f postco ital bleeding
or discharge. On ins pection , th e cervix ofte n appears no r-
ma l. or tl1 ere ma) be ce r. icitis or an e rosion whid1 bleeds
on to uch. So me wo me n present with posune nopausal
bleeding.
The guide lines fo r sc•·eening wo men for \aJ)'
fro m counu1• to counU) '· The cu.-rent!)• followed guidelines in
tile USA are gh en in t11e subsequ em text ( !able 33.3).
411
Scree nin g Recomme ndat ions
< 21 years Do not screen
21 - 29 years Perform cytologic testing alone every
3 yeo:ws
30..65 years Perform cytologic and HPV co-testing every
5 yeo:ws (preferred), or perform cytologic
testing alone f!lolery 3 years (acceptable)
> 65 years Discontinue screening if there has been an
adequate number of negative screening
previously (three consecutive nega·
negative co-tests in the past 10 years,
w ith t he most recent test In t he past
5 years) and if t here Is no history of HSIL,
adenocarcinoma. In situ, or cancer
Women who Discontinue screening If the patient has
have undergone undergone a total hysterectomy with re -
hysterectomy moval of cervix and If there Is history of
HSIL, adenocarcinoma In situ, or cancer
Cytological Screening for Concer Cervix
DNA study. Diploid o r pol)oploid nucle us is no rmal. Aneu-
plo idy is a hallmark o f malign ant po te ntial a nd mandates
treaunent.
Cyto log) alo ne does not indicate which abno nnal cells
will progress to ca ncer. Furt11er testS are required. Useful-
ness o f Pap smear in t11 e scree ning programme fo r ca ncer
ce r.i x is shown b) til e fo llowing:
• Long latent peliod of 10-15 )Cars between tile diagnosis
of ClN and invash·e can ce r allows adequa te treatment of
ClN and pre venti on of invasive cancer.
• Screening progra mmes based on cytOi og)• have proved
successful in reduci ng the inciden ce of invasive cancer by
80% and itS mon ality by 60% in developed countries.
Because of 15%-30% false-negati ve reponing, it is pru-
dent to repea t Pap smea r annuall y for 3 consec utive
years. !fit continues to remain negative, the Pap smear is
repeated 3- to 5-yea rly up to the age of 50 years. After
50 >•ears, tl1e incidence ofCIN drops to l %. T he presence
of endoce rvical cells in the smear ind icates a sa tisfactOI) '
smea.: A false-nega tive report is because of improper
technique in smea rtaking (no t through 360°), d•)' vagina
and poor shedding o f cervical cells or recession of sq ua-
mocolumnar junctio n in e ndoce rvical canal in meno-
pausal wo men.
High-grade squamous intraepithelial lesion . The pres-
e nce of high-grade squa mo us in traepitl1elial neoplastic cells
is sign ificant as these have the potential tO progress to inva-
sive cance r a nd need to be treated .
Sensitivit) of Pap smear for HSIL is 70%-80% and specific-
ity 95%-98%. While false-positive smear may lead to LUmeces-
sa•1' investigations a nd u·eaune nt, false-negative re po n.ing
is mo re o minous as cance r lesion ma)• be missed. Pap smear
in pos un enopausa l women is inaccurate a nd often negative
41 2 SHAW'S TEXTBOOK OF GYNAECOLOGY
on accoum of indrawi ng of sq uamocolu mnarj unction, dry
vagina and poor exfoliation of cells. This can be improved
by administration of oestrogen cream/oral oestrogen daily
for 7-10 da)S. To reduce the incidence of false-negative
reporting. the following procedures are added to Pap
screening:
• Endocervicxrf sa-ape cytology by endocervical bniSh or ruret-
tage: £ndocer"ical scrape should be obtained first
Pipelle/couon swab followed by smear to
avoid the Iauer from air dq ing.
• Incorporating HPV testing by hybridization or polymerase
chain reaction in young women: This improves the predic-
tive value of Pap smear to 95% and reduces the number
of refen<1ls for colposcopic evaluation. A young woman
with 1-IPV infection should be followed up with Pap
smear. Incidentall y, it is observed that the prevalence of
1-IPV-positive cases drops with advancing age (regression)
or is u·ansient, but in pe1-siste nt HPV infec tio n, the inci-
dence of I-lSIL rises after the age of30 yea rs. T he specific-
ity of Pap smear in HPV-infec ted cases is the refore low in
yo tm g women.
C)' to log)' witl1 added II PV testin g helps to u·iage ASCUS
and CIN cells.
• Liquid-based cytvlogy: He re t11 e smeared plastic (not
wooden) fJlaced in a liquid fixative (buffered
methano l solution) instead of smearing on a slide. This
removes the blood, mucus and inflammatOry cells. The
suspended cells are then gently sucked ontO a filter
membrane and the filter is pressed o mo a glass slide tO
fonn a thin monola)er, and then it is stained. The liquid
can also be emplO)ed to test 1-1 PV infection, making it a
cost-effecti'e technique. The cells wash off the plastic
de\'ice more than the wooden one, and the fixation solu-
tion contains haemOI) Lie and mucOI)tic agentS. This im-
proves specificity and sensiti' ity of the test. Besides HPV
testing, the liquid can a lso be used for genetic sLUdy and
repeat cytology if required. Disadvantages are increased
cost, need of u-ained personnel and transportation and
storage of so many via ls.
• Automated computerized image It eliminates 25%
of most li kely negative smear'S and 75% are selected for
cytotechnician screening.
CytOlogy alone does not give a clue as to which abnormal
cell will progress to in vasive and a neuploidy
whi ch suggests tJ1 e ris k of progression is not ro utinely
performed, so it is necessa ry LO subm it all women with
HSIL C)'to log)' for colposcopic study and biopsy of sus-
picious lesions.
• Vil1tal impection of at'etowhite m'f!as (VIA): Beca use of lack
of C)'tology-based screen ing universally and lack of11·ained
manpower capable of reading cytology smears, a newer
technique of screening called VIA has been advocated in
India and other low-reso urce co unu·ies. In tl1is tech-
nique. after exposure of cervix during spec uh.un exami-
nation. cervix is painted witl1 3/5% acetic acid. Areas
which tum white after applica1ion of acetic acid for
I minute are suspicious areas and need evaluation by bi-
ops)/colposcop). VIA has been widely investigated and
as a pote ntial a ltemative to cp.ology in low-
resource settings. Whe1·e t11e facilities for Pap screening
do not exist, VIA is able to select abnonnal areas on the
cervix by applying 5% acetic ac id (downstaging) -acetic
acid dehydrates tl1e abnormal areas containing increased
nuclear material and protein which wrn acetOwhite. The
nonnal cells which contain glycogen remain normal. Al-
though this has low specificit) and high false-positive
mtes, false-negative, which reall) matters, is seen in only
0.9% of cases. The abnormal areas are biopsied. Instead
of acetic acid, Schiller's iodine can also be employed.
• ViStwf inspection with Lugof's iodine ( VIU ): In tllis method,
cervix is paimed witl1 Lugol's iodine. onnal cells contain-
ing gl)cogen take up iodine and lllrn mahogany brown,
whereas abnonnal al'ea remains unstained. Dull white
plaques witl1 faint borde1'S are considered LS IL and tl10se
witll sharp borders and thick plaques contain 1-ISIL
• Sre and troot approach : VIA is a reliable, sensitive and cost-
effective alternative to cytology in low-resource seuings.
'See and biopsy' in one siuing is possible witl1 VIA and
VILJ. Abnormal areas may be ca ute rized (o r cryotherapy)
in the same sitting. Altho ugh it may prove 'overtreat-
me m', as a considera ble numbe r of women may have
benign lesions, this is feasible and co nve nient in rural
a nd peripheral set-ups whe re follow-up visits by patients
are low.
OTHER SCREENING TECHNIQUES
Speculoscopy. It uses a specia l disposab le, low-in tensity,
blue-white magnifYing device or Io upe. This has not
proved effective a nd more false-positive cases are unnec-
essarily referred for colposcopic study.
Spectroscopy. Ce1vical impedance or fluorescence spec-
troscopy is specific and sensitive, and provides instam
reSLLlts Lmlike Pap smears. It is a noninvasive technique
which probes the tissue morphology and biochemical
composition.
Magnoscope has a magnif)ing lens as a built-in source. It
magnifies cells fi,e Limes and enables ' 'isualiation of
punctuation and mosaics. It is portable and useful in rm-al
areas. It has been introduced by ICMR as Magnivisualizer.
Microspectrophotomeu-y is also able to distinguish be-
tween benign and malignant cells.
Colposcopy
T his tec hnique was introd uced in 1936 by Heinselman as a
tec hnique LO visualize t11e surface of ce rvix. Currentl y this
has co me LO occ upy an impo rtant step in the d iagnosis of
preinvasive lesions of ce rvix.
T he aims of colposcop)' a re as follows (Figs 33.8-33. 11) :
• To s tud)' tl1 e cervix when Pap smea r abnorma l
cells
• To locate abnormal areas a nd take a biopsy
• To study the ex tent of ab n0 11nal lesio n
• Conservative surgery under colposcopic guidance
• Follow-up of conservative t11erapy cases
ColposcoP> reduces the false-positive findings. In ASCUS
cases, it is Lt.Sed as a triage to rule out high-grade lesio n. Ab-
nonnal areas appear under colposcop) as acewwhite areas,
mosaics, puncwation and abnonnal ' 'essels (Fig. 33.120).
While Pap smear detects abnonna l cells, colposcopy
locates me abnormal lesion.
 CHAPTER 33 - PREINVASIVE AND INVASIVE CARCINOMA OF CERVIX
Rgure 33.8 Normal colposcopic picture of the transformation zone:
squamous epithelium (SE), columnar epit helium (CE) and squamoco-
lumnar junction (SCJ). From Agure 137-28. John L Pfenninger
and Grant C Fowler: Pfenninger and FoliiAer's Procedures for Primary
Care, 3rd Ed . Mosby: Elsevier, 2011 .)
Figure 33.9 Colposcopy showing aoetowhit e areas. (Souroe: From
137-4 E. John L Pfenninger and Grant C Fowler: Pfenninger and
Fowler's Procedures for Primary Gare, 3rd Ed. Mosby: Elsevier, 20 11 .)
Figure 33.10 Cervical polyp seen. From Rgure 137-40.
Jotn L Plenringer and Grant C FolMer: Pfennhger and Fowler's Pro-
cedures for Primary Care, 3rd Ed Mosby: Elsevier, 2011.)
41 3
Figure 33.11 Squamous metaplasia of cervical transformation zone:
endocervical glands lined by a combination of columnar cells and
abrupt stratified squamous epithelium. (Courtesy: Dr Sandeep Mathur,
AllMS.)
Figure 33.12 Colposcopy showing CIN Ill Lesion
0 Scan to play Colposcopy
Colposcopic sw dy is challe nging in pos tm e nopa usal
wo rn en beca use of the fo llowing reasons: narrow vagina,
se ni le vaginiLis, sq uamocolumn ar j un cti o n indrawn
a nd no t visib le, and au·op ic ce rvix fl us h with vagina .
O es troge n crea m fo r 7- 10 days and 400 meg misop rosLOI
3-4 ho urs before colposco py expose the ecwcervix
better. Colposco p)' decides whe the r a small b iopsy or a
co ne biopsy is requ ired.
Cervicography
This tec hnique was desc ribed in 1990s wh e re a pho to·
graph o f cervix is taken a nd se nt fo r eva Iualio n. It is useful
whe n a colposcopist is not ava ilable fo r spo t evalua tio n.
A of th e e ntire e xte rnal os is take n with a
35-mm ca mera after applica tio n of 5% acetic ac id a nd
sem to the colposcopist fo•· selecting areas fo r bio psy. Be-
cause o f 50 % sp ecificity a nd sensitivity, this technique is
not cos t-effective.
 LLETZ
414 SHAW'S TEXTBOOK OF GYNAECOLOGY

Cone Biopsy
It is botl1 cUagnostic and therapeuuc. Whenever tl1e area of
abnormaUty is large, o r its inner margin has receded imo tl1e
cervical canal. tl1e squamocolumnarjuncuo n is not completely
visible o n colposcop), or there is discrepancy between cytology
and colposcop). a wide cone e xcisio n biopsy inclurung me
enure outer margin of tJ1e lesio n and tlle enure endocervical
lining is obtained using cold-knife tedmique w1der general
anaesthesia. A la•-ge loop excision of me u-ansfonnauon zone
(LLETZ) has become more popular man cone biopsy for ob-
taining biopsies from u-ansformauon Lone because of iLS ease
of doing; it is associated with less bleeding, low chances of
infecuon and faster healing, without scar fonnation.
Cone biopsy (Table :tt:l) can cause bleeding, infection,
cervical stenosis and incompetent os. However, it is also ··e-
quired if endocervical or microinvasive lesion is suspected.
AgNOR is a new molecular tumour marker wh ich stands
for sil ve•'stained nucleolar orga nizer regions; DNA is pres-
ent in dysp lastic cells. The)' appear as black dotS which in-
crease in numbe r but decrease in s ize with advanc ing dys-
p lasia. The lesions with low co unts often regress, whereas
tl1ose wi tl1 hi gh co unts progress and need u·eaunent. T his
test has been u·ied only in resea rch setungs.
HPV Testing
Witl1the knowledge that most cancer cervix occt.u· as a result
of HPV infec uo n, tl1ere has been a trend towarcls so·eening
for HPV infection. CurrenLiy most sc reening progmmmes for
cancer cervix in rich co tulu·ies use HPV tesung as a primary
screening metl1od or in co mbinauon with cyto logical screen-
ing. Most sexual!) active women acquire HPV infection
following first sexual e ncounter. Howeve r, in most women
this infecuo n clears, whereas SOo/'o-90% of HPV infections
are transitol") and self-l imited, and disappear ove r a pe•·iod of
18 montllS or so; o n I) IOo/'o-20% persist and fonn a higlHisk
group bC)oncl 30 >ears of age. lnco•·po•-ating HPV testing
in cytoiOg)' sc•·eening improves the predictive value, and re-
duces unnecessary colposcopy re ferral and overtreaunent,
butjustifies foll ow-up in persistent cases.
The H PV testing is done by either study of cells in liquid-
based cytology or endocervical secreti on and self-obtained
vaginal swa b. A combined HPV testing and Pap smear
yields 96% sensitivity as compared to onl y 60%-70% wim
Pap smear alone. Pol yme rase ch ain reaction, Southern blot
and hybrid capture tec hnique detect H PV DNA. Out of
these, hybrid caplltre tec hnique is the most commonly
used and is co mme rciall )' ava ilab le . The test may cost
Rs 800-1500 or mo re.
ionization knife ionization, laser
cryotherapy coagulation
, ,
layer ablation
TREATMENT OF CERVICAL DYSPLASIA$ AND CIN (Table 33.4;
Figs 33.130 - 33.19) LLETZ
LEEP
Treatmem of dysplas ia based on cyto logy or colposcopy
alone is not appropriate because of their false findings.

Table 33.4 Comparison of Different Methods of Treatment of Dysplasia and CIN

Laser Laser
Characteristics Cryotherapy Coagulation Ablation Conization Knife Conization LLETZ LEEP
Place OPO OT OPO OT OPOorOT OPD OPD
Anaesthesia Nil GA Ni I analgesia GA Local Local Local
instrument's oost Cheap, Cheap, Expensive Cheap, not Expensive, Cheap, Cheap,
and portability portable portable portable not portable portable portable
Risk ol equipment Nil Nil Yes Nil Yes Nil Nil
Complications Nil Bleeding risk Personnel Bleeding risk Personnel Nil Nil
during surgery

Depth of 4-6 mm 8-10 mm 7mm

destruction

Pain Nil Painful Slight Slight Nil Slight

Bleeding Nil + Nil Slight Slight
Sepsis Discharge + Nil Nil Slight Slight
Healing 6-8 weeks 6-8 weeks 4 weeks &-a weeks 4 weeks 4- 6weeks
Tissue for NA NA NA Available with Tissue Available Avai lable
histology excision methods available histology
Cure rate 90% 90% - 95% 90% - 97% 90%- 95% 90%- 95% 90%- 95% 90% - 95%
Pregnancy Nil Nil Nil Stenosis cervix , abor- Cervical
complications tion, premature labour, stenosis
cervical dystocia with
excisional mettocls
Postoperative Indrawn Indrawn Seen Visible with zone
transformation zone excisional method
GA, general anaestheSia, NA, not available.
 CHAPTER 33 - PREINVASIVE AND INVASIVE CARCINOMA OF CERVIX 41 5

All subcategories
(except atypical endometrial cells)

Colposcopy
Colpoecopy (with endocervical sampling) Endometrial and (Regardless of HPV status)
Endometrial samp•ng (<!35 yrs or at risk endocervical
of endometrial neoplasia)' sampling l
+ +
No Endometrial
Pathology
( NoCIN2,3 ) ( C IN2,3 )

'Includes unexplained vaginal bleeding

or chronic anovulation
[ Co,:,, l Manage as per
ASCCP guidelines
Manage as per
ASCCP guidelines

Figure 33.13A Women wit h Atypical Glandular Cells. Figure 33.138 Atypical squamous cells-H.

ASC-US on Cytology

Negative HPV positive HPV negative

Ro utine screening
(Cytology In 3 years)

Figure 33.13C Atypical squamous cells-US.

High-grade squamous lntraeplthellalleslon

OR
Immediate loop
Electrosurglcal Excision

• CIN 2+ Is found at colposcopy in 60"k. HSIL

• This Immediate excision for-
- those who are at risk for Joss to follow-up Manage as per Manage as per
- who have completed childbearing ASCCP guidelines ASCCP guidelines

Rgt..re 33.130 High-grade squamous intraepithelial lesion.

0 Scan to play HP\1 Testing
416 SHAW'S TEXTBOOK OF GYNAECOLOGY

LSIL wijh no HPV LSIL with positive

HPV testing

Cytology Negative and HPV

HPV Negative positive

Repeat Co-testing
at 3 years

Figure 33.13E Low-grade squamous intraepit heiiaiiesion.

Rgure 33.14 Cryot herapy probes with various s ize t ips. (Sotrce:
From Agu-e 2. Stephanie Long and Lawrence Leeman: Treatment
Q:>tions tor High-Grade SQuamous lntraepitheial Lesions. Obstetrics
and Gynecology Cinlcs, Vol 40(2): 291-3 16 , B seviEr", 20 13 .)

c
- Figure 33.16 8ectrodes (Utah Medical, Midvale, Ul) used for a
loop electroexcision procedure. The width of the excised tissue
specimens can range from 1.0 to 2 .0 em, and the specimen depth
can be adjusted by sliding the guard attached to the electrode shall
Following excision, the base of the cervix is often gently cauterized
D
with a ball electrode. (Soun::e: From FIQUre 28. 15. Q-etchen M Lertz,
Roger A Lobo, David M Gershenson, et al Comprehensive Gynecology,
6th Ed. Mosby: Elsevier, 2012.)
Rgure 33.15 (A) Keyes punch biopsy. (B) Cervical punch biopsy
forceps. (C) Iris scissors. (D) Tissue forceps. (Soun::e: From FIQUre 1A.
Pre-prcx:ed.lre. ProoeclJre Consuh 11\Jvar Bbpsy. Edtors: Michael L
Tuggy, Jorge Garda.)
 CHAPTER 33 - PREINVASIVE AND INVASIVE CARCINOMA OF CERVIX 41 7

Cervical
canal

Tissue
removed

Rgure 33.17 Conization tedlnlque. (A) Incision. (B) Removal of tissue. (Soun::e: From Rgure 134·3 John L Pfennnger Cl"ld Grant C Fowler:
Pfenringer and Fowler's Prooedures for Primary care, 3rd Ed. Mosby: Bsevier, 2011 .)

( Treatment of preinvasive lesions )

Local destructive Local excision Radical excision

• cauterization • Conization • Trachelectomy
• Cryosurgery with knife, • Hysterectomy
• Laser ablation laser, LLETZ, with removal of
LEEP, NETZ vaginal cuff If
needed

Figure 33.18 Treatment of preinvasive lesions.

Class IV ClassY
Moderate, severe lnvasiw
CIN II, Ill (HSIL) carcinoma
biopsy, treat
Repeat yearly for 3 years and Test for HPV and acoordlng to stage
Treat Infection and
then 3-5 yearly until 50 years repeat In 3 months follow-up yearly

Normal follow-up
as class 1
*
Persistent
Repeat smear
Colposcopy and biopsy
Normal Persistent
(treat as HSIL)

Conservative ablation
• Coagulation
*
Local excision
• Conization
Radical excision
• Conization
• Cryosurgery • Laser oonlzation • Trachelectomy
• Laser ablation • LLETZ • Hysterectomy with
• LEEP or without removal

*
• NETZ of vaginal cuff
Life long follow-up

Figu re 33.19 Management of CIN. *

Follow-up
*
Follow-up
418 SHAW'S TEXTBOOK OF GYNAECOLOGY
Table 33.5 Criteria for Conservative Methods
of Treatment for CIN- 1/111 (HSIL)
The entire lesion should be visible within the squamocolumnar
junction.
• There should be no m icroinvasion or macroinvaslon as proved
by hi stological study through biopsy.
• There should be No evidence of endocervical Involvement.
• Cytology and histology must correspond .
• In case of a young woman desirous of future child-bearing ,
conservative methods of treatment for CIN-111111 are followed.
A false-positive finding means unnecessa•) treaunem or
ove•·u·eaunem. As mentioned before, more se•·ious is fulse-
negative finding which undermines the u·eaunem and allows
invasive growth to occur. As much as 50% of persistent LSIL
(C IN·I) show HSIL (CfN-ll, Cl N-lll). Before resoning lO any
u·eatmem for cervical dysplasia/CLN, it is mandatory lO per·
fonn colposcopy and directed biopsy. This approach also
helps to n ile o ut invasive cance1:
Mild dysplasia (LSIL) is usuall)' because of infection 1Jy-
or so me other infections, which should be
u·eated and cytology follow-up done every 3-6 months.
Indications fOr colposcopy and treaunentofLSJ Lare as follows:
• Persistent LSlL (Cl -1) over I )ear
• Patient sho\\ing poor compliance
• LS IL showing HSIL on colposcopy or LS IL progressing to
HSIL during the follow-up.
Moderately severe to severe dysplasias (CIN-11 and CIN-lll)
The u·ea un e m op ti ons are th e following:
• Local dest1·uctive methods:
(i) Cryosurger)'
(ii) Fulguration/ e lectrocoagulation
(iii) Laser ablation
• Excision of ab1wrmal tissue:
(i) Cold-knife conization.
(ii) Laser conization,
(iii) Loop electrosw-gical excision procedure (LEEP)
(iv) Needle excision of transfonnation ( ETZ)
• Surgery:
(i) Therapeutic conization,
(ii) Hysterectomy
(iii) I Iysterectomy with removal of vaginal cuff if carci·
noma in situ extends to th e vaginal va ult
Criteria for conservative methods are provided in
Tab le
CRYOSURGERY
Cqosurge•)' was introduced by Townsend; it is suited for
small lesions. It is done as an OPD procedure without anal-
gesia. C•)'OSurgery is the best-tolerated technique, least
painful and ch eap.
MECHANISM OF ACTION
Ct)•osurge•)' refers to destruction of cells b)• CI) 'Stallization
of inu·acellular wate1: tec hnique over
9 minutes desu·oys the tissue up to 4-5 mm depth. It is done
as an OPD procedLU·e analgesia. (-60"C),
Freon (- 60°C) and nitrous oxide (-80°C) are the free.t:ing
agents. C02 is cheaper, but nitrous oxide has a more cooling
effect; hence, depth of penetration and destruction are
more. A small lesion can be dealt with in one stroke applied
for 3 minutes. A large lesion may require segments to be
treated p iecemeal. Application of aceti c ac id, Lugol's iodine
or preferably colposcopic view he lps to erad icate t.he entire
lesion in one sitting. The woman should abst.ain from inter-
course for 4 weeks. Repeat CI)'OSLLrgery can be clone 3 months
later if the ent.ire region is not previoLLSiy treated as seen b)'
C)'tOIOg) or other alternative method d1osen.
Disadvantages are as follows:
• ProftLSe discharge initially fora pe•·iod of7-10days
• lnclrawing of squamocolumnar junction making subse-
quent screening by colposcopy difficult
ELECTROCOAGULATION > 70°C 8-10mm
Elec trocoagulation uses temperature ove r 70°C and de-
su·o)'S the tissue up to 8-10 mm deep. The proced ure is
painful, so it is clone under general anaest.hesia.
Complications: These include recurrence, bleeding, sepsis,
cervical stenosis and indra,,ing of SCJ.
lASER ABLATION
Laser ablation boils, steams and explodes the cells. The la-
ser is very expensive and can be harmful to the personnel
(burn injury to the skin and eyes). It;_, m1 OPD fJrocrdnre done
nuder locol llll(IJ'Stlwsia and ttnder guid(lnfe. It de-
s u·oys tJ1 e tissue up LO 5 mm deep. Curren tJ )•, laser ablation
is not advocated as a method of treatm ent for HSIL. Laser
ablation is useful when the Cl N extends up to the vaginal
vaulL Laser causes minima l b leeding, no infectio n, no post-
laser scar formation and no deeper excision. More
tantly, laser does not caLLSe indrawal of squamocolumnar
junction and, tJ1erefore, repeat laser is possible for residual
lesion unlike cautery or cryosurge•)'· Recurrence of2o/o -8%
is reponed.
Excisional and Cone Biopsy
It provides tissue for histopathological study and can be
therapeutic but needs LO be carded out in an operation
theau·e under anaesthesia and may have risk of co mplica-
tions such as seconda•)' haemorrhage, ce rvical stenosis and
infec tions.
Punch Biopsy
If done under colposcopic view, it can remove tl1e en Lire
lesion. if small, and can be perfonned under sedation or
local anaest.hes ia.
diathermy
Large Loop Excision of the Transformation Zone
(LLETZ/LEEP)
It uses low-voltage diathermy under local anaesthesia. The
loop is adva nced intO the cervix lateral to tJ1e lesion until
the required dep tJ1 is reached. It is the n take n across lO t11 e
opposite side and a cone of tissue removed. A loop size of
less than 2 em gives a better cone t11an a la rger one. The low
cost of t11e eq ui pment and harmless effects o n personnel
 Immediate post menstrual phase
CHAPTER 33 - PREINVASIVE AND INVASIVE CARCINOMA OF CERVIX 41 9

make LLETZ more pop ular than lase t: Besides, it ta kes a
shoner time to perform with similar success and reetuTence
as t11at of laser.
With the availabilit) of LEEP, a simple and effective
method. laser seems to have taken a backseaL
ETZ removes cervical tissue in o ne piece.
All the excisional procedures sho uld be done in the im-
mediate posunenstrual phase, most of them under col-
poscopic view and under local anaestllesia; t11is reduces
incomplete excision to only 2%-3%.
Only 0.1 o/o-0.5% of cases of imoasive cancer are detected
during the follow-up of t11ese cases.
Excisionaltreatment may cause stenosis of the cervix, so
subsequem abortions and pretenn labour, ablation tllerapy
ma>' be beuer suited for roung women desi1ing future child-
birt11. Recun·en ce or persistent lesions in 2%-8% can be
avoided b)' appli cation of Schi lle r's iodine elu ting t11erapy.
Repeat cytology a nd follow-up is indicated after 3 months,
after heali ng of tJ1e ce rvix.
Conization
lt includes the entire o ute r margin (Fig. 33.20) and endo·
cervical li ning short of interna l os. A smaller cone is desir-
able in )'Otm g women to avoid risk of abortio n o r preterm
labo ur subseque ntJy. Complications are bleeding, sepsis,
cervical stenosis, abortion and preterm labo uc
Indications for conization
(i) ln e ndocervical drsplasia
(ii ) Wh en transformation :tone is not completely visu-
(iii ) When there is discrepancy in findings between
C)tOiog), colposcop) and biopsy
(iv) When microinvasion is suspected
Hysterectomy
Hysterectomy as a treaunent for HSIL is considered overu·eat-
ment; however, it still has a place in tJ1e following situations:
• Older and parous women
• When a woman ca nnot com pi) with tJ1 e follow-up
• lf uterus is associated with fibroids, DUB o r prolapse
• lf microinvasion exists
• lf recurt·ence follows conservative therap)' or persistem
lesion
• ln situ adenocarcinoma of t11e cervix
Follow-Up After Treatment of HSIL
Following conservative therapy, cytology is defet-recl for
3 months for inflammatory and regenerative changes tO set-
tJ e. ln some cases, the squamocolumnarjuncti o n may retract
wi tJ1in t11 e os- 5% of women progress to invasive cancer dur-
ing follow-up. Lifelong foll ow-up is therefore necessary.
Compli cati o ns of tJ1ese proced ures are charted in 'Htble 33.7
Choosing betwee n valio us modalities witJ1in tJ1e gro up of
conservati ve trea un en Lis a maue r of gynaecologist's prefer-
e nce, tJ1 e availabili q• of the eq uipm e nt a nd its cosL
GLANDULAR LESIONS OF CERVIX
Preinvas ive gland ular endocervical lesion, also known as
carcinoma - in situ endocervix , or cervical intraep ithe lial
glandular neoplasm (C ICN) -is now proved to exist, though
very rare. Many endocervical cance rs atise de novo witJ1o ut
passing t11rough tJ1e in silll stage. It exists as a low- or high-
grade lesion. ltma) a ppear anywhere a lo ng tJ1e endocervix,
but is mostJ) see n near the squamocolumnar junction.
lf the woman is )Ou ng, nulliparo us o r of low pariLy, HPV
infection and oral combined pills are probable causes of
this lesio n .

/'
.... -...'
I '
II 'I
I
I
I
I
I
I
I
I
I
I
(
1 I
I I
... )
A

Rg ure 33.20 Cone biopsy of the cervix. (A) Diag nostic conization performed when the squamocolumnar junction is not fully visualized
colposcopically. {B) Therapeutic conizat ion performed for disease involving the ectocervix and distal endocervical canal. (C) Loop electro-
surgical excision procedure. The goal of the procedure is to remove the cervical tissue above the squamocolumnar junction, including any
visible lesions. (Soutee: Hacker NF, Ganbone JC, Habel CJ: Hacker and Moore's Essentials of Obstetrics Gynecology, 5th ed. Philadephia:
Elsevier, 201 0.)

Monovalent
-
420 SHAW'S TEXTBOOK OF GYNAECOLOGY
It is difficu lt to pick up th e cells in ro utine cytology and
difficult to inte qlre L Similar!)', colposcopy may miss the le-
sion if it is located with in the cervical canal. Endocervical
brush or endoce1vical curette is required to detect this le-
sion. In a suspected case, when ce1vical cytology shows ab-
no•mal glandular cells, cone biOps) is required.
The lesion is best u·eated with e itJ1er cold-knife conizaLion
or hysterectOm). LLETZ can leave a residual tumour if the
lesion is located high up in the ce rvical canal. Follow-up is
necessa111 as residual tumour can grow into can-
cer. Conitation is applicable only in )Oung women after coun-
selling regarding recu1nnce. H)SterecLOmy is ideal ot11emise.
PREVENTION OF CANCER OF THE CERVIX
The success of sc1·eening progr·amme world over shows that
it is a preventable cancea: Effective screening by Pap smear,
VLA/ VILL and HPV testing ca n detect most of tl1 e lesions in
preinvasive stage and by appropriate acti o n in vasive cancer
can be avoided. Majority of ca ncer cervix are HPV related .
Fo 11.unately, I-IPV vacc ine is now ava ilable, altl1ough it is
expe nsive as of toda)'· Given to adolescents before exposure
to tl1e virus (before sex ual activity begins), a high p ro tec tion
rate is expected. Such a vaccine also protects against geni tal
warts. lnitiall)', three doses of HPV vaccine were advocated
at 0, 0.5 and 6 mon t11s blll da ta availab le s how that eve n two
doses of I-I PV vaccine offer protec tion rate. What is not
known is tl1e duration of imm unity and whetl1er booster
doses will be needed during t11 e reproductive periocl
PROPHYLACTIC HPV VACCINES
Gardasil is a quadrivalent vaccine against i-I PV 6, II , 16 and
18 to be gh en to adolescents at 0, 2 and 6 months intra-
muscularl) in the deltoid muscle.
16, 18 to be gi,en (0.5 mL) at 0, I and 6 montl1S.
Immunity is expected to last 10 years, and reimmuniza-
tion may be required. owaclays, a nonavalent vaccine (Gar-
clasil 9) has become a''llilable which covers I-I PV 6, ll, 16, 18,
31, 33, 45, 52, 58; t11ese types are responsible for 90% of cervi-
cal cancers, 82% of high-gra de anogenital precancerous
lesions and 90% of genital warts.
There is no n eed to test t11 e young woman for H PV infec-
tions if vaccine is given before the stan of sexual activity.
Reported Side Effects of Vaccine
• Local pain and swelling
• Dizziness, headache and lll)•a lgia
• Anap hylac ti c reac ti on
• Lymphadenopa tl1)'
If a pa tient is in the midd le of a vaccina tion course, when
she gets pregnant, all furt11er vaccinations sho uld be stopped
unti l after the de live I)'. Med ical te rm ination of pregnancy is
however not required. The woman can contin ue with re-
maining vaccination after delivery and to continue breast
feeding following vaccination.
HPV Vaccine for Males
The vaccine is also an applicable prophylaxis for male ado-
lescents.
Anotl1er pro p h) lax is is the use of ba1Tier conu-acepLives
to prevent u-a11Smission of ' 'i1-al infections and other sexu-
ally trai1Smitted infections from man to woman.
6,11 , 16,18 , 3433 45,52, 58
,
INVASIVE CANCER OF THE CERVIX
About 132.000 women develop invasive cancer every yea r
in India. In India, the incidence is 20-35/ 100,000 women
between 35 and 65 )Cars, whereas in developed countries,
where screening progmmmes are o n, t11e incidence of inva-
sive cancer of cen ix has fallen to 8/ 100,000 women. Ap-
proximately 7·1,000 women die of ca nce r cen·ix in india
eve!')' year. Cumulath e lifetime •·isk of development of can-
cer cervix is 2.5% among Indian women and cumulaLive
lifetime •·isk of dying from ca ncer cen •ix is 1.4% among
indian women. ln most cases, invasive disease is preceded by
a preinvasive lesion ofseve1-al rears' duration. Ce•·tain women
a1·e at a higher l"isk of development of cancer ce1vix. These
incl ude immunocompromised persons, stan of sexual acti v-
ity at an early age, multiple sex pa rt ners, poor genital
h ygiene, poverty and low socioeco no mi c Status, use of
ho 1monal con u·acep ti on and lack of access LO healtll facili ties.
2
PATHOLOGY ✗ Mpls)
Majority of the invasive cancers of ce rvix are sq uamous cell
carcinomas; howeve1; in 10%-20% of cases, these carcino-
mas are adenocarcinoma in histology. of the can-
cers stan from ectocervix b ut in 10%-20% of cases they may
be located in tl1e endoce1v ix. For a growth or lesion vis ib le
on ectoce1vix, cervical biopsy remains the metllOd of estaJ:>.
lishing diagnosis. Occasionally, a diagnosis may be made by
a Pap smear in case tll ere is no visible lesion on cervix but
the patient presenl.'l witl1 S)lnptoms of irregular vaginal
bleeding. In a Pap smear, invasive cancer shows tadpole
cells, fibres and malignant cells and haemorrl1age, and ne-
crosis in the background.
Common!) two t}pes of carcinoma of the cen·ix are seen;
first and mo•·e common \'lll·iety is the epidermoid carcinoma.
lt arises from tl1e stmtified squamous epithelium of the cer-
vix, and accounts for almost SO% of all cancers in the
The second \'lll·iety, endocen •ical carcinoma, arises from the
mucous memb1-an e of the endocervical canal, and accounts
for 20% of all cervical can cers. Histologically, 95% of cervical
cancers are squamous ca1·cinomas and only 5% are adeno-
carcinomas. T his is beca use t11e column ar epitheli um of
the endocervix often undergoes sq uamous metaplasia
(Figs33.2 l-33.2 1), before undergoing maligna nt change.
Incidence of endoce1v ical ca ncers of the ce rvix has re-
ce ntly increased beca use of prolonged use of oral comb ined
co ntraceptive pills and progestogen pi lls which have a pro-
found effect on gla nd ular epitl1eli um (Fig. 33.22).
HISTOLOGICAL CLASSIFICATION
• Squamous cell carcinoma
• Adenocarcinoma
• Adenosquamous carcinoma
• Clear cell carcinoma
• Rare t)pes such as ne uroendocrine carcinoma
Squamous cell cancers of the ectocervix appear as prolif-
emtive growths. ulcers or Oat indu1-ated areas. The common
prolifemtive or cauliOowel'like growth is vascular, friable
and bleecls on touch. It undergoes ulce 1-ation and necrosis,
which is associated witll an o ffe11Sive fo ul-smelling \'llginal
discharge. The mu coid discharge is often blood-stained.
 CHAPTER 33 - PREINVASIVE AND INVASIVE CARCINOMA OF CERVIX
Figure 33.21 (A) Keratinizing squamous cell carcinoma of cervix: nests
of atypical squamous cells infiltrating Into the stroma. Keratin pearls
are seen. (B) Carcinoma in- situ (GIN IIQ (Source: tor (B) Dr Sandeep
Mathur, AIIMS)
Rgure 33.22 Endocervical adenocarcinoma: tumour is composed of
malignant glands lined by columnar cells with moderate nuclear
pleomorphism and focal intra::ellular mucin. (Courtesy: Dr Sardeep
Mathur, AIIMS.)
Histologically, the tumour is graded as well-differenti ated
(showing epithelial pearl formation- see Fig. 33.2 1), mod·
e rately d iffere ntiated or poorly differe ntiated. A sq uamous
cell carcinoma of cervix us uall)' is non keratinizing b ut at
times can have keratin pearl formation.
421
Figure 33.23 Large fungating carcinoma of t he cervix In a case of
proci dentia.
Figure 33.24 Ulcerative carcinoma of cervix , the specimen was
removed by radical hysterectomy. Note also the parametrium and
2 em of vagina removed.
The endoce•v ical growth remains confined to the cervi-
cal canal for a long time causing a barrel-shaped enlarge-
ment of the ce•vix, a nd onl y at a late stage growth protrudes
beyond the external cervical os and become visible.
MODE OF SPREAD
ln initial stages, the cancer of cervix spreads by its co ntin ui ty
to acUoining su·uctures (involving the vagina, parameu·ium
and bod) of uterus); in advanced stages. it spreads to urinary
bladder and rectum. Lymphatic spread occurs to draining
I) mph nodes (parametrial nodes, obwrator, h) pogasuic and
rarely distam nodes). Vascular spread occurs in late stages to
distant sites such as lungs, liver, bones, kidneys and brain.
Ovmitm metoMa1·is occurs in only 1% in ctlM'l of lquamJHIS cell
wucer b11t. ()('(111') in 10% in cases of tUienowrrinmn(l of tervix.
CUNICAL FEATURES
Most patie nts with invasive cancer of cervix present with th e
complain ts o f irregular menses, menometro rrhagia, con-
tinuous bleeding, postcoital b leeding, leuco n·hoea and
422 SHAW'S TEXTBOOK OF GYNAECOLOGY

blood-stained or offensive discharge. It is not uncommon to

encounter disease in postmenopausal women where the
presenting spnptom is posunenopausal bleeding.
On per speculum examinatio n, ce rvix reveals a growt11
which bleeds o n toucll or a n ulcer with edges that bleed on
touch. On per vaginal examination , the uterus may appear
bLLiky becaLtse of p)Omeu-a in the advanced stage when the
cervix gets blocked b) growth. In lateral fomices indw-ation
is felt, and o n per rectal examination thickening of ULero-
sac•-al ligaments may be noted.
In all suspected cases, a biopsy is needed to confirm the
diagnosis.
Tissue biopsy in a case of frank invasive cancer reveals
loss of su-atification and cellular polarity; the cells show
alteration of mo•·phology, th e nuclear:cyLOplasmic 1-atio is
increased and th e tumour cells show hyperchromatism. Figure 33.26 Adenocarcinoma in situ. The superficial p arts of t he
Thickening of th e nuclea r mem b rane, cl ump ing of crypts are li ned by epit helium whi ch shows loss of polarity and nu-
the chromatin mate 1ial, pe netration of the underlying c lear atypi a (x 155). (Source: From: Haines & Taylor's Obstetrical and
base men t membran e and prese nce of the ca ncer cells in to Gynaecological Pathology, 3rd eel. Churcl'liU, 1987.)
the unde rlying s u·oma arc no ted (Figs 33.25 a nd 33.26).

DIFFERENTIAL DIAGNOSIS
T he cervical growth and ulcer may at ti mes be m istake n for
tuberc ular and S)'p hili tic ulcer, mucus and fibro id polyp an d
rare!)' sarcoma of the cervix. Biopsy helps in mli ng o ut
other conditions.
STAGING OF CANCER OF lHE CERVIX (Figs 33.27- 33.39;
Table 33.6)
Staging of cancer of cervix is based on revised FICO staging
given in >ear 2009. This staging is a clinical staging. For t11e
pw-pose of staging. a careful clinical e xamination of the pa-
tient including per vaginal examina tion, per •-ectal examina-
tion and a combined per rectal-per vaginal examination
is perfonned. Commonly done investigations include cl1est
X-ray, an ulu"3SQund of the abdomen and pelvis and liver and
kidney fw1ction test. Presence of h) dronephrosis makes a
clinical stage as stage Ill b. Use of newer imaging techniques
such as CT scan, MRJ and positron emission tomography
(PET) scan is not•·outinely recomm ended nor is the cli nical
stage changed based on results of these investigations.
Early invasive ca ncer of cervix (stage Ia) is diagnosed by
histological examination of biopsy. Depending o n the depth
of stromal invasion and hori:t.onta l exten t of the spread, the
d isease is fw·ther classified as SL<1ge Ia I o r stage Ja2. If the
invasion is less than 3 mrn in depth and than 5 m m in
horizontal sp•-ead, it is labe lled as stage Ia I. When me depth
of invasion is 3-5 mm and ho •izontal spread more t11an
5 mm, it is labelled as stage Ia2.
The surgical treatment and other modes of Lreaunem
depend on the exact clinical staging.
1l1e staging of in vasive carcino ma of t11e cervix is essen-
tially based on clinical findings (chest radiograph, fVP, cys-
toscopy and proctoscop) are permitted). BecaLLSe of wider
availability of CT and MRI, t11ese are now included in pre-
treatment stmtegy. MRI is mo re sens itive than clinical ex-
amination in d etecting parametrial involvement and re-
gional lymph n odes but FDG-PET is considered the gold
standard in the im estigatio n (see Chapter 40).
INCIDENCE OF LYMPH NODE METASTASIS IN CANCER
CERVIX
Both pelvic and para-aortic lymph nodes can be involved in
cancer ce1vix. Incide nce varies with t11e stage of t11e disease.

Superficial cells

lnlermediale cells

Parat:esal cell

A
Rgure 33.25 Histological appearance of (A) normal ceNical squamous epithelium and (B) carcinoma in situ of the ceNix. In the nom1al epi-
thelium , note the orderly maturation from the basal layer to the parabasal cells, glyoogenated intermediate cells and flattened superficial cells.
In the carcinoma in situ, the entire thickness of the epithelium is replaced by immature cells that are variable In size and shape and have
irregular nudei. Mitotic ligures are seen in the lower two-thirds of the epithelium. (SOtroe: Hacker NF, Gambone JC. Hobel CJ: Hacker and Moore's
Essentials of Obstetres and 5th ed. Pllladelphia: Elsevi=lr, 201 0.)
 CHAPTER 33 - PREINVASIVE AND INVASIVE CARCINOMA OF CERVIX 423

Figure 33.28 The distribution of pelvic nodes draining lymphatics

from the cervix. Lymph node of drainage of the cervix: (1) paracervi·
cal, (2) parametrial, (3) Internal Iliac, (4) obturator, (5) external iliac,
(6) presacral , (7) common lilac and (8) para-aortic.

Figure 33.29 Carcinoma of the cervix. Stage 1: ulcerative type.

Figure 33.27 (A) MRI showing noninvasive cervical carcinoma wit h

no parametrial Invasion. (B) MRI showing carcinoma of the cervix
with parametrial Invasion .
Figure 33.30 Carcinoma of the cervix. Stage 1: Infiltrating type.

ln th e presence of lymp hovascular invasion, the incidence

of lymph node meLastasis further increases.
Incidence of lymph node meLastasis in carcinoma of the
cervix

SLage lal Less 1J1an I%

Stage la2 2%-7%
Stage lbl 10%-15%
Stage Lb2 15%-35%
Stage ll 15%-25%
Stage lll 25%-40%
Stage LV 40%...{)5% Figure 33.31 Stage 1: cauliflower type.
424 SHAW'S TEXTBOOK OF GYNAECOLOGY

Figure 33.32 Stage 1: endocervical type. Figure 33.36 Stage lllb: infiltration of the parametrium. The vagina
is not involved.

Rgure 33.33 Stage lla: infiltration of the vagina. Figure 33.37 Carcinoma of the cerviX. Stage lllb: Infiltration of the
parametrium as far as the periosteum, but not through it.

Rgure 33.34 Stage lib: infiltration of the parametrium.

Agure 33.38 Carcinoma of the cerviX . Stage IVa: Infiltration Into the
rectum and bladder, together with bone metastases.

PARA-AORTIC LYMPH NODE METASTASIS

Pam-aortic nodes are infilu-ated in advanced cases (20% in
Stage II, 30% in Stage ill ). Ureteric obstruction occurs in
30% in Stage Ill and 50% in Stage fV. Hypercalcaemia indi-
cates bone metastasis.

Agure 33.35 Stage Ilib : infilt ration of the parametrium together wit h
DIAGNOSIS
the whole of the vagina Fixity of the parametrium by malignant inva- BiopS)' and histopathological evidence of in vasive malig-
sion Into the pelvic wall. nancy should precede any treatmem moda li ty. This may be
 CHAPTER 33 - PREINVASIVE AND INVASIVE CARCINOMA OF CERVIX 425

\ ..
..--", 4
I
••\a•
•
\
'.
from a suspicious growtJ1, edge o f an ulce r or colposcopy-
directed biopsy from suspicious a reas.
INVESTIGATIONS
Basic investigations include a haemogram, urinalysis, blood

.• :
\
sugar levels - both fasting and postprandial - liver function
tests, renal function tests and serum e lecu·ol)'les. ln advanced
:,:
.
: .. I

disease, LllU'asonograph). inu-ave nOLlS pyelography and cystos-

Stage 1 : copy should also be und e•take n. A •-adi og•-aph)' o f chest helps

..
Stage : • •
li B ,' e f
, LO exclude lung meLaStaSis. A C)'StOSCOP)' and proctoscopy

....
'
Stage
IIA :
/ .· .: may be required to assess th e invoh ement of the bladder and
rectum prior to finall y assigning tJ1e stage of the disease.
,' ,
/

.... ..··•..· ..
/ -·/ • CT allll MRJ are now empl oyed in routine investigations of

...
invasive cancer of the ce•v ix. \.Vhil e they detect lymph
• • • • •• • . /Pelvic wall node enlargement more than I em, multiplanar .MR! of-
.,. . . .... fers improved imaging in staging and in preu·eaunem as-
' sessment oftJ1e growth and its spread as compared LO CT.
Rgure 33.39 Staging of cancer cervix. (Source: From: Wilson et al. .MR! can ide ntify parametrial infiltration, b ut cannot
Textbook of Gynaeoology and Obstetrics. BICL.) always differe nti ate between inflamma tory fibrotic and

Table 33.6 Carc inoma of the Cervix Uteri - Staging (FIGO, 2009)

Stage 1 The carcinoma Is strictly confined to the cerviX (extension to the corpus would be disregarded)
lA Invasive carcinoma which can be diagnosed only by microscopy, with deepest invasion s 5 mm and largest exten -
sion ""-1 mm
IA1 Measured stromal invasion of s 3.0 mm in depth and extension of :S7.0 mm
IA2 Measured stromal invasion of > 3.0 mm and not > 5.0 mm with an extension of not > 7.0 mm
-----------------
depth of Invasion 35mm
16 Cli nically visible lesions limited to the cerviX uteri or preclinical canoer greater than Stage lA•
161 Clinically visible lesion s 4.0 em in the greatest dimension 22cm

2- 4cm
162 Clinically visible lesion > 4.0 em in the greatest dimension 1B3 > 4cm

Stage II Cervical carcinoma invooes beyond the uterus, but not to the pelvic wall or to the lower third of the

upper 43rd of vagina

IIA Without parametrial invasion
IIA1 Clinically visible lesion s 4.0 em in the greatest dimension
IIA2 Clinicall y visible lesion > 4 em in the greatest dimension
liB With obvious parametrial invasion
Stage Ill The tumour extends to the pelvic wall and/or involves lower third of vagina and/or causes hydronephrosis or non-
functioning ki dney" -4 Involves and / or LN
of pelvic
aortic
para "" "
IliA Tumour Involves lower third of the vagina, wit h no extension to the pelvic wall
/ -

pelvic LN
IIIB Extension to the pelvic wall and/or hydronephrosis or nonfunctioning kidney 111C -
pelvic / paragons, [µ
1111oz only
aortic
Stage IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or para
-

⑦
--------------
IVA
rectum . A bullous oedema, as such, does not permit a case to be allotted to Stage N
Spread of the growth to oojacent organs
-------------------
IVB Spread to distant organs

"All macroscopically visible lesions - even with superficial invasion - are allotted to Stage IB carcinomas. Invasion is limited to a mea-
sured stromal invasion with a maximal depth of 5.00 mm and a horizontal extension of not > 7.00 mm. Depth of invasion should not be
> 5.00 mm taken from the base of the epithelium of the original tissue - super1icial or glandular. The depth of invasion should always be
reported in millimetres, even in those cases with 'early (mini maO stromal invasion' (-1
b()n rectal examination, there is no cancer-red space between the tumour and the pelvic wall. All cases with hydronephrosis or nonfunc-
tioning kidney are included, unless they are known to be because of another cause.
Source: FIGO Qlidelnes.
426 SHAW'S TEXTBOOK OF GYNAECOLOGY
ma lignam infi ltration. Because of intestinal peristalsis,
para-aortic lymph nodes are not clearly visible on MRl.
MRI is safe during pregnancy, but CT is not so because of
radiation. A small lymph node less than I em cannot be
picked up b) Cr or MRI. It is imponamto emphasize that
Cr and MRI findings should not alter the clinical staging.
• PET. a noninvasive scan, detects tissue biochemical
changes and para-aortic node involvement, and maps the
area of concern. In PET scan, the whole body is scanned
for an a•·ea of increased uptake of radioactive tracer.
FDG-P£1' u.sing F-18j/twro-2-df'OX)>D-gf.ucose is useful in the
determination of p.-imary disease, lymph node detection
and local recun·ence detection. The test is based on the fact
that malignan ttissue exhibits greater glycolysis than normal
tissue, and FOG accumulates in th e malignam tissue result-
ing in increased tum ou r contrast. Whi le Cr and .MRI show
anatomical changes, PET shows bioch emical changes in the
tissues. A combi natio n of PET and CT would predict the
presence of malignant tumour and its anawmy beuer than
either s ingly. FDG-PET is now considered a gold standard in
th e investi gati on of ca ncer ce rvix.
TREATMENT OF INVASIVE CANCER
Treatment depends on the stage of th e disease. However, in
case tl1ere is a need to preserve fertilit)', a conservative surgi-
cal procedure is possible in early stage disease.
Better understanding of early lesions has permitted a
more conservative surgical treaunen t without compromis-
ing t11 e success, at t11e same Lime reducing the morbidi ty
and retaining the fenilit) potential in yo unger women.
SURGICAL TREATMENT
Stagewise Treatment of Cancer of the Cervix
• Stage Ial : The diagnosis is by cone biopsy. The lymph
node imohement in this stage is only 0.5%. Therefore,
Internal os
b ;
Rgure 33.40 The technique used for radical trachelectomy. Area of tissue for resection (shaded) including cetvlx and upper vagina with pa-a-
cervical and paravaginal tissues up to the level of the uterine isthmus.
conization witl1 a clea r margin is co ns idered adequate
and is diagnostic as we ll as therapemic. HysterectO my in
a yo Lmg woman is considered rather a radical surgical
approach witl1 increased morbidity but without improved
Sttrvival. Hysterectom> (extrafacial hysterectomy- Type I
hysterectom)) is appropriate in e lderly a nd parous
women, or those ha' ing an associated disease in the
uterus. L) mphadenectOm) is not required, but long
tenn follow-up is necessa•y L)lnphatic or vascular
channel infiltration however mandates treaunem as in
Stage lb.
• Stage Ia2: Lymph node imolvementand recurrence rate is
2%-7%, provided vascular and lymphatic channels are not
involved. Extended h)-sterectomy and lymph node sam-
pling are recommended (Type II hysterectOmy) . Nodal
involvement requires postoperative radiotl1erapy. In a
yo ung woman desirous of chil d-beari ng, conservative u·eat-
mem comprising lapa roscopic lymp hadenectOmy followed
by vaginal u·ac helecw my inu·oduced by Daniel Dar-
ge nt( 1987) is approp riate and does not co mpromise on
iLS success. Fertility-conserving trachelectomy consists
of who le or at least 80% re moval of t.he cervix and upper
vagina and cutting Mackcnrodt's ligame m on eitl1e r side.
lnvolvemem of l)'mphatic or vasc ular chan nel needs simi-
lar treaunem as in Stage lb. Be fore conservative surgery,
MRI mapping for local extension a nd lymph node involve-
mentis needed. Obturator gland is the se ntinel node- if
negative, no further 1)1nphadenectomy is requi red. Injec-
tion of blue d)e into t11e cervical tissue before surgery
identifies 1)1nph nodes. Conception rate of at
the end of 1 )ear, with miscarriage (20%-30%), prete1m
labow· (18%) and chorioamnionitis, is reported. Recur-
rence rate of 5% is also reported Contraindication LO
fertilit)·presening operation is a lesion more than 2 an.
cerclage at the time of ptimary surge•) ' may
reduce the pregnancy complications of abo•·tion and
preterm labour (Fig. :n. tO).
Isthmus uterus
Paracervical and
paravaginal tissues
 CHAPTER 33 - PREINVASIVE AND INVASIVE CARCINOMA OF CERVIX
• Stages l b and lla: The treaunem options are as fo llows:
• Radical Abdomina l hysterecLOmy (Type lll radical hys-
tereCLomy)
• Sd1auLa's vaginal h)Sterectomy (known as Mitra opera-
tion in india) and Taussig's or Iaparoscopic lymphad-
enectom>
• Plimal") mdiotherap) with concun·em chemotherapy
• Combined stu·ge•1 and radiotherapy
Injection of blue d)'e into the cervical tissue before sur-
ge•)' identifies lymph nodes during surgerr (sentinel lymph
node). Negati'e sentinel lymph node (obturator lymph
node) helps a\oid extensive pelvic lymphadenectomy.
Wertheim's hysterectomy, also known as Meigs-Obayashi
hysterectomy, is the surgical treaunem in SLage la2, with lym-
phovascular invasion and tumour size of 2 em. Whereas for
Stages lb and lla is sli ghtly more mdical procedure (Type Ul-
radical hysterectomy). It complises exploratOry laparotomy,
removal of the e ntire uterus, botl1 adnexa, pelvic lymp h
nodes, media l one-tJ1ird of tl1e parame u·ium on e ither side
and upper one-tJ1ird of tl1e vagina, spa ring sacral gla nds. T he
ovaries are invo lved in on ly I%, so tl1 ey may be reLained if
appear heal U1)' in a you ng patien 1.. In s uc h a case, tJ1e ovalies
ma)•be u·ansposed outside the pelvis LO avoid damage in case
radiotl1erap)' is requ ired later. L.'lte l)', rad ical hysterectomy is
performed laparoscop ically by a robotic rad ical hys-
terectomy is done in specialised cenu-es.
Schauta's operation is an extended vaginal hysterectomy
consisting of removal of the entire uterus, adnexa, most of
tJ1e vagina and medial portion of tJ1e parametrium. This is
combined witJ1 pelvic l)mphadenecLOmywhich can be done
by extraperitoneal approach. The original vaginal radical
hysterectom> has been •-eintroduced witJ1 modification by a
number of surgeons in France where a laparoscopic ap-
proach or laparoscopic-assisted operation is done. Alterna-
tively, postoperative pelvic radiotherapy may be employed.
\>\lith the possibility of laparoscopic lymphadenectomy and
lesser morbidity of vaginal approach, tJ1is modified laparo-
scopic-assisted radical vaginal h)sterecLOmy is gaining popu-
lality among many oncologists.
Complications of Radical Hysterectomy
• Haemorrhage during surgery
• Trauma to tJ1e bladder and ureter ( I %-2%) causing fistula
• Dysfunction of bladder because of nerve damage
• Damage to tJ1e obwrator and gen itofemoral nerve
• Sepsis
• T h romboembolism, p ulm onary and wi nary u·act infection
• Parai)•Lic il e us, periton itis, wo und sepsis, burst abdomen
and scar hern ia
• Lymp hOC)'St formation in tJ1 e broad ligament
• Lymphoedema ( I0 %-20% )
A radical abdominal hysterectomy is a major surgical pro-
cedure associated witJ1 major and minor complications as
mentioned above; this procedu•-e also has a risk of primary
mortal it) in the region of I% . ot all centres and not all
sw·geons are capable of doing this major surgical procedure.
Radiotherapy
Ad,•;mces in radiotherapy techniques have made it possible
to treat cases of cancer cervix with equally good results
427
as seen witl1 surgery. In addition, radiotherapy is app licable
in sLages sud1 as Stages Ji b, II Ia and Ili b where surgery is
not feasible. Prima11 radiotherapy consists of imracavity
brachytherapy and external radiation to tJte pelvis. It yields
the same 5-)ear cure rate as that of surgery, i.e. SOo/o-90%.
It is, however. obsened tltat many surgical cases show
positive l)lnph node metastasis which requires additional
postoperative radiotJ1erap) anywa), and this combined ther-
apy increases the mo•·bidity in the woman. Therefore, some
oncologislS prefer to a'oid surgical approach and employ
prima•1' radiotherap)' (see chapter 39 on Radiation Therapy
and Chemotherapy).
Addition of chemotl1erapy with cisplatin 40 mg2 weekly
to radiotJ1erap)' imp•·oves the radiation effect, as cisplatin
acts as a 1-adiosensitit.er agenL Current SLandard of radia-
tion therapy is to combi ne it with weekly cisplatin when the
patient is unde•·going extemal beam radiation. Young
women in tJ1is group warrant specia l consideration because
of risk of desu·uc ti on of ovaries, stenosis of vagina and oc-
c u rrence of pyomeu·a fo ll owing radiotherapy. Prima ry s ur-
gery therefore is tJ1e trea un e nt of c ho ice in yo ung women.
In case of a large lesio n, externa l rad iotherapy is used first,
followed b)' two app li cations of brach)•tlt erapy 2 weeks
aparL This s hrinks the tumour, a nd a llows insertion of in-
ternal app licator.
The advamages and dis.'ldvantages of s u rgery and rad io-
therapy are mentioned in Table :tl.7.
Indications for Postoperative Radiotherapy
ln case surgeq was tJ1e first line of treaunent of early stage
cancer cervix. postoperative radiotJ1erapy will be needed for
the following indications:
• Positive l)lnph nodes fo•· metastasis
• Positive resected margin of"agina or parameu·ium
• Evidence of l)lnphovascular invasion or deep su·omal
invasion
• Poorly differentiated tumour
P•·eoperative Chemotherapy
Currently giving p•·eope•-ative chemotJ1erapy to a case of
ca•·cinoma of tl1e cervix is not a sLandard method of treat-
ment; however, people are explo ring this as a mode oftreat-
ment in women with bulky disease.
• Neoadjuvant paclitaxe l 90 mg and injecti o n ifosfam ide
2000 mg p lus mes na 400 mg weekly for three cycles
• C isp la tin 50 mg week ly fo ll owed by s urgery yie lds 94%
s uccess in earl)' s Lages
Recurrence of Cancer
Advanced stage diseases suc h as Stages liB, Ill and rv are at
a risk of recuiTences. Rec urrence can also occ u r in early
stage disease managed by surgery or chemoradiation. Most
patients tend to develop recurrences in t11e first5 years after
ueaunent. Chemomdiotherap) can improve tJ1e survival
and allow tJ1e woman to spend a comfonable life or increase
the duration of remission. A cenu-ally placed a
bladder and rectal fiStula ma> be subjected to exenteration
operation.
Recent trend is to u·eat stage lib with chemo•-acliation or
chemotherapy for tl1e first 3 months followed by surge•1'·
428 SHAW'S TEXTBOOK OF GYNAECOLOGY
Table 33.7 Advantages and Disadvantages of Sw-gery Compared with Radiotherapy
Surgery
Advantages
Accurate surgical staging possible
Pelvic lymphatic glands can be removed
Conservation of ovaries - transposition of ovaries in case post-
operative chemotherapy is required
A more pliable, but short vagina retained
Applicable if fibroids, adnexal masses present
Failed surgery can be treated with radiotherapy
Disadvantages
Surgical mortality - 1%
• Anaesthesia compli cations
• Haemorrhage, trauma d uring surgery
• Sepsis - wound, pelvic, c hest, urinary tract, burst abdomen
• Bladder atonicity, fistula, ureteric Injury, bladder dysfunct ion
because of denervatlon
• Paralytic Il eus, thrombophlebitis, embolism
• Lymphocyst formation
• Many require radiotherapy postoperatively
• Scar hernia, pelVIc adhesions
• Obturator nerve damage
Recurrent Lesion
Twelll) to twenL)·fh e per cent of early lesions recur with in
2 years of prima11 treaunent. This may be cenu-ally located
or on the lateml pelvic wall with l)lnph node invo lvememor
distal in Lhe pam-aonic nodes, lungs, liver or bones. Most
recUJ·rences are related to the siLe of the primary growt.h of
more than 2 em, st.age of cancer, lpnph node involvemem
and tissue dilfel'·e ntiation.
T he srmptoms appear late, but are similar to t.hose of
earl)' cancer. The development. of sciat.ic pain, lymphoe-
dema of the leg and fistula are sure signs of recun·ence. It.
is import.ant to differentiate infla mm atOry from malignant,
parameu·ial tl1i cke nin g. On pelvic examinatio n, in flamma-
tory infiltraLion is s moo th, whe reas malig na nt infiltratio n is
nodular.
Follow-Up of a Treated Case of Cancer of the Cervix
Pap s mear is diffic ult to in terpre L. T he ce lls appear large
with C)'toplas mic vacuo lation, multinucleation a nd nuclear
shrinking wi tJ1 in flammatory cells in th e first few months of
radiotherap)'. Cli nical exam inatio n and combination with
investigations if indicated can detect rec urrences. Fine-
needle aspiratio n C)'tologr (FNAC) and tricot needle biops)'
confirm tl1e recurrence. Cystoscop)', sigmoidoscopy, CT,
MRI and PET are required to study the extent of the
gt"OWth .
MRl is superior to Cr in idenLifying malignam infilu-a-
tion in Lhe pammeu·ium, but in case of difficulty, MRl is
repeated 3 momhs later; PET also helps. Cr is specific in
60%-70% of cases, but MRJ is specific in 70o/o -90% of cases.
PET-CT is more specific than t.he two.
Radiothera py
Survival rates for surgery and radiotherapy a-e similar
Applicable to all stages between Stages IB and rJ
OPD procedure
No immediate mortality
• Anaemia
• Ova-ian destruction
• Pyometra
• Decreased libido because of ovarian failure
• Vaginal stenosis
• Bladder - cystitis, fistula, ureteri c stenosis
• Bowel - chronic diarrhoea, proctitis, rectal stricture, fistula - skin
burn
• Avascular necrosis of femoral head
• Not applicable in the presence of ovarian tumour, adnexal mass,
fibroids, prolapse
• Risk of sarcoma a few years later
Management of Recurrences
Recun·em growth following •-adiotherapy can be t.reated by
hysterectom) in a small cenu-al growtJ1 or exente1-ation
opemLion. Most recun·ences a•·e cenu-all) placed and 30%
are fit to be managed by peh·ic exente1-ation opemLion.
Amerior exente1-ation comp•·ises hysterectomy a nd re-
moval of the bladder with ureteric implantation in t11e il-
eal conduit. Posterior exeme•-ation removes the utems
and t11e rectum with low rectal anastomosis, avoiding per-
manent colostomy. In total exentemtion, both bladder and
rectum are removed in addition to t11e uterus. Vagino-
plasty ma y be required in youn g women. Exememtion
operation is indicated in recurrent a nd resid ual tum o urs
centrally located.
Exenteration s w·gery ma kes t11e li fe of t11e woman comfo rt-
able, witJ1 5%-15% s urgica l mo rta lit)' but 60% !).year c ure ra te.
T he are t11e co nu;1indica ti o ns LO t11i s opera tio n:
• Age over 80 )'ears
• Woman not accepting colosto m)'
• Presence of l)'mph node o r distal me tastasis
• Fixed tumoms
Lateral recurrence is ma naged by racliotherap)' in a pre-
vious SLtrgical case, but repeat •-adiotherapy can cause fistula
unless mdiotJ1erapy was applied more than I year ago.
Distal met.astasis has a 5-)ear survival rate of o nly 5%,
but chemotJ1e1<1p) has recent!) shown considemble im-
provement in short-tenn remission in 20%- '10% of cases.
Of all drugs. cisplatin proves most promising, singly or in
combination.
The details of mdiotherapy and chemolhe•-apy are given
in chapter on Radiotherapy and Chemolhe•-apy.
 CHAPTER 33 - PREINVASIVE AND INVASIVE CARCINOMA OF CERVIX 429

Stogewise Treahnent of Cancer of the Cervix 2. Transposition of the ovaries outside the pelvis in case
radiotllet-ap)' is required
Stage Ia l Coniation or exu-afacial 3. OOC)Le and embt)'O Cf)Opreservation prior to chemo•-a-
hysterenomy (Type I) di ation
Stage la2 Modified 1-adical hysterectomy
(Type II)
Or Radical trachelectOmy in CARCINOMA IN PREGNANCY
yo ung wome n
Stage lb l Rad ical h)•Sterectomy (Type Ill ) PREINVASIVE CANCER IN PREGNANCY
Or Rad ical trache lec tomy in When a yo ung woman presents witll bleed ing el uting preg-
yo ung women nancy or postcoital b leeding, it may be a sign of early stage
Stage lb2 Radical hysterecto my (Type lll) disease of ce rvix.
Or Chemoradiation The cervix may appear nonnal or show chro nic cervicitis
Stage Ila Radical h)Sterectomy (Type Ill) or erosio n. Pap smear and colposcop)-directed biopsy con-
O r Chemoradiatio n finn the diagnosis. Cone biopS)' should be avoided in preg-
Stages lib, lil a, Illb Chemoradiation nancy whene,er possible, because of •·isk of postbiopsy
Stage IV Palliative •-adiotherapy bleeding and abo•·tion. Besides, transform ation LOne is usu-
ally clearly visible dut·ing pregnancy for biopsy. In case of
Recu.-rem carcinoma Exenteration operation/ preinvasive lesion and Stage la 1 lesion, the woma n is al-
of the cervix chemotherapy lowed a vaginal deli ve ry, provided invasive lesio n is ex-
cluded. Six wee ks postpartum, ano ther Pap smea r followed
Conservative Surgery in a Young Woman b)' colposcopy will he lp to evaluate Ll1e case for an)' furtl1er
In a yo ung woman d iagnosed lO have ea rly stage cancer treatm ent (Fig. 33.'1 1).
cervix (Stages Ia, lb1) , it is possible LO preserve her uterus INVASIVE CANCER OF THE CERVIX IN PREGNANCY
for fuwre childbearing. ln a )Oung woman wishing to
co nse rve fertility potential , the following measures are The incidence of cancer of tile cervix is reported in 1:2500
recent!) being u;ed: pregnancies.
The woman presents ameparLum haemon·hage.
I. Trachelectomy with lymphadene ctomy and cervical The cervix presents a similar pictu•·e as in the nonpregnant
cerclage condition. Confinnation of diagnosis is based on a cervical

Abnorm al Pap smear in pregnancy

Multiple biopsies/LLETZ/LEEP
Repeat 2-3 monthly
(no cone biopsy)

t !
Normal cytology
l 1
t CIN!Stage lA >Stage lA

Vaginal delivery
l l
l Vaginal delivery
l 1
Repeat Pap smear
in 3-6 months l
Follow w ith repeat
Terminate in
early pregnancy
Near term,
wait for viability

smear in 3112
l
Classical CS and
appropriate to
management
4 weeks later
Rgure 33.41 A bnormal Pap smear In pregnancy.
 430 SHAW'S TEXTBOOK OF GYNAECOLOGY
biopsy. Cone biopsy can ca use profuse bleeding; therefore,
t11e diagnosis is confirmed on mu h.iple biopsies or colpos-
copy-directed biopsies. MRI is permissible as it does not
cause radiaLion. CT is comraindicated. Staging of invasive
cancer of cervix in pregnanC) is done on t11e same lines as
in nonpregnam state.
MANAGEMENT IN PREGNANCY
The p1·egnanC)• does not appear to alter tlle biological be-
of the tumour, and u·eaunent, t11erefore,
depends on stage of t11e disease and duration of pregnancy.
For Stage lb or lla cancer of tlle ce1v ix detected before
20-24 weeks of p1·egnancy, a su1·gical treaunem by Wert-
heim 's hysterectomy (Type III 111dical hysterectomy) is desir-
able. Alternately, pr·imary radiot11erapy is also feasible after
termination of pregnancy by upper segment h ysterotOmy.
If pregnancy is more than 24 weeks or approaching term,
it may be prudent tO wait unti l t11 e fetus is viable. Elec tive
class ical caesarean delivery is foll owed by rad ical hysterec-
to my in the sa me sitting or racl io t11e rapy in a no npregnant
state. Breast-feedin g is usuall y avoided d uring radio tl1erapy
or chemotherap)'·
For advanced disease, it is bette r to te rmin ate pregnancy
b)' upper segme nt hyste rotOill)' o r a classical caesarean sec-
tion fo llowed by rad ical che mo rad iation.
ENDOCERVICAL ADENOCARCINOMA
OF CERVIX
Endocervical cancer occurring in younger woman around
35 years. nulliparous or of low parity. Viral infections and
combined oral pills probabl) cause tllis cancer. The spnp-
toms, similar to tl1ose of cancer, appear late. The
cervix appears barrel-shaped witll the growt11 pouting
tllrough the extemal os in the advanced stage. The parame-
u·ial infllu11tions occur early, so also the spread lO t11e uterus.
Pap smear has low sensitivity, but endocervical cytology,
radiation
curettage or con e biopsy improves the detection 111te.
chemo6Wh In invasive ca ncer, ch cmo•11diation for 6 weeks should be
for followed by Wert11 eim 's h ysterectom y. The ov:uies should be
removed beca use of t11c adva nced growth at diagnosis and
b 's
distal spread. T hey a re involved in I 0% of cases.
Wertheim H RT can be presclibcd following oop horec to my in cancer
cervix.
RESULTS
Refer to Table !3!3.8.
PROGNOSIS
Prognosis is related to tumo ur vo lume, staging, lymp h node
involvemem and grad ing of t11e tissue. It is worse t11an that
of SCJLtatllo us cell carci noma. Ra ised carci noembryonic anti-
gen (CEA) level indicates bad prognosis.
Stump Cancer
Stump cancer cen ix occurs in I %-2% of cases following
subtotal h)sterectom) performed for benign lesions. If it oc-
curs "ithin 2 )Cars of surge ry, it is like I)• mat it 'vas present at
tlle time of hysterectomy. Pap smear p1·ior to hysterectomy
reduces its risk. Management is difficult, botl1 sur-
Table 33.8 Comparison of RGO Staging
and 5-year Survival Rate
AGO Staging 5 -Year Su rvival Rates (o/o)
Stage 1 > 90
Stage IIA >80
Stage liB > 65
Stage lilA About 45
Stage IIIB About 35
Stage w < 15
gery and radiotherapy. Co ni:t.atio n \\1th externa l radiotller-
apy is recommended.
PAlliATIVE TREATMENT IN TERMINAL STAGES OF CANCER
OF THE CERVIX
• Pa in re lief with morphin e and tramaclo l; ora l mo rphine
5-60 mg
• Vomiting: Dehydration a nd e lec trOI)•te imbalance cor-
rec ted; neuu·openia, uraem ia and chemoradiation are
the causes of vom iting
• Ha lopetidol 1.5-3 mg (dopam ine rgic antagonist)
• Appetite improved by metoclopramide, domperidone
and corLicosteroids for bowel oedema (60-100 mg daily
prednisone); dexamethasone 4-S mg daily for 3-5 days
• Lymphatic leg oedema stockings, garments a nd massage
• DiLLretics and spironolactone for ascites
• Vaginal discharge - Betadine douche or metronidazole
irrigation
• O ndat1seu·on I mg Li.d. for 111diation vomiting
• Ascites tapping
For profuse vagi nal bleeding, packing and adminisu11-
tion of tranexamic acid 500 mg i.v. &--8 hourly are help-
ful. Rare!)•, emboli:t.ation / Ii gation of imem al iliac artery
is needed.
FUTURE DEVELOPMENT
A new line of approac h in th e form ofVEGF fitcwr such as
bevacizumab is be ing u·ied alo ng with sta ndard u·eaun e nt
prow col to ac hi eve be tter stuv ival ra tes. Otl1er forms of
chemotherapy such as pacli taxe l + ca rboplatin are also
being evaluated for trea tme nt of adva nced d isease. Gene
therapy ma)' have a role in locall y adva nced d isease. It is
possible for tl1e direct iqjection of DNA-liposomal com-
p lexes and human leucOC)'Le antige n, which may promote a
favourable cytotoxic immune response. T his may have a
ro le in reducing local recurrence.
KEY POINTS
• Carcinoma of tl1 e cel'\ ix is the most com mon genital
U11Ct cancer in women and 111nks next tO breast Catl-
cer. It is a disease of )Oung " omen betwee n the age of
35 and 50 )eai"S.
 CHAPTER 33 - PREINVASIVE AND INVASIVE CARCINOMA OF CERVIX
• H uman papillorml\irus (H PV) infeclion is now proved
to be the most important cause of preinvasive and in-
vasive cen ical cancer. It is sexually transmitted. Ot11er
con u-ibutOI) factors are earl> age of sexual
multiple partners, poor h)giene, multiparity and im-
munosuppressi'e conditions such as I-I IV.
• lJse of ban·ier contracepti\ es prC\ems transmission of
'iral infection to a ''oman and prC\enLS preinvasive
and irwashe cenical cancer. Prolonged use of oral
combined pills increases t11e r·isk of cancer cenix, es-
pecially endocen•ical cancers.
• Ninety per cent of young women witl1 H PV infeclion
show spontaneous resolution within 2 years and do
not develop cancer: Only those \\ith persistem infec-
tion after the age of 30 years are at a high risk for
preinvasive and invasive ca ncer.
• Stepwise development of ca ncer cervix from HPV in-
fec ti on and iLS persistence leading LO preinvasive an d
invasive ca ncer takes I 0-15 yea rs. T his lo ng period
all ows ro uti ne screening and u·eaune m of preinvasive
cance r; so that invasive ca nce r does no t develo p.
• Ro uti ne Pap smear and colposcopic su.rdy and b iopsy
p ick up preinvasive lesions (C IN) effeclive ly in 90%
of cases. Add ing HPV testing further improves the
pick-up rate.
• Ab lative therapy for early stage d isease is a successful
fertility-conserving therapy in yo ung women, b ut life-
long follow-up is necessal) to detect recurrence. Hys-
terectom> is reser\ed for elderly and multiparous
women. Follow-up is necessal) irrespeclive of treat-
ment for preinvasi'e cancer.
• Endocer\ ical cancer is difficult to diagnose in iiS early
stage, as the tissue is not available for cywlogy and
colposcop). Endocenical scrape and cone biopsy are
required for diagnosis. Treatmem is chemoradiation
followed by Wenheim 's hysterectomy.
431
• Radiotherapy is app licable in all stages of invasive
cancers. 1-lowe,er, because of ovarian atrophy, vaginal
stenosis and p)ometra, primal) surgery is preferred in
)Oung women.
• Prognosis in invashe cancer depends on the size of
the lesion. stage of t11e disease, imohemem of lpnph
nodes and cell differentiation.
• Proph) lactic vaccine againstllP\1 is now available. Given
before the start of sexual acti' it), t11e vaccine is expected
to reduce the incidence of cen ical cancer in futw·e.
SELF-ASSESSMENT
I. Discuss tl1e causes of carcinoma ofthe cervix.
2. Discuss the clinical feawres and management of prein va-
sive cancer of the cervix.
3. Describe the clinical features of invas ive cervical ca ncer
and the d ifferen ti al d iagnosis.
4. How will yo u inves ti gate a case of ca nce r of the cervix?
5. Disc uss the manage men L of st.age lb ca nce r of the cervix.
6. Describe the FICO staging of cancer cervix.
7. Disc uss the d iagnosis and management of endocervical
cancer:
8. Discuss management of a case of cancer cervix witll preg-
nancy.
SUGGESTED READING
DuncanJ. Shulman P. Yearbook of Ob.tctric., C)naecology and Women's
llcalth: 40: 42!1. 2010.
Studdj. liP\' role in cancer cenix : In: Progreso in Obstetrics and C)n-
aL>Col<>g) Vol: 14. 2000.
Studd J. Prognosis in cancer ccn i x. Progres. in Obste trics and C)nae-
cology 15. 200!1.
Studd J. Progress in 0 b;tctric> a nd Cp mecology 7: 1989.
StuddJ. Screening cancer ccr,ix. PrOf..'Tes> in Obste trics and
ogy 16: 32!1. 2005.
 Cancer of the Body
of the Uterus

Endometrial Cancer 432 Key Points 440

Sarcoma of the Uterus 438 Self-Assessment 440
Endometrial Stromal Tumours 439

T he body of tl1 e ute rus is the site of e ndomeu·ial cancer, the

most freque nt ge nita l tract ca nce r in rich countries;
it ranks tl1ird in India after cancer of cervix and
cancer of oval')'·

ENDOMETRIAL CANCER

Endometrial cancer has recently emerged as the more

frequelll.l) encoumered ID naecological ca ncer accoLmting
for 20%-25% of all genital cancers in tl1e developed
countries. notonl) because oft11e longerSLLrvival of women,
but mainl) because of the marked dedine in cervical cancer
b)• screening programme (Fig' 31.1-31.5). In developing
countries including India, tl1e incidence has remained low
at 5%-7% of all genital cancers; cervical cancer continues
to predominate and is seen in 1.8 per I 00,000 population.
T he majority of tl1e endometria l cancer is seen in the
55-70 years age gmup, 20%-25% of cases occur in peri-
menopausal women and only 5% of cases develop in women
youn ger tl1 an <10 yea rs when they t11ese ca ncers are well-
differenti ated with good surviva l. Women are eimer
nulliparo us or of low parity. An ea rly menarche and late
menopause is a characteristic of wom en suffering from this
Figure 34.2 Stage II carcinoma of the endometrium. The musde is
deeply and extensively infiltrated, but has not yet readled the serosa
cancer, indicating tl1e prolonged exposure to oestrogen
hormone. Se,·emy-five per cent of the tumow-s :u·e
localiLed in tl1e ULenLS when diagnosed, and surgery is tl1e
cornerstone in its management. Surprisingl)', oestrogen-
dependent endometdal cancer can develop in au·oph ic
endometrium in a postmenopausal woman when tl1e level
oflhe hormon e is lowesL However, tl1e behavioural pauern
differs; endometdal ca ncer is poo rly diffe rentiated in post-
menopausal women, whe reas in )'Ottng women it is well-
differemiated and curab le . After tl1 e age of 80 years, the
incidence drops. Two t)•pes of e ndom etria l ca nce rs have
been idemified: The 'l')'pe I ca nce r occ urs mostly in
obese perso ns wi tl1 excess of endoge nous or exogenous
oestrogens and is histo logically e ndo me u·io id adenocarci-
noma. The T)•pe II e ndometrial ca ncer is histo logically a
clear cell variety or papillary serous variety see n in elderly
women without :u1y evidence of a hyperoestroge nic state
and is associated with poorer prognosis.

PREDISPOSING FACTORS (Table 34.1)

Any factor tl1at increases tl1e exposure of endomeuium LO
Rg ure 34.1 An adenocarcinoma of the endometrium. The growth unopposed or high oesu·ogen level, eitl1er e ndogenous or
forms a large tumour projecting into the cavity of the uterus. exogenous, increases tl1e tisk of endomeu·ial cancer. This is

\iew the k-cturc note> :.can the >pnbol or log in to rour account on

432
 CHAPTER 34 - CANCER OF THE BODY OF THE UTERUS 433

Figure 34.5 Endometrold adenocarcinoma Grade 3, Endometrium:

Tumour cells arranged In glands as well as solid seeds, showing
a marked nuclear pleomorphi sm and prominent nucleoli. (Courtesy:
Dr Sandeep Mathur, AIIMS.)

Fortunate!)', the malignan cy is well-d ifferenti ated with

Rgure 34.3 (A) and (B) Invasive cancer of endometrium - localized
and diffuse varieties.
good progn os is.
• Chronic anovulalOI) ' cyc les as seen in PCOS.
• I n some f amilies, a stron g familial predisposition is
noticed. This may b e due to gen etic o r dietetic habirs
such as animal pro tein and fat. The oesu·one is derived b y
p eriph eral aromatiLatio n in the fat tissue from andro-
sten edio ne and co n t ribu tes to a high level o f oesrrogen.
Women with th e familial L ) nCh 11 syndrome suffering
f rom an orectal and b reast can ce r are also likely to suffer
f rom endomeLrial cance r.
• Tam oxifen give n to wo men su ffering fro m breas t ca ncer
increases t h e ris k of endomeu·ial h ) pe•·plasia and ca n cer
to two- to t h reefold. Ral o xifen e has n o adverse e ffect o n
the endometrium.

Table 34.1 Risk Factor s f or Endom etrial Cancer

Risk Fact or Relat ive Risk

Long-term unopposed oestrogen 1Q-20
Lynch syndrome 6-20
Oestrogen-producing tumour >5
Older age 2-3
Higher income and education 1.5- 2
White race 2
Nulliparlty 3
Figure 34.4 Well-differentiated endometrial adenocarcinoma (back-
to-back glands with minimal Intervening stroma and the gland -within - Menstrual irregularity 1.5
gland pattern). (Cou'resy: Dr Sandeep Mathur, AIIMS) History of infertility 2-3
Late age at menopause 2-3

also linked to d ose and duration o f e xposure; the risk persistS Early age at menarche 1.5-2
for 10 )ears after t h e h ormon e exposure. The endomeuial Tamoxifen 2-3
can ce r th ere fo re is en coun tered in th e following conditions:
Obesity 2- 5
• n opposed and unsupe" ised adminisu-alio n o f h or- History of type 2 diabetes mellitus (T2DM), 1.3-3
mon e after m en opause predisp oses hypertension (HTN) or thyroid disorder
th e woman to endom eu·ial h ) p erplasia and cancer.
434 SHAW'S TEXTBOOK OF GYNAECOLOOY
• Obesity, hypertension and diabetes are seen in 30% of
cases of endomeuial cancer. Obesity reduces the level of
serum sex hormone-binding protein and allows free
oestrogen to circulate in the body. Moreover, a peripheral
conversion of epi-androstenedione is aromatized to
oestrone in the pe•ipheral fat.
• lnfe•·tile women and women with poi)C)Slic ovarian
syndrome on accoum of nonovulalion have high oes-
u·ogen. These women ha'e more chance of developing
endometrial h)perplasia and endomeu·ial cancer than
normal women. The uterine fibroid is associated with
endometrial cancer in 3% of cases after the age of
40 years.
• FeminiLing ovarian tumotu· such as gramtlosa cell tumour
or th eca cell can have associated endomeu·ial cancer in
15% of cases.
• Combined ora l contracep tive pills have a protective effect
and red uce its risk by 40%-50%; adding proges togens for
12 days eac h cycle to oestrogen in hormone rep lace ment
th erapy (HRT) red uces its risks to 2%.
PATHOLOGY (FIG. 34.6)
Endomeu·ial ca ncer may be locali:t.ed or diffuse. lt may
appear as a nodule, polyp or diffuse lesion in volving the
entire uterine cavity. Histologicall y most endometrial
cancers are adenoca•·cinomas and are called endome-
u·oid adenocarcinoma. About l 0%-15% endometrial
cancers can have other histological \'3riams such as papil-
lary serous, clear cell, adenosquamous or pure squamous
\'31·iety.
B Normal endometrial cells Normal endocervical cells
RgLre 34.6 (A) Endometroid carcinoma: Malignant endometrial
glands showing moderate nuclear atypia infiltrating the myometrium.
(B) Normal endometrial and endocervical cells. (Courtesy: tor (A)
Dr SMdeep Matll.Jr, AJIMS.)
MODES OF SPREAD
Endomeuial carcinoma sp•·eads b)' following routes:
I. Direct extension to adjacent strucnrres: Most common
mode of spread is by penetration of the myomeu·ium
and eventually the serosa of the ute•·us. The cervix,
fallopian tubes and ultimately the \'<!gina and parame-
u·ium ma) be im'3ded.
2. A transtubal passage of exfoliated malignant cells imo
ac!join ing oval"). pel' is and peritoneal cavity.
3. Lymphatic dissemination: L) mphatic channels pass
directly from the fundus of the uterus to the para-aorlic
nodes. It can spread to the obturator nodes and other
pelvic lymph nodes, if Lhe growth is in tl1e lower half of
the uterus. Spread to inguina l lymp h nodes can take
p lace tl1 ro ugh th e ro und ligament.
4. Hematogenous spread : Most com mon sites are lung,
liver, brain and bone. Rarel)•, o tl1er sites can be in volved.
Histologicall y, e ndome u·ial ca nce rs are endometrio id
adenocarcinoma in 75% of cases. T he rest are clear cells,
squamo us and serous variety, whi ch are more ma lignant
than adenocarc ino ma.
TUMOUR DIFFERENTIATION
The grading of these tumours is based on differentiation,
glandular architeclllre and anaplasia of tl1e cells. Adenoac-
anllloma is t11e least malignant (Figs :H. 1-31.6). Necrosis in
the tumour has an acherse effect on women's survival.
This grading is pan of International Federation of G)maeco-
Jom•and Federation (FICO) staging for endometrial cancer.
Grade l : The glandular pattern is but cells
show atypia.
Grade 2: Some glands show a papilla!") pattenl and are solid.
Grade 3: The glands are solid with cellular proliferation,
and glandular architecture is lost. The endometriLUn is
packed witl1 glands and liLLie su-oma.
TYPES OF ENDOMETRIAL CANCERS
T here are two varieties of endome u·ial cancec
Type I is oestrogen dependent and accoun ts for 90% of
the cases. T he so urce of oestrogen may be endogeno us or
exogeno us. T his type is mostl )' we ll-differentiated with good
prognosis.
Type U is oestrogen independent and deve lops in au·opic
endomeu·ium . T his t)•pc is mostly undifferentiated ,,1 t11 poor
prognosis. Pr13 mutations are recognized in Type lltumours.
Histologicall y, these tumours may be papilllll")' serous or clear
cell variety, metaStasis occu•'S relatively earl)' and tumour may
metastatize to omentum, lymph node and other structures.
As mentioned earlier, oesu'Ogen-stimulated endometrial
cancers are well-differentiated, whereas cancers developing
in au-ophic endomeuium in menopausal women are poorly
differentiated.
CUNICAL FEATURES
Endometrial cancer ma) be as)lnpLOmatic in 7%-lO% LO
begin witl1. The most common presemalion of endomeuial

cancer is in the form of postmenopausal b leeding or dis-
dmrge. lt may manifest as menorrhagia or irregular periods
in perimenopausal women. Past history of PCOS or HRT
may be elicited. The woman may be obese, hypertensive or
diabetic. Pain and lumps appear late in the advanced stages.
On per vaginal examination, the uterus may appear
bulk) or ma> be normal in siLe. The clinical features of
a bulk) uterus ma> not always be present. A bulky uterus
is due to growth itself o•· due to associated fibroid or pyo-
metra. An adnexal mass, if present, is often a fem inizing
tumour of o'•ary or a metastasis to the ova•·ies. ln the
ad,'<lnced stage, the cervix is bul ky and the os is pamlous
with the gr"Owth protruding through the os. Rarely a meta-
static '"'gina! nodule is visible in the suburethal area.
Discovering a lower genital tract lesion in a postmen o-
pausal woman does not rule out endometrial can cer. Both
may exist and investigations are req uired to rul e out endo-
metrial cancer.
INVESTIGATIONS
Vario us investiga ti ons confirm the di agnosis a nd assess its
stage and ex te nt of the d isease, so that an app ropriate and
op timal u·eaunent may be plann ed. Obtaining a sa mp le of
endometria l tissue fo r histopathology he lps tO confirm the
diagnosis.
Un like cancer of cervix, a cost-effective so·een ing pro-
granm1e is not available for endometrial cancer. ln high-risk
cases a periodic transvaginal ultraso und combined with an
endometrial tissue sampling may be used tO pick up disease
in an earl) stage.
• Pap smear is not a good method LO pick up endometrial
cancel'S as it is onl) 50% sensitive and not reliable. The
presence of nonnal or abnonnal endomeu·ial cells in Pap
smear increases the prC\alence of premalignant ULerine
disease or endomeuial carcinoma.
• Endometrial aspiration from the ute•ine cavity is effective in
screening high-1isk cases, and those on tamoxifen and HRT
if presented with bleeding per \'<lginum. The aspiration is
done ''ith a Pipelle cu•-ene, Isaac aspiratOr, Vibra aspirator,
Gravely jet wash and Novak cureue as an O PD pmcedure
(Fig. 3 1.7). A simple cost-effective method is tO aspirate
endomeuial cavity with a fi ne 4-mm Kannan's cannula
attac hed to a d isposable 20 mm syringe.
• Fractional curettage comprises ob1a in ing endocervical
scraping befo re d ilating the ce rvix, followed by cervical
di latation and cure LLage fro m the whole endo metrial
cavit)'· 1\vo specimens a re exam ined separately for the
presence of cancer. and On hysteros-
copy, one visualizes the enti•-e llleri ne lining and obtains
biopsy from suspicious a •-eas; it red uces the chan ces of
missing a lesion. Even then, this is not 100% predictive,
F1gure 34.7 Vibra aspirator for suction curettage.
CHAPTER 34 - CANCER OF THE BODY OF THE UTERUS 435
as an early lesion can be missed. Some people have raised
the concern regarding spilling of cancer cells into the
peritoneal cavity during hysteroscopy.
• Transvaginal son ography is useful in studying the endo-
metrial thickness before resorung 1.0 endometrial tissue
sampling. Increased endomeu·ial thickness, an irregular
line and the presence of pol)pS are helpful in indicaung
the need for endomeuial tissue sampling. O ccasionally
associated O\'<ll'ian tumou•· or O\'<ll·ian metastasis can be
picked up. The extension to the endocervix can also be
recogniLed. ln a postmenopausal woman, the nonnal
endomeu·ium should not exceed 4 mm in thickness and
this cut-off value is 10 mm in a perimenopausal woma n.
ln a menopausal woman with '"'gina! bleeding, C\•en an
endomeu·ial thickness of less than 4 mm has th e risk of
cancer and the entire endometrium should be
to a h istopath ology study ( Fig. 3 1.8).
• Doppler ultrasound revealing a low resista nce index of
0.37-0.7 or below is seen in endometrial malignant
lesions.
• Sonosalpingography. In the absence of facili ty fo r hyste r-
oscopy, so nosalp ingograp hy is useful in de tec ung endo-
me trial pol)'P whi ch co uld be malignan L
• CA-125. This tum o ur marker if ra ised above 35 LU/ mL in
a case of endomeu·ial cancer suggests extraute rine sp read
of the disease.
• Contrast-enhanced computed tomography (CEcr) has a
predictable rate of 85% in swclying the extent of tl1e
lesion spread. llypodensit) in the myometri um suggestS
myometrial infilu-ation. The pelvic and aoruc nodes are
defined if enlarged to more than I em. CT is superior tO
MRl in detecting ascites, bowel and omental metastasis,
but radiation exposw·e is the clisacl,'<lntage.
• MRI is superior tO Cr in cletecung m)Omeu·ial involve-
ment and noclal enlargement \\ith a 90% cletecuon rate
and without a radiation haarcl. onnally, between t11e
endometrial and myometrial junction, a low-intensity
Lone exists and if t11is lOne is intact, myomeu·ial im'<ISion
can be ruled out, and the tumour is staged as Stage l. MRl
is more expensive and time-consuming, but accurate
Figure 34.8 Transvaginal ultrasound showing heterogenous growth
in the cavity with infiltration Into the myometrium suggestive of
carcinoma endometrium.
436 SHAW'S TEXTBOOK OF GYNAECOLOGY
Figure 34.9 MRI showing extension of endometrial cancer into t he
cervix. (Courtesy: Dr Parveen Guiatl, New Deihl.)
staging is possible in 80%-90% (sensitivity 72% and
specificit)' 96%) (Fig. 3 1.9). MRI is a lso useful to know
endocervical su·omal invasion by the disease.
• X-ray of the chest is done as a routine to mle o ut ltmg
metastasis. For bone and liver metastasis, radioisotope
scanning is useful.
• PET-CT can reveal a metabolic activity in the tissue and
1)'111ph nodes. Although it is a gold standard for staging,
but is not indicated as a routine preoperative investiga-
tion due to radiation ha.t:ards and limited ava ilability of
tJ1is facilit).
DIFFERENTIAL DIAGNOSIS
Endomeuial cancer can be mistaken for tJ1e following entities:
I. Senile endometl'itis
2. Tubercular endometritis
3. Aty pical hyper·plasia
4. Endometrial polyp
ENDOMETRIAL HYPERPLASIA
Endometrial hype rplasia appears to be a precursor to
tJ1e deve lopment of endome tria l ca rcinoma in Type I
endometrial cancers. Prese nce of increased exogenous or
endogenous oestroge n levels resultS in hyperp lasia of
endometri um. Longstand ing hype rplasia can result in the
developmem of enclomeuial cancer:
2014 REVISED WHO CLASSIFICATION
OF ENDOMETRIAL HYPERPLASIA
New classification simp I) classified endometrial hyperplasia
into the following two groups based on the presence or
absence of C) to logical at) pia:
(i) H) pe•plasia "ithout at) pia
(ii) At) pi cal h) pe•·plasia
The complexity of arc hitec wre is no longer part of
the classification. The diagnosis of endometrial intraepi·
thelia! neoplasia (E I ) in the new WHO classification is
considered imerc hangeable with atypical hyperplasia.
TREATMENT
Endometrial hyperplasia wilJlout atypia: Progesterone given
both orally or as inu-autel"ine (Le,·onorgesu·el-releasing inu-a-
uterine system [L 'G-IUS)-Mirena) is effective in
regression of endomeu·ial hype•·plasia without atypia. The
LNG-IUS should be the first-line medical treatment, because
compared witJ1 oral progestogens it has a higher disease re-
gression •-ate "itJ1 a mor·e favoltl-able bleeding profile and is
associated "itJ1 fewer adve1-se effects. Continuous progesto-
gens should be used (medroxyprogesterone 10-20 mg/day
or norethisterone 10- 15 mg/ day) for women who decline
use of LNG-I US. Treatment with oral progeswgens or the
LNG-I US should be for a minimum of 6 montJ1s to induce
histological regression of endome trial hype rplasia without
atyp ia.
Atypical hyperpL'lsia: Wome n with atyp ical hyperp lasia
have a substan ti al risk of develop ing endome uial carci-
noma. It can be as high as 8%-29%; the refore, they sho uld
undergo a total h)•Ste rectOm)' to red uce tJ1e risk of develop-
ing malignancy. Rare l)•, in a yo ung woman desiro us offertil-
ity atypical hyperplasia may be treated witJ1 high doses
of progesterone witJl frequent evaluatio n of endo metrial
biopsy to nile out progression to cancer.
TREATMENT OF CARCINOMA OF THE ENDOMETRIUM
Almost all paLien ts diagnosed to have endomeu;al carci-
noma are iniliall) treated by surge•') except those with
advanced disease or found unfit for surgery on account
of associated medical conditions such as cerebrovascu-
lar accident (CVA), coronary artery disease or morbid
obesity.
STAGING (FIGO STAGING 2009) (Tobie 34.2)
Surgical staging is now recommended, but clinical staging is
applicable in inoperable cases. A staging laparowmy is
recommended tJu·ough a midline lower abdom inal incision
and any peritoneal asci ti c fluid or washing is collected
for cywlogy. The complete abdom inal exploratio n fol-
lowed by LOtal abdo min al h)•Sterectomy (TAH) alo ng with
bilateral salpingo-oophorec tOm)' (BSO), pelvic and para-
aonic lymp h node sampling re mains the co rnerswne in tJ1 e
management of earl)' endome u·ial ca ncec
TREATMENT
SURGERY
The main modality of treatment in carcinoma endome-
trium is surgery, if the patient is medically fit for surge•)'·
Surgical staging, alxlom inal hysterectomy, bilateral
salpingo-oophorectOm), omentectomy and pelvic as well as
pam-aortic I) mph node sampling remain tJ1e come•-stone in
the management of earl) endomeu·ial cancers.
l. Steps ofsw-ge•1: The abdomen is opened b)•a ve•·tical inci-
sion which allo"s a tJ10rough inu-aabdominal explomtion.

Table 34.2 Carcinoma of the Endometrium Staging
(AGO 2009)
Stage 1• Tumour confined to the corpus uteri
lA· No or less than half myometrial invasion
18• Invasion equal to or more than half of the
myometrium
Stage II' Tumour invades cervical stoma, but does not
extend beyond the uterus"
Stage 111• Local and/or regional spread of the tumour
IliA• Tumour Invades the serosa of the corpus
uteri and/or adnexae•
1118• Vaginal and/or parametrial Involvement•
Ill CO Metastases to pelvic and/or para-aortic
lymph nodes"
IIIC1• Positive pelvic nodes
--------------------
Positive para- aortic lymph nodes with or
IIIC2"
without positive pelvic lymph nodes
Stage Ill" Tumour Invades b ladder and/or bowel mucosa,
and/or distant metastases
r.tA• Tumour Invasion of bladder and/or bowel
mucosa
r.t8• Distant metastases, including intraabdominal
metastases and/or inguinal lymph nodes
•8ther G1 , G2 or G3
bErdocervical glandular irnolvement only should be consi:fered as
Stage I and no boger as Stage II
•Postive cytology has to be reported sepa-ately \\ithout ch<Ylging
the stage.
Source: RGO guidelnes.
2. Peritoneal washings are obtained from subdiaphrag-
matic areas, pa1-acolic gutters and the pelvis, and sem for
cytology.
3. H ysterectomy and BSO,
4. Omentectom y only if the hi stopathology report sugges-
tive of non enclo metrioid variety.
After remova l, tJ1 e ute rus is cut opened tO loo k for tu·
mour s i:t.e, myome tri al in vasio n a nd ce rvical extension are
assessed. The froze n sectio n is preferred. Lymph node
sampli ng or lymp hadenectomy is indicated, if tumo ur is
more than 2 e m in si:t.e, it in vades more th an half the thick-
ness of endomeu·ium o r the exte nsion of th e disease is up
to endocervix and if the preoperative grad ing of the tu-
mour was grade 2 o r 3. All grades 2 and 3 in Stage I, clear
cell. serous a nd ade nosq uamo us cancers and myo metrial
invasio n require pelvic l)lnphade necwmy and para-aortic
lymph nod e sa mpling. The re is no need to remove the
vagi nal cuff. However, omentectOmy is advisable in the
adva nced stages.
AltJ1 o ugh for surgeq an abdom ina l ro ute is convention-
a lly used, a vaginal route ca n be prefen·ed in o be se dia-
betic women a nd women with prolapse because it resultS
in lesser mo•·biclity. This is combin ed with laparoscopic
CHAPTER 34 - CANCER OF THE BODY OF THE UTERUS 437
lymphadenecto my o r postoperative radiotherapy. With
increased experience in lapa roscopic surgery, most cases
of endometrial cance r ca n be managed by this technique.
A robotic e ndoscopic surge!) is gaining popularity as a
me tJ1od of surgical treatment.
POSTOPERATIVE RADIOTHERAPY
Applicatio n of postoperative •-adiothe•-ap)' depends on tJ1e
surgicopa thological findings a nd staging.
The commonest local metaStaSis occurs in the vaginal
vault in 15% of cases. The incidence now has been reduced
to I %-2% by delh·e.-i ng radiation to the vaginal vault with
the help of tJ1e colpostat 4 weeks after th e surge•) ' (brachy-
therap)•). A dose of 6000-7000 cGy is delivered over a
period of 6 weeks. Vaginal stenosis and dyspareunia are tll e
complications.
Pel vic postoperative radiothe rapy (ex te rnal) in a dose of
6000 cGy over a 6-wee k pe riod is also reco mmended in
high-lisk cases such as undiffe rentiated myo metlial
infiltrati on, pe lvic node involve me nt and in sero us, clear
cell and adenosq uamo us ca rcinoma. The postOperative
radio tJ1erap)' is required in Stages lA (Grade 3), LA2, lB
and ll. For stage Ill and IV, chemo radiation therapy yie lds a
better effecL
Whole-abdomen radiation is requi red when para-aortic
lymph nodes are invo lved, wh ile protecting the liver and
kidneys.
lt is observed tJ1at women who receive pelvic radiother-
apy ofte n develop distal metastasis. There fore, so me advo-
cate pelvic as well as abdominal radio111erapy to improve
their survival.
The most importa nt factors in conside ring tJ1e need for
postsurgical radiotherapy a•·e as follows:
( I ) Histology
(2) Grading as studied by biopsy
(3) Depth of myomeu·ial invasion as seen by ulu-asound,
MRI and at the time of surger y
PRIMARY RADIOTHERAPY
Stages lll and LV are not ope ra ble. They are u·eated with
brachytherapy followed by exte rnal rad iation. T he uterine
cavity can be packed with lleyman capsules. Adjuvant
chemotherapy and progestoge n therapy prolong remission
and improve quality of life. llormona l th erapy is nontoxic
and does no t need hospitali:t.ati on.
PROGESTOGEN$
• Medroxyprogesterone ace ta te (MOPA) I g weekly or
200 mg o rally daily.
• 17-a progesterone or noretJ1 isterone I g i.m. weekly. Nor-
e tllistero ne is su·onge r tJ1an MOPA and suppresses oestro-
gen receptors. Thirt) per ce nt response witJ1 honno ne is
repo11.ed. especiall) with lung metaStasis. Tamoxifen I 0 mg
twice dail) is also useful in reducing oestrogen receptors
(for dlemothemp), refer to chapter 39).
Doxorubicin, platinum and taxa ne/ ca rboplas tin a re
under trial.
438 SHAW'S TEXTBOOK OF GYNAEC OLOOY

• Mirena IUCO is effective against simple endometrial

Stage-wise treatment of carcinoma of the endometrium
hyper-plasia.
Stage lA GI Sur-gery only • Oral combined pills reduce cancer r·isk by 40%-50%.
G2,G3 Stu·ge•1' + vaginal brach)therapy • Tibolone also reduces the r·isk.
Stage IB GI, G2 Stu-ge•1' + vaginal brachytherapy • The complete treatment of PCOS avoids the risk.
IB G3 Stu-ge•1' + \oaginal brachytherapy +
external beam radiotherapy (RT)
to peh is SARCOMA OF THE UTERUS
Stage II Stu·ge•1 + extemal RT + 'oaginal
bracll) the rap) Sarcomas arising from the bod) of the uterus are far less
Stage Ill Surgel') + extemal RT + common than endometrial carcinoma. A sarcoma can arise
brach) the rap)+ chemotherapy either from myometrium or from stroma of endomeuitun.
Stage IV Palliat.he liT + chemotherapy + The uterus can be a site of rare l)pes of sarcoma such as
high-dose progesterone rhabdomyosarcoma, osteosarcoma, chondrosarcoma; the
tissues wh ich are normally not found in the uterus.
Uterine sarcomas are rare mesodermal tumours compris-
RECURRENCE OF CARCINOMA ing 3%-7% of all malignant growtl1s of the uterus and
l %-3% of all ge ni ta l tract cancers. Abo ut 0.5% of all
OF THE ENDOMETRIUM
undergo a sa rcomatous change (Fig. 3 1.10). T he
Recurre nces are not comm on with the ea rly stage disease tumours arise most freq uent! )' in women be tween the ages
(Stage lA, IB); however, rec urrences may be see n with more of 40 and 50 yea rs, and a re rare before 30 years. T he
adva nced stage of the d isease. incide nce of pre menopa usal and postm e nopausal sarcoma
Most recurre nces are observed in fi rs t 2 years; may occ ur is almost eq uall y d ivided. Twen ty-five per cent of pa ti en ts
as late as 5 )'Cars or longe r: a re nulli pa ro us, b ut parity is unrelated in tl1e aeti ology.
About 8% of sarcomas occur in women who received
radiation for carcinoma cervix 8-10 years earlier.
SITES OF RECURRENCE Historicall y, uterine sarcomas have been classified into
The most common site of •·ecurrence is upper 'oagina. The carcinosarcomas, accounting for 40% of cases, leiomyosar-
metastasis occurs in the 'oaginal vault, lateral pelvic wall, comas (40%), endometrial stromal sar·comas (IOo/o-15%)
lymph nodes,lungs,Iher, brain and bones. Distal metastasis and undifferentiated sarcomas (5%-1 0%)
occurs mostly in women who ha'e undergone surger1• and Leiom)osarcoma is the most common t) pe, it is a spindle-
postoperative pelvic radiotherapy. celled wmour arising fr·om a smootl1 muscle of myome-
Poswperative 'oaginal vault radiotherapy reduces the u-ium. To the naked e)e, the cut surface of the tumour is
recurrence in the vaginal \'<lulL haemor-rhagic and irregular, witlJOut the whorled appear-
Recurrences are managed b) palliative chemotherapy. ance of a myoma. The consistenc) is r.;able and soft.
There is a place for radiotherap) in case patiem did not The outline is irregular witl1 imoasion in to the SLUTOunding
receive radiotherap) initiall). structures witl1out a demonstrable capsule. The mucosal
Prog11osis: It depends on the histology of the tumour, form sometimes tends to project in the fonn of a polyp imo
grading, myometrial infiltraLion, pelvic node involvement tile cavity of the uterus, whereas in otl1er cases it spreads
and s taging. Although a 5-year survival rate in Stage l aro und the cavity of the uterus to produce a tmiform
is 75%, it red uces tO 10%-20% in Stage [V. A surv iva l enlargement. Two-t11irds of cases are inu·am ural, one-fifth
rate of 55% in Stage II and 30% in Stage Ill has been of cases are subm uco us and one-tenth of cases are subse-
repo n ed. ro usly located.

Stage-wise !).year survival rates in carcinoma endometriUJll

Srage I 75%
Stage II 60%-70%
Stage III 25%
Stage IV 10%-20%

It is important that a woman who has been treated for

uter·ine malignancy should not be offered HRT for meno-
pausal symptoms.

PREVENTION OF ENDOMETRIAL CARCINOMA

• Adding progestogen for 12 da)S in HRT reduces the risk
of endometrial h)perplasia and cancer to 2%.
• A woman on tamoxifen needs a periodical ultraSound
scanning to stud) the endomeuialthickness. Raloxifene Figure 34.10 Histological picture of leiomyosarcoma (showing
has no adverse effect on the endomeu;tun. mitotic frgures > 10/HPF). (Courtesy: Or Sardeep Mathur, AIIMS)

Metastasis occurs relatively early; the spread OCC tLrs by
t11e bloodsu·earn, by by d irect spread and by an
implantation. As a result of bloodstream dissemination, it
can metastasize to lungs and kidneys and ot11er organs.
Lymphatic spread invo lves pelvic lymph nodes in 35% of
cases in Stages I and II, and para-aortic glands in 15% of
cases. Di rect spread into the peritoneal leads w
multiple metastases over the peritoneum with accompany-
ing ascites and large depositS in tlle omemum. Most
patientS ha'e poor su rviva l after tlle diagnosis of leiomyosar-
coma is made, with an average duration of life of about
2 years from t11e commencement of symptoms.
ln most cases, a diagnosis of a sarcoma comes to light on
t11e basis of histopathology of a specimen of the uterus or
myoma removed at myomectomy or hysterectomy. Failure to
respond and shrink in size follo,,1 ng GnRH administration in
a case of fibroid should stro ngly suggest t11e possibili ty of
malignancy. Positron e mission tOmography (PET), Doppler
ulu·asound and MRI may help in t11e d iagnosis. Witl1 subm u-
cosal wmow-s which produce co ntinuous bleeding, a histo-
logical exa minati on of cure LLings may e nabl e a diagnosis to
be made. Again, a rap id enl arge me mofa quiescent myo ma
in a woman ofposunenopausal age is almost pat11ogno monic
of a sarcomatous change. A sa rcoma of t11e ute n1s usuall)'
causes a rapid en largement of the uterus witll profuse and
inegular vagina l b leedin g. Pain is present in 60% of cases
and fever due to degeneration or infec tion may also occ tu· in
about one-tl1ird of the patientS. If t11e tumour has encroached
upon tl1e of t11e lllenlS and caused posunenopausal
bleeding. diagnosis ma> be made by curettage. The imerpre-
tation oftl1e histoloro is vel') difficult becatt.Se of the presence
of degenerative and infective changes. However·, a mitOtic
cotUH more t11an 10 per 10 high-powered fields and an atypi-
cal cell would suggest a diagnosis of leiomyosarcoma.
Staging of leiomyosarcoma
Stage I Tumour limited to the uterus
lA <5cm
lB >5cm
Stage II Tumour extends to the pelvis
llA Adnexal in volvement
liB Tumour extends to extrauterine pelvic
tissue
Stage Ill Tumour invades abdo minal ti ssues (not just
prou·ud ing into the abdomen)
lilA One s ite
lllB More tha n one site
lllC Metastasis to pelvic and/ or para-aortic
lymph nodes
Stage IV
IVA Tumour invades b ladder a nd/or rectum
LVB Distant me tastasis
TREATMENT
l11e u-eatmem of a sarcoma of t11e uterus consistS of total hys-
terectomy with bilateral salping<H>ophorectomy, followed by a
full course of radiation therap). If t11e growth is in the region
of t11e istl1mus or cen·ix, a radical hysterecwmy of t11e Wert-
heim t) pe with a bilateral I) mph node excision probably offer'S
the best chance of cure, because in many cases t11e glands may
CHAPTER 34 - CANCER OF THE BODY OF THE UTERUS 439
be imolved. This is followed by radiation t11erapy. The &-year
cw·e rate is under 30% and large ly depends on t11e type of
growth, being t11e wor-st in the round cell variety where the
growth originates in t11e e ndomeui um. Metastasis sud1 as
ILmg. liver or brain metastasis is a contraindication to surgery.
Radiotherap) is ineffective in distal metastasis. Chemo-
therapy is the onl) hope and comprises a combination of
cyclophosphamide, vincristine, doxorubicin and dacarba-
Line or vincristine, actinOm) cin and C)clophosphamide
(VAC). lt reduces t11e recurr·ence rate. The conservation of
ovaries does not ach·ersely influence the prognosis, and it is
a wise decision to leme them behind during h)'Sterectomy in
a young woman. Br-east can cer is seen associated witl1 leio-
myosarcoma, so it is pr·udent to screen t11e woman's breasts.
Rhabdomyosarcoma is a rare, highl y malignant tumour
in children. lt is now managed by ch emoradiotl1erapy. The
prognosis is poor with a 5-year survival rate of 40%. A 50%
response is reported ''1th docetaxel a nd gemcitabine.
Progeswge n an d am matase inhibitor hold future promise.
MAUGNANT MIXED MUllERIAN TUMOURS
These uncomm on tum ours of t11e uterus co mprise elements
of mesodermal a nd ec todermal o rigin. In tl1e past, these
twno urs were comm only named as carcinosarcomas; how-
ever, now a preferred te nn is malignan t mixed Mullerian
tLUllo w·s (MMMT). Although the is a common site for
these tLUllOLu·s; howeve t; t11ese can be seen in vagina, cervix
or ovaries.
MESODERMAL MIXED TUMOUR (INCLUDING BOTRYOID
AND GRAPE-LIKE SARCOMA)
Uterine sarcoma arises t) picaII) in t11e body of the utent.S,
whereas a sarcoma of the cen ix is ' e r1 rare. Eight per cent
of cases follow peh·ic racliotherap)'· Pathologically, t11e
tumour-s should be regarded as mesocler·mal mixed wmours
as tlley often contain canilage, striated muscle fibres, glands
and fat. The su·oma is embl')Onic in type, similar LO t11e em-
br)'Onal mesench>•me. A grape-like sarcoma of the cervix
arises typically in adult women, metastases develop rapidly
and local recurrence follows their removal.
Somewhat similar LUmours are known 1.0 develop in t11 e
vagina in children at a ver) ' ea rl y age, and such tumours
contain su·iated muscle fibres and a n embryo ni c stroma.
Rat11er similar wmo ut'S some tim es develop in t11e bod)' of
the uterus in o ld wome n, and in t11is way three types of
mixed tum o w'S, namel)' the vagina l tumours of children,
the grape-like sarcoma of t11 e ce n•ix and t11 e mixed tumours
of the bod)' of tl1e ute rus of old women can be distin-
guished. ln all cases, the prognosis is bad a nd a rap id recur-
rence follows t11e ir re moval.
ENDOMETRIAL STROMAL TUMOURS
Sarcomas can arise rarel) from t11e su·oma of endomeuium.
ll1ese su·omal tumours ha'e a variable course and have
been classified as follows:
l. Stromal nodul es/ su-omal h) per·plasia
2. Low-grade su-omal sarcomas
3. High-grade su·omal sarcomas
440 SHAW'S TEXTBOOK OF GYNAECOLOOY

In most cases, diagnosis is made on the basis of histOlogy

• Alll10ugh simple endomeu·ial hyperplasia leads to
of hysterectomy specimen conducted for irregular, abnor-
endomeu·ial cancer in 2% of cases, atypical hyperpla-
mal uterine bleeding. Sometimes diagnosis can be sus-
sia leads to endometrial cancer in 8%-29% of cases.
peCted on the basis of D&C matetial submitted for histOpa-
• Early stage of endomeuial cancer is treated by h)'Sterec-
thology in a case of abnormal utetine bleeding (AUB).
tomy, bilateral salpingoo()()phorectomy. L) mphadenec-
Although a low-grade stromal sat·coma does not require any
tomy is required in case of deep m)omeuial infiltra-
acljuvant treaunent, patients with a high-grade stmmal s:u·-
tion, endocel"\ical imohement, poor!) differentiated
coma require radiotheraP> and chemotherapy as an aclju-
tumours.
vam treaunenL A high-grade stromals:u·coma is associated
• Cf, MRI are helpful in mapping tl1e m)ometrial in\'a-
with poor prognosis.
sion and l)lnph node imohement.
• Surge I") is the primal") mode of u·eaunent. PostOpera-
Staging of endometrial stromal tumours (FICO 2009) tive radiotl1erap) is required in the advanced stages,
and for reducing the recurrence in tl1e vaginal vault.
Stage I Tumour limited to the uterus • Progestogen and Mirena can prevent endometrial
LA Tumour li mited to endometrium/ hyperplasia. Progestogens are effective in 30% of
cndocervix with no m)'Omeu·ial cases wit.h lung meL<'\SL<'\Sis.
invasion • Sarcomas are mrc tumours arising from the bod)' of the
IB Less than o r eq ual to half myometrial uterus. They ca n be le iom)'OSarcoma, endodem1al stro-
invasion ma l sarcomas, ma li gnam mixed Mu llerian ttunours or
IC More th an half myomeu·ial in vasion rare ly rhabdom)'OSarcoma, osteosarco ma, chondrosar-
Stage II "1\tmour ex tends to the pelvis comas. In most cases, diagnosis comes to li gh t on ll1e
ILA Adnexa l invo lvement basis of histopathology on a hysterec tom y specimen.
JIB Tumour extends to extrauterine pelvic
tissue
Stage Ill Tumour invades abdominal tissues (not
just pt·otruding into the abdomen)
li LA One site
SELF·ASSESSMENT
III B More than one site
I. Describe the clinical featut-es of endometrial cancer.
IIIC Metastasis to pelvic and/or para-aortic
How will )OU investigate the case?
l)lnph nodes
2. What are the high-t·isk cases for endomeuial cancer?
Stage IV
3. Discuss the management of endomeuial cancer.
IVA Tumour invades bladder and/or rectum
4. \\'t·ite shon notes on:
IVB Distant metastasis
• Endometrial h)perplasia
• Mixed mesodermal tumours
• Sarcoma of the uterus
KEY POINTS
• Endometrial cancers account for 20%-25% of all SUGGESTED READING
genital tract cancers. In rich counuies, tl1is is the most Berek and Nomk"s Textbook of Cynaccology, Ada>hi EY, Hillard PA
common gen ita l u·act cancer, whereas in India it ranks (cds}. Nc_mtk"s Cynt-cology. 15th <"<1. Philadelphia, PA: Williams &
Wilkins, 2014.
third after cancer of cervix and cancer of ovary.
Duncan J, Shulman f'. Yearbook of Ob.lclric., Cynaccolob'Y and
• The risk factors are e lder!)' age, unopposed oestmgen Women's llcah h 41:437,2010.
therapy, tamox ifen, obesit)' and hypertension, diabetes S1udd J. Pro!,>Tt"SS in Obs1c1rics and Cynaccology 14: 2000.
as we ll as chroni c anovulaLion seen in PCOS. S1uddj. Pr<>!,>Tt"SS in Obslclrics and Cynaccology 7: 1989.
S1uddj. Pr<>!,>Tt"SS in Obslclrics and Cynaccology 16: 343,2005.
 Pathology of Ovarian Tumours
and Benign Ovarian Tumours

Pathology of Ovarian Tumours M 1 Benign Ovarian Tumours 452

Tumours of the Surface Epithelium
Borderline Ovorion Tumours 444
Germ Cell Tumours 444
Sex Cord Stromol Tumours 447
Feminizing Tumours 447
442 Ovarian Tumours Associated
with Pregnancy 456
Ovarian Cyst in a Menopausal Womon 456
Ovarian Remnant Syndrome 456
Ovarian Tumours in Adolescents 457

_
Virilizing Tumours 448 Key Points 457
Tumours Arising from Connective Tissues Self-Assessment 458
of the Ovary 449

PATHOLOGY OF OVARIAN TUMOURS PATHOLOGY

Ovaries can be the site of a variety of benign and malignant
tttmours. These wmours can be cystic or solid, often a com-
bination of the two. can val) in siLe from as small as
3-5 em to as big as equal to a fu ll-term pregnam uten.lS. They
can be seen in an) age group starting from prepubertal 1.0
adolescent du.-ing reproducti,·e life and postmenopausal age
group. Malignant tumours can develop in any age group.
Ovaries are the site of th ree common types of tumours:
(i) epithelial tumours: those which arise from surfuce lining
of ov;u·ies; (ii) germ cell tumours: those which arise from
germ cells within ovaries; and (i ii ) sex cord stromal tumours:
those which ar·ise fr·om sex cords present in ova ries.
O varian tumour is nota single entity, but a complex wide
spectn.rm of neoplasms in volving a variety of histOlogical
tissues ranging from epithelial ti ssues, connective tissues
and speciali zed horm o ne-sec re ting cells lO germin al an d
embryonal cells. The most common are epithelial tumo urs
forming 80% of all tumours. Eighty per cent are ben ign
tum ours and 20% a re ma li gnant. Of all the malignant
tumours, 90% are epithelial in origin, 80% are primary in
the ovary and 20% secondary from breastS, gastro intestinal
u·ac t a nd colo n. Be nign tumo urs can become secondaril)'
maligna nL Mucinous cyst becomes ma lignant in 5%-9%
but papillary cyst adenoma becomes malignant in 30%-50%
if left un treated.
Unfortunately, patients with ova rian tumotu·s are often
S)'lnptom-free for a long time, and the signs are often non-
specific. B) the time diagnosis of ovarian malignancy is es-
tablished. about two-thirds of t.hese are already fur advanced
and the prognosis in sud1 cases is unfuvourable.
An ova.-ian tumou r· in adolescem and posunenopausal
women is more often malignanL Most genn cell tumour-s
occur in )Ounggirls )Ounger than 25 )ears of age.
ln an attempt to standardi:t.e the nomenclat.ure used in de-
sc.-ibing the diverse varieties of ovarian uuno urs, the World
Health Organiation (WHO) devised a classification listing
nine major groups for benign and malignant tumotu'S
(Table 35.1 ).
Epithelial ova.-ian neoplasms ar·ise from the mesoepithe-
lial cells on the ovar·ian surface. Epithelial cance r'S consti-
tllle about 80% of all ovar·ian cancer'S. The most common
histological t)pe is the papillary serous cystadenomas and
carcinomas accounting for almost 50% of a ll epithelial m-
mow-s. MucinotlS tumotu'S account for 12%-15% of the
cases, clear cell and endometrioid combined about 10% of
the cases, and the unspecified types 25%-27% of the cases.
lf the li ning of tumour-s resembles the lining of epithelial
tumout'S of fallopian tubes, they a re labelled as serous tu-
mours; if th e lining of epitheli um resembles e ndocervical
epitheliu m, they a re labelled as mucinous tum o urs; if the
li ning of epithe liu m resembles e nclome u·iu m, th ey are la-
belled as enclometrio id wmours; and if the lining of epithe-
liu m rese mb les b ladder epithe lium, Lhey are called clear
cell va rieq•.
The degree of cellula r d ifferentiation of the epithe lial
ovarian neoplasm expressed as histo logical grade has an
important sign ificance in prognosis as we ll as in identifying
malignancy.
The criteria of grading used include mitotic count,
stratification, cellular pleomorphism, nuclear atypism and
proportion of solid areas within ll1e tumour.
Grade '0' tumours, also known as borderline malignan-
cies or wmours of low malignant potential (LMP), may
demonsu-ate papillar> wfting, stratification, epithelial
atypia, exfoliation of cellular· cltlSter'S and minimal mitotic
but no stromal invasion. The 5-)ear surviva l of pa-
tients with Stage I Gmde '0' tumour'S is more than 90%
441
4.42 SHAW'S TEXTBOOK OF GYNAECOLOGY

benign coun terparLS. Histologically, tlle benign variety shows

Table 35.1 WHO Classification of Ovarian Tumours C)'Stic spaces, and the lining of the tumour consistS of tall
(Major Groups)
columnar ciliated epithelium resembling tJ1e endosalpinx.
I. Common epithelial tumours: The loculi contain a serous straw-coloured Auid, which may
• Serous t umours be blood stained when malignant transfonnation occurs.
• Mucinous t umours Unless cell ular atypia exceeds four-cell-layer tJ1ickness or
• Endometrioid tumours stromal invasion occ urs, the tumour is classified as border-
• Clear cell (mesonephroid tumours) line or ben ign (Fig. 35.1).
• Brenner tumours
• Mixed epithelial tumours
• Undifferentiated carcinoma MUCINOUS TUMOURS
Unclassified epithelial tumours
Mucinous wmours are multilocttlat.ed cysts lined by epit.he-
II. Sex cord (gonadal stromaQ tumours: lium resembling the endocervix (Figs and 35.3). For-
Granulosa stromal cell tumours, theca cell tumours mer!). were refeJTed 1.0 as pseudomucinotlS C)'SLS, as
Androblastornas: Sertoli-Leydig cell tumours their contentS are not. chemically u·ue mucin. The cut. sur-
Gynandroblastomas
face shows multi loculi and hone> comb appearance. The t.u-
Unclassified
mours are not infrequent, can grow 1.0 a large si£e and oft.en
Ill. Lipid (lipoid) cell tumours weigh as much as 5-10 kg; tJ1ey are often pedunculated.
These may be combined with a dermoid cyst or a 13renner
IV. Germ cell tumours:
• Dysgerminoma
tumour (Fig. 35.'1 ). T hey are us ua ll y tmil at.eral; only 5%-
• Endodermal sinus tumour 10% are bilat.e ra l. T he tumours are most.ly benign; only
• Embryonal carcinoma 5%-10% beco me malignam and 10%-15% a re of LMP.
• Polyembryoma 13ilate ra l wmours are often metastatic from t.he g.lsu·oimesti-
Choriocarcinoma nal u·ac4 main ly mucocele of appendix or prima•)' adeno-
Teratoma carcinoma of appendix or stOmach.
Mixed forms

V. Gonadoblastoma:
Pure
Mixed with dysgerminoma or other germ cell tumours

VI. Soft-tissue tumours not specific to overy

VII. Unclassified t umours

VIII. Secondary (metastatic) tumours

IX. Tumour-like condit ions

compared to 54% survival for patientS with SLage I Grade 3

serous cystadenocarcinomas.
Besides hisLOiogical LLunour grading, Aow C)'lOmeu·y
analysis of wmour DNA comelll provides another method
of assessing wmour differentiation and prognosis.

TUMOURS OF THE SURFACE EPITHELIUM

SEROUS CYSTADENOMA
AND CYSTADENOCARCINOMA
Serous cystadenoma and cystadenocarcinoma are amongst
the most common of cystic ovarian neoplasms, acco unting
for about 50% of all ovarian tumours; of t.hese, 60%-70%
are benign, 15% borderline and 20%-25% are malignam.
Se•·ous C)'St.adenomas occur in the thi•·d, fourth and fifth
decades of life; malignam C)'Stadenocarcinomas tend to oc·
cur more frequently with advancing age; however, no age is
ban·ed. In about half of the cases, they are bilateral. Figure 35.1 (A) A papillary form of serous cystadenoma of t he
Delicate papilla•) ' excrescences may be seen on the sur- ovary. The epit heli um, t hough hyperplastic, Is un doubtedly ben ign
face and with in the loc uli in a benign cyst. In of sero us (x 60). (B) High-power serous cystadenoma (Source: tor (A) Rao KA:
cystade nocarcinoma, coarse papilla•)' growths sp read to Textbook of Gynaecology. India: Elsevier, 2008. Courtesy (B) : Dr Sancleep
tJ1e periLOneal surfaces. T he papillae are friab le unlike th eir Mathur.)
 CHAPTER 35 - PATHOLOGY OF OVARIAN TUMOURS AND BENIGN OVARIAN TUMOURS
Rgure 35.2 Mucinous tumour.
Rgure 35.3 (A) Mucinous cystadenoma. (B) Mucinous cystadenoma.
High power shows cells resembling endocervix. (Courtsey: !X Sa1deep
Mathur)
443
Rgure 35.4 A combined Brenner tumour {solid area) and multilocular
mucinous cystadenoma.
Mucinous lltmo tu-s occur in women between 30 and
60 )'ears. They have a gliste nin g surface, and th e cut section
reveals loc tJi fi lled with mucinous co me ms (Fig. 35.5) . Lfthe
tumour n.tptures, it may lead LO fo nn aLion of pseudomyxoma
peritonei and tJ1e viscera show extensive adh esions. Appencli-
cec tom)' at the Lime of primary surgery preventS pse udomyx-
oma peritonei, as often mucocele of appendix is known to
cause tJ1is complication.
ENDOMETRIOID TUMOUR
Endometrioid wmours are moSU) malignant and accoLUH
for about 20% of all ovarian cancers. They are lined
by a glandular epithelium resembling the e ndometriLUn.
Figure 35.5 A mucinous cystadenoma with its appear-
ance and delicate septa. (Sour09 The Female Genftal Systen1 and
Breast. Base Pathology, Bsevier, 2007)
444 SHAW'S TEXTBOOK OF GYNAECOLOOY
The tumours are of moder-ate size, and are essentiall y
solid, with cystic areas in between filled witl1 haemorrhagic
fluid. In 15% of cases, ovarian endometriosis may coexist.
They are associated witl1 endometrial cancer in 20% of
cases.
CLEAR CELL (MESONEPHROID) TUMOUR
Mesonephroid tumour, also called clear cell carcinoma, is an
tmcommon wmour of the oval). It is composed of large cu-
boidal epithelial cells witl1 abtmdam clear cytoplasm charac-
teristically forming wbules, glands and small C)'Stic spaces
lined by clear cells showing large, dark n llclei prot.ntding into
the lumen (hobnail cells). The LUmour is highly malignant.
BRENNER TUMOUR
Brenner tumour is an un common solid fibroepithelial
tum our acco unting for abo ut 1%-2% of all ovarian neo-
p lasms. On gross appearance, it resembles a fibroma of the
ova ry (Fig. 35.'1 ); its cut Stll'face appears griuy and yellowish
grey. It is generall)' uni latera l, small to moderate in s ize,
mostly ben ign and has no e ndocrine function. Brenner t u-
mour ca n occasion all)' be ma lignan t.
T he tumour is generally seen in women at·otmd meno-
pause, and causes posunenopausal bleeding. Occasionally,
it may be associated with ascites and hydrotl1orax (pseudo-
Meigs S)'ndrome). In rat·e cases, it becomes malignant.
Histologically, the tumour shows a background of fibrous
tissue - interspersed within it are nests of transitional epi-
tllelium (Walthard cell rests). These cells demonstrate a
longitudinal groove t·esembling puffed wheaL As men-
tioned earlier, this tumour may be combined witl1 a muci-
nOLIS adenoma of the ovaq.
SPREAD OF EPITHEUAL TUMOURS OF THE OVARY
When these tumours become malignant and extend
through the capsule, llle) may be seeded on to the peritO-
neal s urface, omentum and intestinal viscera and by trans-
coelomic spread reach the subdiaphragmatic space. The
asc itic fl uid is often b lood-stained and shows the presence
of of tumour cells. The tumour cells ma)' spread to
ll1e para-aortic lymp h nodes, and metaStaSize to tll e liver,
lu ngs, gasu·oin testinal u·acL and other areas. In over half of
ll1e cases, the opposite ovary is also in volved.
BORDERLINE OVARIAN TUMOURS
Borderline ovarian tumour'S or ovarian epithelial tumours
of LMP were first dcsctibed by Taylor in 1929. There is a
broad agreement that a categor)' of borderline tumour ex-
istS. Histologically, these tumours are intermediate between
u·uly benign neoplasms and tl1ose witl1 invasive charactet·is-
tics. Clinically these tumours tend to have LMP.
They are pre,<alent in 2.5/ 10,000 women and account for
IOo/o-20% of all epithelial wmours. 1 o mauer how malig-
nam tlle epithelial ce lls appear, unless the)' invade the
su·oma or are at least four cells high in t11e mucinottS tu-
mour, the) must be classified as of LMP. Miwtic figures
should be less than 4 per 10 high-power fields.
CHARACTERISTICS OF BORDERUNE
OVARIAN TUMOURS
• PatientS have a high survi\<al r-ate of90%.
• Tumours run a t)pical indolent course. It may however
progress to malignancy in 10-15% cases.
• SpomaneottS regr-ession of peritoneal implants is known
to occur.
• Diagnosis mttSt be based exclusive!) on tlle hiswlogical
examination of the ovarian wmour.
• Multiple sections must be examined to exclllde invasion.
Nonepilllelialwmours (germ cell and gonadal stroma) do
not lend ll1emselves to a diagnosis of LMP tumour. Borderline
malignant tumours occ ur in yo unger women (35-55 years),
10 years younger ll1an ll1eir malignant coumetparts.
RISK FACTORS
Low parity, infertility and fa il w-e to lac tate increase the risk
of deve loping t11 ese wmout'S. Unopposed oesu·ogen and
obesity are also like l)' risks. Smoker'S are prone to LMP
tumours. Induction of ovulaLion may also be a tisk factor.
Oral combined p ills do no t provide any protection against
development of a borderli ne ovarian tumour.
PATHOLOGY
Borderline ovarianwmours are mainly serous (endosalpinx
and endocervical type) and mucinous, tlle former being
more common t11an the Iauer.
The clinical features are similar to tllose of benign ovar-
ian tumotu-s, so also ar·e the imestigaLions. The diagnosis is
entirely dependem on several sections studied hiswlogi-
cally; froLen section is necessar1 in )Oung women.
Managemem is individualiLecl according to age, parity
and desire tO conser'e the fenilit) ftmction. Conservative
surgery in the form of O\'llrian qstectomy. ovariotOmy or
salpingo-oophorectOm) is performed. In mucinoLtS border-
line tumo ur, it is prudent to perform appendicectomy as
we ll, because many believe that ll1is ovarian tumoLu· is sec-
ondary to 1J1e appendix. Appendicectom)' avoids occ ur-
rence of pseudomyxoma peritonei. No adj uvant chemo-
therap)' or radiothempy is necessar)', but fo llow-up is
mandatOf)', as rec urrence of l 0%-30% is reponed. Routine
lymp hadenectomy is also not req uired.
GERM CELL TUMOURS
Genn cell wmours arc usua ll y seen in yo ung adolescem
girls before t11e age of25 yeat-s. They account for 15%-20%
of all ovarian tumotu'S. The majol'ity of tumow'S (about
95%) are benign qstic tet-atomas, also called dermoids.
Below t11e age of 20 )Cat-s, 60% of tl1e tumours are of the
genn cell origin, and in girls )Ounger tllan 10 >ears, almost
85% belong to this group and ar-e inmriably malignant.
DYSGERMINOMA
Dysgenninoma corresponds to the seminoma of the testis
and accounts for 3%-5% of all ovarian tumotu·s. It ttSually
 CHAPTER 35 - PATHOLOGY OF OVARIAN TUMOURS AND BENIGN OVARIAN TUMOURS
Rgure 35.6 Ovarian dysgerminoma (Courlesy: Dr Scr;deep Mathur,
AllMS.)
arises in yo un g girls or in c hil d re n, with a n average age of
20 years. T he wm our tends to be solid with a peculiar elas-
ti c rubbery consiste nC)' and a smoo th , finn caps ule. The
cut s urface is ye llow o r grey with areas of degeneration and
haemorrhage. T he si:t.c is va riab le, usua lly moderate usu·
all)' moderate (10·15cm), altho ugh large tumo urs have
been desc ribed. IL is usua lly unilatera l, bilateral in 10% of
cases, occasio na lly undergoes torsion and may, like a ll
solid wmours, be associated with asc ites. The mmour con-
sists of large cells arranged in bunches or alveoli. Lympho·
C)'l.es and giam cells are always found amo ngst the wmour
cells. This appearance of large dark-staining nuclei witl1
clear. almost translucent, cytoplasm and lymphocytic infiJ.
tration of the fibrous septa is diagnostic (Fig. 35.6). The
tumour is neutral and does not secrete either male or fe-
male sex honnones but secretes placental alkal ine phospha-
tase (PlAP), lactate cleh)drogenase (LOH ) and j3-human
chorionic gonadotropin (hCC). A number of patients witl1
a dysgerminoma of the ovary have been reported to show
genital abnormality, with hypoplasia or absence of some
pan of the genital tract. It has been reported in pseudoher-
maphrodites. uch congenital abnonna lities are not caused
by the dysger·minoma and its re moval has no beneficial
effect on tl1 em. The ma li gnancy nne is 30%-50% and
depends largely on tJ1e findings at laparotOmy:
• A unil ateral tum our co nfin ed LO one ovary may behave in
re latively beni gn manne r.
• Extra capsul ar sp read of disease indica tes poor prognosis.
• T he presence of ex trape lvic metastases in tl1e ge neral
peritoneal cavit)', lymp h glands or ome ntum indicates
advanced disease. Conservative surger)' is recommended
as most patients are )'Oung girls. T ho ugh highly radiosen-
sitive, ovarian clesu·uct.ion con u·aindicates the use of
racliotl1erapy in youn g girls. Postoperative chemotherapy
yields 90% success. C hemotherapy comprises:
• Injection bleomycin I5 mg i. v. or i.m. weekly for 12 weeks
• Injection etoposide 100 mg/ m 2 1-6 days every 3 weeks
• Injection cisplat.in 20 mg/ m2 1-5 days every 3 weeks
Alternate chemotherap) regimen are as follows:
• Vincristine, adriam)cin and C)clophosphamides (VAC)
for 12 C)cles cure 86% in Stage I disease.
445
• Vincristine, bleomycin and cisplat.in (VBP) are also effective.
• Carboplatin and ifosfamide combina t.ion is better and
Jess toxic than cisplatin.
• Radiotherap) is emplo) eel only for residual and recurrent
tLLmours.
TERATOMA
Germ cell tumour-s that show differentiation along embry-
onic rather than exu-aembqonic pathways are grouped to-
gether as ter-atomas, and divided into t11ree categories:
(i) mature (benign), e.g. der·moid C)st; (ii ) immature (es-
semially malignant), e.g. solid t.eratoma; and (iii ) monoder-
mal or highly specialited, e.g. struma ovarii.
DERMOID CYSTS (BENIGN CYSTIC TERATOMA)
Of all cystic wmow-s of tJ1 e ovary, 5%-10% are dennoids. A
dermo id cyst is usually uni loc ul ar with smooth surface, sel-
do m a ttaining more tJ1 an 15 em in diameter. It co ntains se-
baceous material and and tJ1e wa ll is li ned in part by
sq uamous epitJ1elium whi ch contains hair fo llicles and seba-
ceous glands. Teeth, bone, ca rti lage, th)•ro id tiss ue and
bronchial mucous me mbrane are often found in the wa ll
(Fig. 35. 7). Sometimes, tJ1e sebaceo us material collects to-
getller in the form of small balls, a nd as many as 1000 seba-
ceous balls have been recovered in a dermoid cyst. The in-
ner surface is called a 'focus' or 'embryo nic node ' from
which the hair project and in whid1 the teeth and bone are
LLSually found. The nomenclature 'dermoid cyst' is inaccu-
rate. for in add iLion to ectodermal tissues, tissues from both
the mesoderm and the endoderm are also see n in some pan
of t11e tLLmour. Moreover, although squamoLLS epitl1eliLUn
usually lines the C) t, columnar and u-ansitional t) pes ar·e
also found. It is extremely r-are for pancreas, liver tissue ar1d
intestinal mucous membr-ane to be presem in the wall of a
dermoid cyst (Figs :l5.8 and :l5.9).
Dermoid C)Sts frequently arise in association with muci-
nous C)Stadenomas to form a combined tumour, pan of
which consists of a dennoid cyst whereas the rest has
Figure 35.7 Dermoid cyst showing a tooth. (Courlesy: Dr KK Saxena,
New Delhi.)
446 SHAW'S TEXTBOOK OF GYNAECOLOGY
Ftgure 35.8 (A) Gross appe<Yance of a cut -<>pen dermoid cyst. Note the
presence of har-bea-ing skin. (B) MRI shcming a dermoid cyst. (C) Tooth-
like calcifications seen In the right hemipehlis suggestive of dermoids.
(Srurt::e (A): Had<er NF, Garrbone ..C. Hebel CJ: Had<er and Moore's
Esser1tials d Obstetrics and G}fleCdogy, 5th ed. Philadelphia: ElsEMer,
2010; Courtesy (B): Dr Parveen Gulati, New Delhi.)
the charac te ris ti c stntcture of a mucinous cyst.aden oma.
Perhaps as many as '10% of dermo id cysts are combined
tumours of this kind. T his assoc ia tion suggestS th e common
origin of t.h e two forms.
Multiple dermoid cysts in t.h e same ovary are we ll recog-
nized and it is not un common LO find two to three separate
dermoids. Extraovarian dermoid cysts arise occasionally in
t11e lumbar region, uterovesical area, parasacral region and
rectovaginal seplltm. Combined tumours tend to arise in
patients between the ages of 20 and 30 years, whereas sim-
ple dennoid C)'SLS ha'e the highest age incidence between
40 and 50 >ears. Ttunours ma), however, arise at any age.
Oermoids are bilateral in 12%-15% of cases.
Dennoid C)'SLS are innocent O\<at·ian wmours but. epider-
moid carcinoma occurs in 1.7% of cases and sarcomaLOus
Figure 35.9 Histological appearance of t he Dermoid cyst of t he
ovary (Mature cystic teratoma). The cyst Is lined by squamous epithe-
lium, Sebaceous glands open Into t he cavity of the cyst, hair folli cles
are also present. (Courtesy: Dr. Sandeep Mathur, AIIMS.)
changes have been desc tibed. Us ually, a sq uamo us cell car-
cinoma deve lops from the ectoderma l tissues but mammary
carcinomas and malignant tJ1yro id tumours have also been
described.
SOLID TERATOMA Of THE OVARY
These tmnours are rare. The) are mostly solid and L11e cut
surface has a peculiar trabeculated appearance. invariably
large loculi are found beneath t.11e capsu le. The solid pan
of tlle tumour contains cartilage and bone, whereas hair
and sebaceous material are found in t.he C)'SLic spaces. The
solid area also contains plain muscle, brain tissue, glia, pia
mater and intestinal mucous membrane. The aLLempt.ed
formation of a rudiment.ary eye has been desnibed
and even the pattern of a fetus has been simu-
lat.ed, tlle so-called embt")Oma. As a rule, however, t11e
formation is a conglomerate, wit.hout. order or arrange-
ment. Most. solid teratomas of t.he oval')' are malignam
tumours because of sat·comatous ch ange, but. about. 20%
are innocent. (Fig. :l5.JO).
Figure 35.10 Benign cystic teratoma. (Source: Diagnostic Gyne-
cologic and Obstetric Pathology. Germ Cell Tumors of the Ovary.
Saunders, 2011 .)
 CHAPTER 35 - PATHOLOGY OF OVARIAN TUMOURS AND BENIGN OVARIAN TUMOURS
ENDODERMAL SINUS TUMOUR
(YOLK SAC TUMOUR)
This is tJ1e second most common type of ovarian genn cell
tLUnour. It is mostJ) unilateral and is characterized by tJ1e se-
a·etion of a large amountofalpha-fewprotein (AFP) in circu-
lation. It is one of tJ1e fastest growing nun ours in the human
bod). Most patients tend to be )Otmg girls between 15 and
25 >ears of age. GI'Ossly these tumours tend to be 10-20 em in
si.t:e with solid-<ystic feel. Cut section shows a variegated ap-
pearance of solid and cystic areas. Microscopically diagnosis is
made based on tJ1e presence of tissue similar 1.0 yolk sac con-
tents. The presence of Schiller-Duval bodies under mia·o-
scope is a diagnostic feature. They tend to spread r·apidly by
local vascular and lymphatic routes. Before tJ1e use of
chemotherapeutic agents, these tumours were considered
highly mali gnanL Howeve r, witJ1 effective tl1erapeutic regi-
men suc h as ' B£P regi me n'. Now a days cure can be expected
with preservaLion ofmensu·ual and reproductive functions.
STRUMA OVARII
Su1.un a ovarii (Fig. :35.11 ) consists of th)•t-oid tissue similar to
that of a Ul)'roid ade nom a. The is solid, consisting
almost en ti re i)' of thyro id tissue, and sho uld be clearly distin-
guished from a dermo id cyst witJ1 tJ1yroid tissue in its wall. To
tJ1e naked eye, the tumour resembles a small mucinottS cyst-
adenoma, but tJ1e material contained in the vesicles is colloid
and gives reaction Lo iodine. Some cases develop lllyrowxico-
sis. Most of tl1e LLUnours are innoce nt., but malignant tl1yroid
tttmotu·s have been recorded. The histoge nesis is supposedly
a dermoid in which the th)rOid tissue dominates at the
expense of the other e lements.
CARCINOID TUMOURS
An interesting tumour of the ovat)', sometimes primary
and sometimes metastatic, is the argentaffinoma. It oc-
curs as a malignam ch ange in a benign dermoid cyst and
presents as a solid yell ow wmour with the histological
pro pert)' of t·educing silver salts derived from the special-
ized Kulchitsky cells of the in testine. It produces 5-
hydroxytrypta mine which ca uses attacks of flushing and
cyanosis.
Figure 35.11 Struma ovaril showing space filled with colloid.
447
MIXED GERM CELL TUMOUR
Mixed germ cell tumours contain two or more recognizable
germ cell enLities, e.g. combination of dysgerminoma, go-
nadoblastoma. teratoma, endodennal sinus tumo urs and
choriocarcinoma. Conadoblastoma contains calcified ele-
mentS, andY chromosome is detected in 90% of nunotu·s.
Fifty per cem tum malignan L
Tumour markers secreted by germ cell tumour
AFP hCG LDH
Dysget·minom a
Yolk sac tumour
Embryonal cell carci noma
.,.,_ -I-
Chol'iocarcinoma
SEX CORD STROMAL TUMOURS
Sex cord su·omal wmo urs o ri ginate e itJ1er from the sex
cords of tl1 e e mbr)•On ic go nad (before tJ1 e d ifferentiatio n of
the gonada l mesenc h)•me into ma le or fema le) o r from tl1e
stroma of the ovary. T heca cells are tJ1 e so urce of ovarian
steroids, so man)' of these are functional and exert feminiz-
ing effects. The embryo nic sex cords may differentiate
along the male line, giving rise to Sertoli or Leydig cell
tumours called androblastomas. The sex cord twnours are
also referred to as
FEMINIZING TUMOURS
GRANULOSA CELL TUMOUR
Granulosa cellwmours are imeresting growths of tJ1e ovary
composed of cells closely resembling the granulosa cells of
the Graafian follicle.
CUNICAL FEATURES
Granulosa cell tumotu-s are fairly comm o n and represem
10% of all solid ovatian wmout'S. T hey can occur at any
age. Of all tJ1e tum o ut-s, 80% occur in women oldet· tJ1 an
40 yeat-s and 5% in prepubertal girls. T he main clinical
feature depends on the oestrogenic acti vity of the tumour
and o nly the larger ones ca use pain and abdom inal swell ing.
Fe mini zing wm o urs secrete oesti'Ogen.
• Whe n thi s uun o ur occ urs befo re puberty, a precocio us
pubert)' (see Fig. 6.5) resu lts with the deve lop mem of
secondary sex ual characteristics, h)•penrophy of breasts
and external ge nitalia, pubic ha ir and myohyperplasia of
the uterus. The endo metrium shows an oesu·ogenic, an-
ovulatory pattern. Removal of the tumour ca uses regres-
sion of all tJ1 ese manifestations.
• When occurring in adu lt life, the oesu"Oge nic effect is less
marked than in tJ1e prepubertal stage. There is no
change in tJ1e secondal") sexual characteristics because
these are alread) established. The effect o n tJ1e endome-
trittm is tl1at of h) peroesu"Ogen ism in ge neral, i.e. an ex-
aggerated proliferative pattern, endomeu·ial hyperplasia
or endomeu·ial carcinoma (Fig. 35. 12). Supet·threshold
level of serum oesu·ogen may lead to amenorrhoea,
448 SHAW'S TEXTBOOK OF GYNAECOLOGY
Figure 35.1 2 Cystic glandular hyperplasia. (Courtesy: Dr Sandeep
Mathur, AIIMS.)
followed b)' prolonged bleeding. In fac t, the behavio ur of
the e ndometrium closely resembles that of metropathia
haemorrhagica.
• ln the posunenopaus;\1 patient, th e most remarkable fea-
ture is postmenopausal bleeding (Fig. 35.12). The sec-
ondary sexual characteristics are less affected, although
h)'Pertroph) of the breast is sometimes seen. The uterus
shows m)Oh) perplasia and cystic glandular hyperplasia
similar to metropathia. Removal of the wmour causes
regression of a ll theseS) mpLOms.
MACROSCOPIC FEATURES
The tumour varies in sit.e from tiny to gross, the average
being LO em in diameter. The shape is oval and the consis-
LenC)' soft. The cut surface is reticular or trabeculated with
areas of interstitial haemorrhage, and shows yellow areas.
The outer surface is smooth and lobulated.
The cells are an-a ngcd either in cords or in trabeculae,
and are often surrounded by stntctureless hyaline tissue,
which resembles the glass membrane of a n atretic follicle.
Moreover, small CaiJ- Exner bodies ca n usually be found in
some pan of the tum o uc These s mall cyst-li ke spaces are
characteristi c fea tures of the granu losa cells of th e Graafian
fo llicle. T hree histological types o f granulosa cell tmnours
have been identifi ed : (i) an ea rly undifferen tiated form
which consists of a solid mass of gran ulosa cell, (ii) a tra-
becular form and (iii) a foll iculo id t)•pe in which the granu-
losa cells are grouped aroun d spaces fi lled with secretion.
Most granulosa cell tumo urs are encapsulated and appear
to be clinically benign. Both appearance of the gross
specimen and the histological picwre may be misleading
as judged by the subseq ue nt recurrence of the tumoLU:
Recurre nce ma> be dela)ed for many years. Kotuneier
reported that malignant recurrence occurs in 50% of
granulosa cell tumours and the term gra nulosa cell carci-
noma is justified.
There is a cenain con-elation between the histo logical
appearance and malignancy. A well-differentiated follicu-
loid appearance has 10% ma ligna nt potential, whereas an
anaplastic, almost sarcomatous appearance has 65% malig-
n am potential.
The metastases are interesting, because Lhe opposite
ovary first becomes invo lved, and then metastases develop
in the ILUnbar region; secondaf) deposiiS become scanered
in the meselllef). liver and mediastinum.
ASSOCIATION OF CARCINOMA OF THE ENDOMETRIUM
WITH GRANULOSA CELL TUMOURS
Excess production of oestrogen can lead to endomeLrial
hyperplasia and development of endomeu·ial carcinoma.
There is a su·ong evidence that carcinoma of the endome-
trium ma>' be associated with feminizing tumours of the
ovat)' in posunenopausal women. It h as been estimated
that in one-fifth of oestrogenic ovarian tumours, an endo-
meLrial cancer will develop. A theca cell tumour is four
Limes more commonly associated with endometrial cancer
tha n the gran ulosa cell beca use of its high oestro-
gen secreti o n.
THECA CEll TUMOUR
T his tumou r is usua ll y seen after me nopause. lt is nearly
a lwa)'S unilateral and forms a solid mass. T he cut surface
is >•e llow in colour and, if stained selec tive ly, lipoid mate-
ria l is characteristically present. The tumour consisiS
of spindle-shaped cells reminiscent o f an ovarian fibroma
LOgetJ1er witJ1 fat-lade n pOI)hedral cells which resemble
the t11eca lutei n cells of the Graafian follicle. The tumour
is imensely oesu·ogenic and causes posLmenopausal bleed-
ing. lt usual!) runs a benign course but malignant fonns
have been described. IL has been shown that both gra mt-
losa cell tumout-s and theca cell wmours mar show lute in-
it.ation of their cells, witJ1 the result that progesterone is
secreted and secretory h)penrophy can be demonstrated
in the endomeLrium.
VIRILIZING TUMOURS
The ovarian tumours which produce male sex hormones
are called viri lizing Ltunours. Virilizing mesen ch)'moma and
o th er virilizing wmo urs of the ovary are grouped together
here for convenience.
ARRHENOBLASTOMA (SERTOI.HEYDIG TUMOUR)
ArrhenoblasLO ma are rare tumours th at secrete androge ns
which cause defeminizaLion fo llowed b)' masc ulinizatio n.
Women in t11e childbearing age may comp lain of altered
body comours, Ratten ing of th e breasiS, and scanty and ir-
regular mens u·uatio n endin g ultimately in amenorrhoea.
Later signs of masculinization sucl1 as increased hair growt11
on t11e face (hirsutism) appeat: Coarsenin g of the features,
enlargemem of the cliLOris (Fig. :33.13) a nd even breaking
of the voice ma> occur. Removal of tJ1e tumour reverses
most of t11e above-mentioned features of e ndome u·ial carci-
noma except the voice change.
The gross appearance of the wmour is like Lhat of other
mesenchpnomas. Gene mil)', ontr one O\'llt) ' is affected. LIS
 CHAPTER 35 - PATHOLOGY OF OVARIAN TUMOURS AND BENIGN OVARIAN TUMOURS
Rgure 35.13 Hypertrophy of the clitoris In a patient with arrheno-
blastoma.
assoctauon with pregnanq• has been reported. The inci-
dence of malignant transformatio n is rmed to be higher
than with feminizing wmours.
Histological!). the tumour reveals a ll grades of differen-
tiation from the testicular adenoma showi ng perfecLly
fo1med seminiferous tubules to a sarcomawus anaplastic
variety, wherein lipoid-containing cells are seen. The diag-
nosis is usually made on the basis of the endoc1·ine behav-
iour of the tumour.
ADRENAL CORTICAL TUMOURS OF THE OVARY
Adrenal cortical tumours ohhe ovary have a resemblance tO
the adr-ena l cortex when examined microscopically and
have been called hypem epluo ma, masculinovoblastoma,
vili li zing luteo ma or clea r-celled tumours. T hese various
appellations show tJutt tJ1 e constituent cells resemble the
large clea r cells of the adrenal con ex or lute in cells of the
corpus lute um. Whateve r may be tJ1 eir u·ue origin, they are
very rare uun o u1'S. The)' a re so metim es masc ulinizing.
HILUS CELL TUMOUR
A rare viri lizing wmo ur a lising from cells in the ovarian
hilum has bee n described in women after menopause. One
interesting feature of tJ1 e hilus cell tumour is the presence
of Reinke crystals in tJ1e cells, a distinguishing featLu·e ofL11e
Leydig or interstitial cells of tJ1e testis.
GYNANDROBLASTOMA
A g) nandroblastoma combines the characte1·istics of Llle
granulosa cell tumou1· and an arrhenoblastoma. This rare
LUmour sometimes arises in d) sgenetic gonads.
449
TUMOURS ARISING FROM CONNECTIVE
TISSUES OF THE OVARY
Of Llle innocent connective tissue tumours of the ovary,
fibromas are the most common.
OVARIAN FIBROMA
Ovarian fibroma comp1·ises about 3% of ov:uian neoplasms
:md has no pa1·ticular age incidence. The twnour is oval in
shape with a smootJ1 surface and large veins always notice-
able in the capsule. The consistency is firm and harder tJum
that of a uterine m)oma. The tumour frequently undergoes
degener-ation so that cystic spaces are found tOwards tl1e
centre. Calcareous degeneration is not uncommon. Th e
tumours are usually about 15 em in diameter but sometimes
become much larger than tJ1is and may weigh as much as
25 kg. Torsion may occur with tJ1 e larger tumo urs.
Microscopic examina ti on shows tJ1e LUm our to be com-
posed of a network of spind le-shaped cells wh ich closely
resemble the spin cUe cells of tJ1e ovalian co n ex. The cell ular
pauern is striking!)' uniform and there is no aue mpt at
nuclear ac tivit)'· Th e association of Brenne r LUmo urs with
ovarian fibroma is known. In large tumours, tl1 e connective
tissue cells are elo ngated and a n inte rcellular matt·ix be-
comes prominent. The tumours are ofte n accompan ied by
ascites. Sometimes, the patient has hydrothorax. T he combi-
nation of an ovarian fibroma with ascites and hydrothorax,
usually right-sided, is known as Meigs syndrome. It is now
accepted Ll1at the diaphragm is porous e ither by reason of
minute foramina or' ia the l)lnphatics. Meigs S) ndrome can
occLLr witJ1 other solid ovarian wmours such as granulosa
cell tumour and Brenner tumour.
Three t) pes of fibromas are recogniLed. In the first type,
the tumour takes tJ1e form of a su1-face papilloma on tl1e
ovary. Ln the second type, tJ1ere is a small encapsulated fi.
broma arising in an ovary so tJ1at nonnal ov:uian tissue c:u1
be recogniLed at one pole of the tumour. In tJ1e third type,
the fibroma replaces tJ1e ovary completely.
HISTOGENESIS OF OVARIAN TUMOURS
FIBROMAS
Small ovarian fibromas form white, ro unded excrescences
in tJ1 e co rtex of the ovaq•. The tum our a rises from the
s u·o ma cells of th e ova ri an co rtex. H istologicall y, a fibro ma
a nd a Brenner wm o ur have a close rese mb lance, apart
from th e inclusion of the epithe lioid Wa ltJ1 ard restS in the
la tter. With subseq ue nt growth , a ca psule becomes differ-
entiated and tl1 e wmou r grows at the expense of the nor-
mal ovarian tiss ue, so that fina lly tJ1 e ovary is completely
replaced by the fibroma. The structure of a large ovarian
fibroma is not unlike tJ1at of the stroma of the ovarian
cortex. except that the constitue nt cells are more primitive
in type.
PAPILLARY SEROUS CYSTADENOMA
Papillary serous qstadenomas almost certainly ongmate
from downgrowths of the su1-face epithelium of tl1e ovary
into the cortex. Small of this son :u·e
450 SHAW'S TEXTBOOK OF GYNAECOLOGY
exu·emely common, even in normal ovaries, and small
cysts, only recognized b)' microscopic examination, are
fairly frequem. Papilla!") forms result from inrracystic
growths inLO these wmours. Papillary serous carcinomas
of the ova11 arise when the imracystic growths become
malignanL
The origin of the wmours from downgr0\\1.hs of Lhe sur-
face epithelium of the ova11 is generally accepted and Lhe
LUmours are regarded as examples of ov:uian Mullerianosis,
with epithelial cells resembling endosalpinx.
GRANULOSA CELL TUMOURS
Granulosa celltumotu-s consist of cells identical to the granu-
losa cells of Gt-aafian follicles and theca cell tumours similar
to the theca interna cell (Fig. 35. 11). As both types of tu-
mours may at·ise after menopause, ,,11en there at·e no Graaf-
ian follicles in the ovaries, the wmours can not be regarded as
being derived from mature cells of this type. They are there-
fore regarded as oliginating in mesenchymal cells which are
differen tiated sexually. The ard1enoblasLOma is regarded
as being derived from mese nchyma l cells of the male type.
The theca cell is rega rded as the honnone prod ucer
in th e oval)'·
TERATOMAS
Teratomas probably arise from totipotent cells, i.e. cells
which are capable of producing ectodermal, mesodermal
and endodermal su·ucture.
MUCINOUS CYSTADENOMAS
The cells of the tumour resemble those of the cervix and
tJ1e large imestine. ·n1e two presem-day tJ1eories are (i) Lhe
tumour represents an example of ovarian Miillerianosis,
with metaplasia of tJ1e ovarian surface epimelium into
cal epimelium and (ii) the tumour at·ises from l:u·ge intes-
tine elements of a dennoid C)'SL
BRENNER TUMOUR
Brenner tumours are often associated witJ1 a mucinous cyst-
adenoma, whet·e tJ1et·e is probably some relation between
tJ1eir origins. The similarity to Walthard inclusions has al-
FIQure 35.14 Granulosa cell tumour, folliculoid pattern. (Crurtesy:
0" Sandeep MathlJ", AIIMS.)
ready been noted and this suggests that Brenner tumo urs,
like WaltJ1ard inclusions, are derived from the genninal
epitJ1elial layer of the ovaq•.
COMPLICATIONS OF OVARIAN TUMOURS
(Table 35 .2)
AXIAL ROTATION: TORSION
Torsion of an ovadan cyst is a common complication, and
occurs in about 12% of cases. Dennoid cyst is me most com-
mon ov:uian cyst to undet·go torsion. Chocolate cysts and
malignant ov:uian wmotu-s are usually fixed by adhesions, so
it is very rare for these ovarian tumours to undergo LOrsion.
On me conu-ary, paraovatian C)'Sts and broad ligament cysts
at·e the most likely pelvic tumours to undergo tOrsion, prob-
ably because tJ1ey develop in the outer pan of the broad liga-
ment and come to lie above the infundibulopelvic fold and
above the pelvic brim so that they have a greater degree of
mobility than otJ1e1· ovarian tumours. In most cases, tJ1e cyst
is about 10 em or more in size when it undergoes torsion.
Because of the hi gh incidence of mucino us cystadenomas,
dermoid cyst torsion is most frequen tJ y seen \\1 \Jl these tu·
mours. There is no particular age incidence. The right and
left sides are involved witJ1 eq ual frequenq•. Usually, the tu-
mour rotates so tJ1at its ame rior surface turns towards the
patient's tight side. It is not uncommon for the twnour to be
rotated tJuough tJu-ee or mot-e complete circles. As a result
of rotation, tJ1e veins in tJ1e pedicle become occluded, the
tLunour becomes congested, and there is interstitial haemor-
rhage in tJ1e wall of tJ1e tumour and imo the loculi. The in-
creased tension causes severe abdominal pain and the signs
of petitoneal irlitation. SubsequentJ), adhesions fonn wim
sunuunding su·uctures, so that tJ1e omen tum and intestines
become attached to the tumou.-. On occasions, me cyst may
become infected.
The most pt·obable explanation of rotation of an ovariru1
cyst is haemod)namic. It is suggested tJ1at some violent
movement, a history of which is almost invat·iably obtained,
initiates tJ1e twist and as a result the ovarian artet)' itself
becomes twisted. The pulsation in the vessel will then cause
a series of tin)' impulses to be u-ansmitted to the pedicle,
each of whicl1 will aggt-avate the twisL After a time, the de-
gree of torsion will be such that tJ1e veins in tJ1e pedicle
become occluded and tJ1e patient compl ains of severe ab-
dominal pain (Fig. 35.1 5).
CUNICAL FEATURES OF TORSION OF OVARY
The woman often presents witl1 ac ute abdom inal pain, fever
and vomiting. Sometimes, she complains of inte rmittent
abdominal pain referred along the ob turato r nerve to along
Table 35.2 Complications of an Ovarian TUmour
Torsion
Rupture
Haemorrhage
Infection
Pseudomyxoma peritoneum
Malignancy
 CHAPTER 35 - PATHOLOGY OF OVARIAN TUMOURS AND BENIGN OVARIAN TUMOURS
Rgure 35.15 The pedicle of an ovarian cyst showing the relations
of the ovarian vessels, the ovarian ligament and the fallopian tube,
together with the anastomosing branch of the uterine artery.
the medial aspect of the thigh. SpnpLOms may start after
empt)ing of bowel in the mom in g.
Ultrasound shows a swollen oedemaLOus ovary, globu-
lar in shape, and free fluid in the peritoneal cavity. The
pelvic findings re,eal a tender mass separate from the
utet·us.
This is an emergency requiring tu·gent laparotomy. The
appearance of torsion of the ovati an tumour does not cor-
relate with the ova.-ian viability, even when the LUmow· ap-
pears blackish. The refore, one is advised LO try and conserve
tlte ovary if possible, unless ga ngrene h as set in. DetOrsion of
tlte ovary and ovariopexy, after remova l of tlte
should be attempted. The ova ry sho uld be observed fo r co-
lo ur cha nge fro m bluis h blac k appea rance to its no rmal ap-
pearance. The tJ teo re tical risk of embolism with detOrsion
does no t normall )' occ ur. The ova ry recove rs and becomes
functional. T his approach is especial!)' important in a yo un g
woman.
RUPTURE
Rupture of an ovatian cyst may be u<u.unatic or spontaneous.
Traumatic ruptLu·e results from direct violence to the abdomen.
It may happen during labour when a cyst is impacted in
tlte pouch of Douglas in advance of the presenting part
(Fig. :35.16). It is not uncommon for a small thin-walled
retention C)Stto rupture during bimanual examination.
Spontaneous rupture of an ovaria n cyst is not uncom-
mon. With malignam O\at·ian tumours, particularly those
of the papillomatous t) pe, the carcinoma cells infiltrate
451
Figure 35.1 6 Ovarian cyst obstructing labour. (Sowce: From Eden
and Holland's Manual of Q)stetrics.)
through the connective tissue caps ule to ulcerate into the
peritOneal caviL). Witl1 innoce nt papillary sero us cystade-
nomas. a similar process ma) take place. The most inter-
esting cases of spontaneous rupture are those arising with
actively growing mucinous cystadenomas. The epithelial
elements of the growt11 g•·ow so rapidl) that t11e connec-
tive tissues of the capsule are unable to keep up
them, and spontaneous ntpwre of the tumour is tlte re-
sult. The mucinous material is discharged into the pet·ito-
neal cavity. In most cases, with a small lea k there is no set·i-
ous but in rare cases, the condition called
pseudom>•xoma of the peritoneum develops (pseudo-
myxoma peritonei).
HAEMORRHAGE
Haemorrhage may occur in a n ovarian cyst. It mostly occ urs
spontaneously, giving rise to ac ute pain s imilar to pain
because of torsio n . Occasiona l! )•, haemo rrhage in cyst can
occur fo llowing asp ira tio ns of cyst.
PSEUDOMYXOMA OF THE PERITONEUM
In this condition, tl1e pe ri to neal ca vit)' is fi lled wi t11 coagu-
lated mucinous mate ria l ad he rent to the omemum and in-
testines. The findings at lap.-·uotomy almost exactly resemble
a boiled sago pudding. The mate tial cannot be removed
completely at operation because of itS auachment to t11e
bowel, and the condition tends LO recur after operation.
Pse udom)'XOma of t11e peritoneum occurs with a
mucinous C)Stadenoma of the ovary, but it has also been
reponed with a mucocele of the append ix and carcinoma
of tlte large intestine in men. In pseudomyxoma of
the peritoneum, the mesothelium of the pet·iLOneum is
converted, in part, inLo high columnar cells which are
452 SHAW'S TEXTBOOK OF GYNAECOLOGY

histologically sim ilar to those lining a mucino us cystade-

noma oftl1e ovary, and these cells secrete mucinous material
into the peritOneal caviL). The prognosis in pseudom)'XOma
of the peritoneum is bad, even afi.er tl1e ovaries and the
appendix are removed, as it is to recur again and again. It
is now believed that mucocele of the appendix may induce
secondaf) ovarian tumour. Tlum:fore, there is a tendtmC)'
gyrwecologiJI!. to rrmmw tilt appemli-Y tiS well, when en-
coulltered tuith muci11011.1 IJII(Iritm tumour, a11d trooid pseudom)'X-
oma of the peritolleum. Pseudom>xoma may be treated witl1
palliative chemotl1erapy.

INFECTION
Infection of an ovarian wmour is infrequent. Most cases
follow acute salpingitis or when the cyst becomes infected
during the pue1·perium as pan of an ascending genital
tract infection. Infection may also follow torsion when, as
a res ult of ad hesions to the intestine, th e tu mou r becomes
direc tly i nfec ted. Infectio n by the bloods u·eam is vef)' un-
co mm on. Infec ted ovarian wm o urs are always adh e re nt
to adjacent viscera and occasionall y disc ha rge the ir co n-
te n ts into th e rec llt rn. Sebaceous ma te rial in a de rmo id
cys t also causes infection in t11e tu mo ur; it may also cause Figure 35.17 A very large beni gn mucinous ovarian cyst wh ich
periton itis. weighed about 50 kg. Note the prom inent veins, displacement of the
umbilic us and oedema of the lower abdomen.
EXTRAPERITONEAL SPREAD
Some ovarian tumours b urrow ex u·aperitOnea lly d t.Lring
tl1eir development and may spread upwards into tl1e peri-
nephric region. The removal of these wmours is extremely
difficult and there is danger of injuring Lhe ureter. During
dissection and removal of such a cyst, large vessels may be
tom in the retroperitoneal space and subsequent leakage of
blood will form a retroperitoneal haemaLOma gi'1ng rise to
shock and requires drainage.
Malignant change : Secondary malignam changes occur
in 50% of serous qstadenomas and 5% of mucinous cyst-
adenomas, but only in I. 7% of dermoid cysts. A long-
standing ovarian cyst may become me site of malignant
change.

BENIGN OVARIAN TUMOURS

T hree commonly seen benign ova ri an tumo urs are Sero us
Cystadenoma, Mucino us C)'Staclenoma and Benign Cystic
Terato ma. T hese can be see n in any age group, however,
more co mm only seen between 20-25 yr of age. T hese three
common benign tu mours ca n prese nt witl1 a variety of symp-
toms such as lu mp abdomen, pain abdome n o r detected
inc idemally at Ll1e Lime of ul traso und being done for some
other ind ications. Figure 35.18 A lateral view of the same patient as In Fi g. 35.18.
Note the lumbar lordosis.

SYMPTOMS
Altl1ough benign ovarian cysts occasionally attain enormous
lllmours. the) catl.Se relat.ivel) few symptoms. Indeed, in
innocent ovarian tumours, t11e patient's attention is first
directed to the abdominal swelling. The average pseudomuci-
nOLIS cystadenoma removed at operation is about Ll1e size of a
football, and it is not until the tumour has read1ed Ll1is size
mat it causes sufficient alxlominal enlargement tO make Ll1e
patient real ice mat sometJ1ing is wrong (Figs 35.17 and 35.18;
Table :l5.:l).
MENSTRUAL IRREGULARillES
Ov;u;an tumours. e'en bilateral, do not generally affect
the menstrual C)cles. The onl) tumours caLISing menor-
rhagia are granulosa and t11eca cell wmours by \1rtue of
Lheir oestrogen honnone secretion. Similarly, masculiniz-
ing tumours cause amenorrhoea and \'iriliLation. Post-
menopausal bleeding may occur in benign Brenner ru1d
femini.dng wmours.
 CHAPTER 35 - PATHOLOGY OF OVARIAN TUMOURS AND BENIGN OVARIAN TUMOURS 453

Table 35.3 Featwes of Benign and Malignant Ovarian Tumours

Benig n Ovarian Tumours Malig nant Ovarian Tumour
History

Not related to age or parity, though most common
during childbearing period
Slow-growing tumour, no pain. No menstrual disorder
unless it is a feminizing tumour or masculinizing tumour
Seen most commonly in adolescents and elderly women- mostly after
50 years of age; low pa-ity or infertile woman
Rapidly growing tumour, pain in advanced stage; postmenopausal
bleeding
Family history of breast, ovarian or colonic cancer

Examination

Usually unilateral, cystic, well-defined and mobile; no • May be bilateral and solid, fixed; ascites may be present; metastatic
ascites (except in Meigs syndrome); no nodules in the nodules may be per abdomen; nodules In the pouch of Douglas
abdomen or pouch of Douglas
Ultrasound

• Cystic well defined w it h or without echoes; no ascites • Often soli d and bilateral fixed wit h Internal echoes, ascites may be
(except In Meig s syndrome) presen t; metastatic nodules may be seen

Doppler Ultrasound

• No increased vascularity • Increased vascularity

PILI RICO -4
• Pulsatile index < 1
• Resistance index < 0.4
MRI andCT

• Similar to ultrasound findings • Metastatic and enlarged lymph nodes may be detected
• CA-125 normal • CA-125 raised more than 35 IU/ml

Operative Findings
Well-defined ovarian cystic or solid tumour; no ascites • Fixed solid tumour, often bilateral - with blood-stained ascites;
or metastatic nodule; often mobile metastatic growth over the omentum and peritoneal cavity; lymph
nodes may be enlarged

PRESSURE SYMPTOMS
The O\'<ltian tumour placed in the uterovesical pouch amerior
to lhe lllenas and those impacted in the pouch of Douglas may
cause increase in fre<1uency of mictu•·ition a nd even UJinary
retention. Pressm-e on lhe rectum is hardly ever notice<!. Mam-
moth tumotu-s such as mucinous tumours may cause d)spnoea
and palpitation, and bi lateral pitting oe<lema of the feet.
PAIN
Normall y, be nign ovarian tu mo urs cause no abdominal pain
a nd are comfortably placed in the abdominal cavity which is
diste nsible. T he ma mmoth wm o ur may however cause ab-
do minal disco mfo rt a nd d iffic ulty in wa lki ng. Acute ab-
do minal pain develops if t11e ova ri a n wm o ur undergoes
tors ion, n tpture o r haemorrhage. An in fected dermoid cyst
is li kel)' to lead to pain a nd fever.
With torsion, t11e woman develops ac ute abdom inal pain,
vomiting and a t tim es low-grade feve•: T he patient may be in
shock, tl1 ready pulse. The abdomen is distended, and
moves poorly respiration. The cyst is tense and tender.
Immediate laparotom) is required to remove tl1e tumour.
Occasional I), tJ1e germ cell tumours occurring in adolescent
and young women grow rapid!) a nd catase alxlominal pain,
which ma) be lhe firstS)Inptom notice<! by tl1ese )'OLUlg girls.
PHYSICAL SIGNS
The O\oarian cyst may present as an abdom inal swelling de-
tected by inspeCLion. The abdom ina l wall can be seen to
move over the swelling when the patiem takes a deep inspi-
ration. The tumour is S)mmeu·ically situate<l in the alxlo-
men. On palpation, tJ1e upper and latera l limiiS of the tu-
mour can be defined, but it is impossible to identil)• tl1e
lower pole of tl1e tumour except in case of a relatively small
cyst with a long pedicle. The surface of the tumour is
smootJ1, or it may be slightl y bossed with multi locular cysiS.
Small cysiS at·e usuall y movable from side to side, but large
tum OUI"S fil ling tl1e abdo me n a nd tumours which have bur-
rowed ex u·aperitoneall y arc fixe<!. T he consisten cy of the
cys ti c tum o ur is te nse and C)'Stic a nd a fluid tl1rill can be
eli cited. So me tim es, a cyst is fla ccid, when a well -ma rked
fluid th rill is obtain ed. It is not unco mm o n fo r hard areas
to be palpated, eve n in la rge ovaria n cystS. T hese a reas in
mucino us C)'Stadenomas arc co mposed of small loc uli
whic h give the wrnour a n almostso lid fee lin g on palpation.
All patieniS wi tl1 an ovaria n cyst s ho uld be examined care-
fully for ascites, beca use the presence of asc ites is a st:J·ong
evidence that tl1 e tum o ur is ma lig na nt Exception is the
Meigs syndrome associated with fibroma, Brenner wmour
and occasionally gmnu losa cell tumour. An ovarian tumour
on percussion is dull over the centre of the tumour but
resonam in the flanks which are occupied by tl1e displaced
large and small bowel. This sign is reversed in ascites. The
legs should be examined for oedema (Fig. 35. 19 ).
The physical signs on bimanual examination vary ac-
cording to the sit.e of the wmour. \Vilh small tum out-s, tl1e
uterus can be identified without difficulty, and lhe ovarian
cyst outlined bimanually. The C)St usually displaces tl1e
454 SHAW'S TEXTBOOK OF GYNAECOLOGY
\ I
I
I
I
8
Rgure 35.19 On the left Is a case of ovarian cyst (A), whereas on the right is the abdomen (B) of a case of ascites. In ascites, the abdomen
spreads much more laterally than In the case of an ovarian cyst.
uterus to th e opposite side. With large C)'SLS, it may be dif-
ficult to o utline the uterus. Even with a large cyst, the lower
pole of the tumo ur may be palpable thro ugh one of the
fornices. The finn, rounded lower pole of the tumour has
a characteristic feel, and Oucwation can usually be de-
tected between the fingers placed in the vagina and tl1e
external hand. It is imponan tto ide nti fy the position ofthe
uterus if possible, as mistakes in diagnosis with innocem
oval;;m C)SLS are almost always because of failure to identify
the body of the uterus separate from the wmour. An ovar-
iall C)'St may simulate very closely a C) stic degenerated
lll)Oma and the diagnosis cannot be made with accuracy
unless the position of the body of the utetus is established.
The cardinal sign that distinguishes a mobile ovarian tu-
mour from a uterine tumour is when the ovat·ian tumour is
raised up by the abdomen and the cervix •·emaitlS station-
ary to the vagi nal finge•-s. In all cases, the pouch of Douglas
shoul d be examined carefull y as the presence of hard n od-
ul es is a strong evidence that the tumour is ma lignanL Per-
rectal examination ca n help to differemiate a n ovari an
mass groove be twee n ute rus and ad nexal mass.
DIFFERENTIAL DIAGNOSIS
T he abdom inal p h)•Sical signs of an ova rian C)'St ma)' be simu-
la ted b)• a fu ll bladder, a pregnan t ute rus, a m)•oma, asc ites
and oth er abdominal tum ours such hydronephrosis, mes-
emeric cyst, retropetiLOneal wmo ur and tuberculous perito-
nitis, especially if encysted by coils o f adherent intestines.
FULL BLADDER
Full bladder is tense and tender, fixed in position, <Ulterior to
the uterus and projecting anteliorly more than an ovariall C)'St,
alld a catheter should be passed to establish the diagnosis.
PREGNANT UTERUS
A pt·egnam ltlerus shou ld be thought of whenever a
tumour is found a.-ising from the pelvis. The exclusion of
pregnanC)' offers no d iffic ul t)' if a ca reful bimanual ex-
amination is made and signs of pregnancy loo ked for.
Appropriate investiga tions such as ultraso nic examination
and a pregnancy test will he lp to rule out pregnancy. Mis-
takes are made because this possibility is not considered,
especially in all unmarried girl who denies history of
amenorrhoea.
MYOMA
A myoma is usuall) hard o•· finn, '' ithout the tense C)'SLic
consistency of a t) pi cal O\oat·ian C)SL Pedunculated alld
degenerated fibroid may ho"e'er be mistaken for all 0\'llr-
iall tumour. Imaging studies such as ulu-asound or 1\00 will
help to rule out such a possibility.
ASCITES
Sometimes great difficulty is felt in distinguishing between
a large O\oarian cyst and ascites. \Nith a lat·ge ova ti an cyst, the
percussion note over the tum our is dull , whereas both
flanks are resonant, In ascites, the note is dull over th e
flanks, whil e tl1e abdomen is t)•mpaniti c in the midli ne.
tl1e physica l s igns of shi fting du ll ness may be ob-
tained. Even witl1 large ova ri an C)•Sts, t11e la te ral borders of
the tumo ur ma)' be palpable a nd the tumo ur may have
some degree of mobi lit)' (Figs 35. 19 and 35.20). Ulu·asound
distinguishes tl1ese two co ndi Lions.
T he most difficu lt cases are those of encysted tubercu-
lo us peritonitis with asci tes. Often, a histOt)' of oligomen-
orrhoea or amenorrhoea ca n be e licited. The tympanic
note over the tumour suggests intesti nal adhesions over
tl)e cyst. The cyst is a lso fixed. In most cases of tuberculous
pe.-iLOnitis. the patient has lost weight a nd is pyrexial,
and tllere ma> be other signs of tuberculosis in the body.
A diagnostic cureuage ma) re,eal wberculous involve-
ment of the endometl'ium.
Ln r;u·e cases, obesit) can be mistaken for an O\'ll tiall C)'St.
The surest method of excluding an O\oat·ian C)'St is tO percuss
tile abdomen below tl1e le,el of the umbilicus. Lf the note is
 CHAPTER 35 - PATHOLOGY OF OVARIAN TUMOURS AND BENIGN OVARIAN TUMOURS
Rgure 35.20 On the left, a cross·sectlon of the abdomen is shown
from a case of an ovarian cyst, whereas on the right is a cross-section
from a case of ascites. With an ovarian cyst, the intestines are dis·
placed dorsally, whereas with ascites, the intestines lie immediately
beneath t he abdominal wall.
tympanitic, an ova r·ian cyst can be excl uded. An ultrasound
scan may be necessa ry in a few cases.
OTHER TUMOURS
Other tum o urs may ca use d ifficulty in diagnosis. Fo r exam·
pie, a large hydronep hrosis may prqject fo rwa rds into the
abdomen. Such a tum o ur always peneu·ates back into the lo in
and is situa ted hig h up in u1e abdomen, we ll above the pe lvis.
Investigations b)' inu·aveno us or re u·ograde p)•elograp hy will
estab lish the diagnosis. Othe r wmo urs s uc h as en larged
spleen, mesenteric cyst, m ucocele of the appendix or gall-
bladder, hydalid cyslS a nd pano·eatic cystS should be consid·
erect iftl1e physical signs of an ovarian cyst are atypical, and if
tl1e tumour lies in mid or upper a bdome n.
Small ovarian C)StS whid1 lie in th e pelvis are palpated
without much difficult). They are movable, witll a tense con·
sistenc) and a smoou1 rounded surface. l unay be difficult to
establish the diagnosis \\ith accuracy if u1e tumour is fixed.
INVESTIGATIONS
• Ultrasound: A transabdominal or transvaginal ultra·
sound (1VS) is the most important investigation. Trans-
abdomina l transducer is employed if tl1e tumour is ab·
domina I. Ou1erwise 1VS gives more detai led features of
Ule tumour.
• A benign cyst is cha t<ICteristically unilateral, unilocular or
multilocular with a u1in wall a nd tl1in septa of less than
5 mm in a multiloc ular cysL The con te nlS are no necho·
genic. T hese Findings alo ng wiu1 no rm al CA-125 level
(below 35 U/mL) in d ica te u1 e benig n na wre of the epi·
Ule lial wm o ur in 95% of cases.
• A raised C'.A-125 leve l is also re poned in abdo minal tuber·
cu losis and pelvic e ndome triosis. On the o ther hand,
on l)' 50% of Stage I ep itJle lial ovarian malignant tumours
have raised levels.
• A solid tum o ur suggests ma ligna ncy except in a fibroma
and Brenner tumo uc Dermoid can be identified by solid
areas in a cystic tumour and occasional presence of a
tooth on ultrasound scanning.
• A menopaus<ll ovat) measures not more Ulan 2 x 1.5 x I em
2×15×1 am in sit.e (voltune 8 mL). A si.te more u1an this is suspicious of
an ovarian growtJ1.
A malignant O\'llt·ian wmour is suspeCLed if ulu-asound
reveals bilateral or a solid tumour with ascites. The tumour
wall is usually thick wiu1 echogenic areas within the tumour.
455
The septtun is more Ul an 5 mm u1ic k wiu1 pap illary projec-
tions from itS wall. E.xcept in Meigs syndro me, tl1e presence
of ascites as shown on ultrasound strongly poinlS to tl1e ma-
lignant nature of the wmour.
Colour flow D oppler, which adds furd1er infonnation of
neO\'liSCttlariLation, indicates increased blood flow tO u1e
tumottr and probabilit) of the wmour being malignanL
Low pulsatile index also suggeslS increased blood flow in a
malignant tumour.
Additional infonnation may be pro\·ided by Ule fol-
lowing:
• Radiograph of abdomen/ pelvis may demonstrate a soft·
tissue sh adow, or· teeU1 in a dermoid (molar tOOth).
• Diagnostic lapar·oscopic examin ation may be needed in a
few cases.
• In all suspected m etastatic ovaria n ca ncers, an upp er
gastrointestinal e ndoscopy and colo noscopy m eal
s ho uld be performed to exclude gastrointes tin al pri-
mary carcinoma.
• Radi ograp h of c hest will ru le o ut pu lmonary metastasis
a nd also hydrothorax in case of Me igs syndro me.
• Breast examina ti on \\1 11 n tl c o ut a primary disease in breast.
CT and MR1 are useful in identif)•ing a dermoid cyst,
haemon·hagic cyst, fibroma, e ndometriosis and hydrosal-
pinx (Fig. :35.1 0 ).
In a malignant tumour; CT a nd MRI ide ntify Ule spread
of the tumour a nd en largement of pelvic and para-aortic
lymph nodes. This helps in planning surgery and poswpera·
tive chemotherap).
Tum our markers such as CA-125 a nd carcinoembryonic
antigen (CEA) are tLSeful main I) in u1e follow-up of cen.ain
tumours. CA-125 is a gi)COpr·otein and surface cell antigen
which is secreted by the malignant epithelial twnours. A
level more tllan 35 U/ mL suggestS malignancy. CA-125 is
also raised in abdomina l tuberculosis and endomeu·iosis.
CEA mor·e tllan 5 ng/ ml is seen in a mucinous ovarian
tumour. It sh ould be emphasi.ted u1at CA-125 is raised in
only 50% of cases in Stage I ovarian cancer and in 90% of
cases in Stage II oval'ian cancer.
Germ cell tumour'S produce hCG, AFPs, PLAP a nd LDH,
and, when combined \\1th ultraso und , improve predictability
of u1 e type of lllmour.
Cytology of asci ti c fluid or asp ira ted cyst flu id either
laparoscopicall y or tu1de r ultrasound g uida nce may reveal
malig na ncy, but false-nega tive ra tes a re hig h. Fine-needle
asp ira ti on cyto logy (FNAC) of a solid tum o ur may give a
clue LO the natw·e of u1e tumour.
TREATMENT
A simple unilocular cyst less than 7 e m is often a functional
cyst and should be observed. Most fun c tional cystS resolve
spontaneotLSly over 4-6 months. A repeat ultrasotmd will
pick up a persistent C)St which requires laparoscopic evalu·
ation. To expedite itS resolution, oral combined pills may be
prescribed for 3- 1 mon UlS in women of reproductive age as
dlis may help in itS resolution.
Simple aspiration of a cyst is not ach·isable, because of u1e
high risk of recun·ence. Besides, if the cyst proves malig·
nant, tlle outcome will be compromised.
456 SHAW'S TEXTBOOK OF GYNAECOLOGY
Laparotomy or laparoscopy is requi red in other cases to
obtain the specimen for histology and for definitive treat-
ment. Even a benign ovari;\n wmour more than 7 em
requires removal; otherwise, it may grow in size, undergo
complications or wm malignant.
Open laparotom) is preferred 10 laparoscopic excision,
although latel) some expert laparoscopisLS are carrying out
Sllrge•) for an 0\'a•·ian tumour laparoscopically.
PROPHYLACTIC OOPHOREOOMY
Bilateral removal of ova•·ies at h)'Sterectomy is also desirable
in a high-risk woman with a fami ly history of ova1ian cancer,
colonic and breast cancer, and previous hyperstimulation of
ovaries in infertility, and in a woman ca•·•) 'ing BRCA-1 and
BRCA-2 gene mutation.
The exact age when p•·oph ylactic oophorectom y is ben-
eficial is difficult to decide and depe nds on the foll owing
considerations:
• At what age does the ovary cease to functio n? This is dif-
ficult to de te lln ine.
• Does the preserved ova ry cominue to function afte r hys-
terectom)'? It is ol)served that fo llowing hysterecto my,
ovarian blood supp ly is compromised and at best it may
retain its function for about <I )'ears.
• Following oop ho rectomy, is H RT effective? T ho ugh effec-
tive, it is advisab le not to continue Hl{f for more than
5 yea rs because of the risk of breast cancer.
• It can cause ovarian remnant syndrome.
SURGICAL TREATMENT OF BENIGN OVARIAN TUMOURS
1l1e u·eatment comprises:
• Abdominal hysterectomy and bilateral salpingo-oopho-
rectomy
• Unilateral ova.-iotomy
• Ov;u·ian cystectomy
• Lapa•·oscopic C)'SteCLOill)"-<>'>arioLOmy
• Lapa•·oscopy/ ultraSOund-guided aspiration and removal
of the C)'St
Abdominal hysterectomy and bilateral salpingo-
oophorectomy is reco mm ended in a perimen opausal
woman, even if th e wmour is be ni g n and unil ateral. The
probability of discove ring mi croscop ic evidence of malig-
na ncy in histologica l s pecimens and th ereby the need for
seco nd s urgery ca n be avo ided.
Ovariotomy/ cystectomy. In a yo ung woman, irrespective
of parit)', conservation of a healthy oval')' is highly desirab le.
T herefore, tJ1e ovarian cyst sho uld be en ucleated (cystec-
tom>'), and iftJ1 is is not possib le, ova rio tomy sho uld be done
by clamping the infund ibulopelvic ligament latera lly, mes-
ovarium in tJ1 e middle, and fallopian tube and ovarian liga-
mem medially. It is important to be certain that the
tLtmour is benign and tJ1e other ovary healthy b)' frozen
section biops).
Laparoscopic cystectomy-ovariotomy is a minimal imoasive
SlLrge•) in 'ogue for small cysts.
Because of the risk of spillage of C)'St comem in a der-
moid C)'St resulting in pe•·itonitis and mucinous material
spillage causing pseudomp:oma pe•·itonei in a case of mu-
cinous C) st, some prefer open surge•) '· In a laparoscopic
sLU·gery, reu·ieval of tJ1 e tumo ur in a plastic bag red uces the
risk of spillage of cyst co men ts.
Laparoscopy carries a low morbidity and allows a quick
recovery without a conventional abdomi nal scar.
Laparoscopic ovarian C)StectOm) is performed by first
aspirating the qst Auid followed b) dissection of the C)'St
wall or by ablation. Mere aspiration of Auid is not recom-
mended on account of recurrence of tJ1e wmour. Aspi-
rated mate•·ial/qst wall shou ld be subjected to histopa-
thology to rule out cancer. Ablation of the cyst \\'<Ill
carried out wiili cautery or laser ca•..-ies the risk of recur-
rence of the C)'St. While dissection or peeling off of the
cyst " -all avoids •·ecu1-rence, bleeding du•·ing dissection,
adhesion formation and !'eduction in the ovarian reserve
(because of desu·uction of a portion ofthe ovary) are tJ1e
disadvantages.
OVARIAN TUMOURS ASSOCIATED
WITH PREGNANCY
A variety of cysts o r tum o urs may be d iscovered in assoc ia-
tio n with pregnanC)'· T hese include corp us lULeum cyst,
dermoid C)'S4 germ cell wrn o urs or rare l)' epithe lial ovar-
ian carcinoma. An asymptomatic tumo ur is discovered
during ro utine ultraso und scannin g in ea rly pregnancy.
Symptomatic tumo ur however presents with abdom ina l
pain in pregnancy.
Corpus luteal C)Sl regresses after the 12th week and can
therefore be observed. The benign tumo ur sho uld be
removed in the second trimester between t11e 14tll and
l6tJ1 weeks. Earlier stwge•) ma> increase the .-iskofabortion,
whereas laparotom) in the tJ1ird u·imester increases tJ1e sur-
gical difficult) becalLSe of tJ1e growing utenLS; pretenn la-
bour is also a possibility. The tumour discovered late in
pregnancy should be remo,ed in early pue•·pe•·iwn to avoid
torsion and infection. The malignant O\'<llian tumour re-
quires laparotomy at tJ1e earliest, irrespective of tJ1e duration
of pregnanC)'·
OVARIAN CYST IN A MENOPAUSAL
WOMAN
A sim ple unil ocular cys t measuring less tJ1 an 5 em can be
observed with repeatu lu·asound and CA-125 eve ry3 months.
Many a tim e the cyst resolves in 6 mo ntJ1 s. A pe rs is te nt cyst
calls for its re movallapa roscopically or by laparo tomy. Asp i-
ration of the C)'St is co ntra ind icated because of low yield of
malignan t cells (false-nega tive) and possibilit)' of sp read of
malignanC)' if tJ1e C)'Sl proves ma lignant. Many perform bi-
lateral oophorectomy and hysterectomy in perimenopausa l
women with persistent o'oarian cyst.
OVARIAN REMNANT SYNDROME
O varia n rernnam S) ndrome follows hysterectOmy in 1.4% of
cases. It is calLSed b) O\'<llian ad hesions to the 'oaginal \'<lult,
and causes C)clical abdominal pain and deep d)-spareunia.
It requires oophorectomy. The retained ova•)' may also de-
velop malignancy in I% of cases. A pan from these, it is also
 CHAPTER 35 - PATHOLOGY OF OVARIAN TUMOURS AND BENIGN OVARIAN TUMOURS 457

( Ovarian Tumours J

Adolescents Reproductive age Elderly Women

1
Tumour dysgerminoma. yolk • Fooctional cysts Most tumours are malignant
sac tumour, teratoma and • Endometrioma • Surgery
Olher germ cell tumours • Benign ovarian • Hysterectomy +bilateral

1
• Malignant ovarian tumour salpingo-oophorectomy
• Radical with lymphadeneciOmy

Conservative surgery followed

by chemotherapy

L
Functional cyst <7 em
l
Ovarian tumou r surgery
( Chocolate cyst]
• Observe lor 6 months - oral • Surgery • Hysterectomy + BSO
contraceptive 3-4 months • Ovariotomy
• Persistent- conservative surgery • Cystectomy
• Peel off/excise
• Ablation

Rgure 35.21 Flowchart of ovarian tumours in adolescents.

observed that man> ovaries atrophy premarurely (within

4 years) following h)Sterectomy, if the ovarian vessels get KEY POINTS
kinked and obliterated during hysterectomy. • A \'ariel) of ovarian tumours are known LO arise from
the ova•)· t. lan> of these are malignam potential. The
tumours are often as)lnptomatic to begin with, and
OVARIAN TUMOURS IN ADOLESCENTS are often fur ach anced b) the time the) are diagnosed.
(Fig. 35.21 ) These tum out-s can be C) stic or solid.
• ln young girls below the age of 25, most tumours are
Before the age of20 )Cars, of all ovarian tumours, 60-80% germ cell tumours. Conservati'e surgery followed b)'
are genn cell tlUnours and most of them are malignanL chemotherapy (BE.P) helps to cure these tumours.
Epithelia! tumotu-s are uncommon in adolescent pe- • Sex cord tumout'S have a potemial to secrete hor-
•·iod. Dysgerminoma is the commonest tumour in this mones which may present with clinical S)'mptoms such
group. Conservative surgery followed by che_mother·apr ts as precocious puberty, mensu·ual disturba nces and
the best approach in management. It helps m preservmg postmenopausal bleeding. Vi.-ilizing effectS may be
menstrua l and reproductive functio ns. observed in masculi nizing tum ours.
• Bilate t-al tum ot u-s, rapidly growing tum o urs and pres-
Differential diagnosis of adnexal masses
ence of asci tes are suggesti ve of malignancy and
Pr-emenarchial Reproductive Age Postmenopausal require investi ga ti ons.
• Tum o ur market-s s uch as C'A- 125 and CEA are particu-
Ge rm cell Fu nc tio na l ova ri an Ovarian la rly useful in postme nopa usal wo men suspected of
tu mo urs cyst malignancies having a malignan t. epit.helial cell uuno ur. Markers
Tuberc ular Pelvic innamma tory Subsero us such as alp ha-fet.opro te ins, LOH and hCG are helpful
masses d isease fib roid in making a d iagnosis of germ cell tu mours.
Pelvic kidney l!:ndomeu·ioma Pyometra • Imaging moda li ties such as ultrasonogmp hy, CT scan
Ectopic pregnancy Colonic carcinoma and MRI he lp to detect ovarian neoplasms, and assist
Broad ligament in staging of ovarian cancers.
tumour • It is important to differentiate between benign and
Tubercular masses malignant en largemen LS of the oval') to instirute
Ovarian tumours time!) and effecti'e treaunent wit.hout dela).
• Benign O\'a.-ian tumours are surgicall) dealt with by
Often to make a co•,.ect diagnosis ulu-asound, CT, MRl ovarian qstect.Om). ovariotOm), laparoscopic dissec-
and tumour marker a•·e needed. Treaunem depends upon
tion of the C)St in a )Oung woman and hysterectomy
age of patient, underline pathology and her desire to pre-
with bilateml remo,oal of adnexa in an older woman.
serve reproducti'e organs.
458 SHAW'S TEXTBOOK OF GYNAECOLOGY

4. Write sho rt notes o n:

SELF-ASSESSMENT • Brenner tumour
• Mucino us epithelial wmo ur
I. An l 8-yea1'-0id girl prese ms with a n a bdo minal tLunoLtr • Arrhe noblastoma
and slight a bdo min al pain. DisctLSS the differential diag- • Theca cell tumo ur
nosis and manage men L
2. A 36-)ear-old parous wo man preseniS with ascites and
SUGGESTED READING
alxlo minal lump. Discuss the diffe rential diagnosis.
Sengupta S. Chauopadh)il). \'anna. Cp1ac<:ol01>') for Postgraduate and
3. A 30-yeai'"Oid 110man, pru-a 2, preseniS 11ith menorrhagia of Practidoners. 2nd Ed. El,.,1icr, 2007.
6 months' dw-ation. An abdominal twnour is palpable ab- Studdj. T he ad nexal mas.. In: Pr<>l>""'" in Obstetrics and C p1aecology
dominally. Discuss the differential diagnosis and managemenL 17: 306. 2006.
 Ovarian Malignancies
dinicol Features 465 Germ Cell Tumours
Screening for Ovarian Cancer 466 Sex Cord Stromal Tumours 469
Investigations 4 66 Fallopian Tube Cancer 469
Surgical Treatment of Carcinoma Ovary 467 Key Points 470
Chemotherapy for Ovarian Carcinoma 467 Self-Assessment 471
Ovarian cancer is u1e fouru1 most common cancer among
women afler breast cancer, cervical cancer and gall b ladder
cancer. ln India 45,23 1 ovarian cases occ urred in 2015 and
estimated 59,276 cases wi ll occur in 2020. Ovarian cancer is
u1e second most common of all geniLal cancers with high
case-fatality rate and accounts for 10%-15% of all gynaeco-
logical cancers in developing counu·ies including 1ndia.
Over the past two decades, u1ere has been an increase in the
incidence as well as SUIVival rate amongst women with ovar-
ian cancer. The l'isk of a woman developing cancet· of the
O\'<ll")' in her lifetime is a•·ound I :70 to I: I 00. Women of low
patity, decreased fenility and dela)ed childbearing appear to
be more predisposed. There appears to be a familial predis-
position to the disease. Association between O\'<ll·ian cancer,
colon, breast cancer and endometrial adenocarcinoma has
also been •·ecogniL.ed. In such families, cancers tend to occur
at a younger age (less Ulan 40 years). Five to ten per cem
malignam ovarian tumours at-e genetic, and BRCA-1 and
BRCA-2 gene muLations are implicated. BRCA-1 gene muta-
tion on chromosomc-17 and BRCA-2 gene mutation on
chromosome 13 are noted. 13RCA-1 is more carcinogenic
Ulan 13RCA-2, it occurs cadi er in life. With one family mem-
ber affec ted, tl1e lifelong risk is 2.7%, but it goes up to 13%
two or more relatio ns. T he risk increases with age up to
70 years. T he pattern of inheriLance is aULosomal dominant,
and ovarian tum our occ urs at a younger age below 50 years,
assoc iated witl1 a risk of breast and colon ic cancer. Occur-
rence of mumps before menarche and multip le ovulations
in LVF (in vitro ferti li:t..'ltion) programme appear to increase
u1e tisk of ovarian malignancy in later life. Geographical
variations are suggestive of u1e fact u1at high dietary fat
intake, the use of talc on the petineum and industrial pollu-
tion are environ men La I facLOrs implicated in the high inci-
dence in the West. Protective facLOrs include multipal'ity,
breastfeeding, anovulation and use of oral conu-aceptive
pills. These conu-aceptive pills reduce the incidence of O\'<ll"·
ian cancer b) 10%-50% and the beneficial effeCL extencls
for about LO )Cars after stoppage of pills. The effect is also
dose dependent. Repeated ovulation as seen in induction of
of Ovary 468
ovulation, LVF, low parity suggests ov ulation u·auma to the
epithelial lining to be carcinogen ic. La te diagnosis and earl)'
metastasis are responsible for the poor sutv iva l rates. No
satisfactory method of mass screen ing has as yet been devel-
oped, so only 20% of cases at-e confined to the ovaries at tl1e
time of diagnosis. Eight)' per cent of ovarian malignancies
are of epit.helial ol'igin and almost SO% are in SLage lll or rv
at tl1e time of diagnosis. In )Otmger patientS, genn cell
tLunow·s are more frequenU) encountered when tumOLLr
markers such as alpha-feLOproteins (AFPs), carcinoembry-
onic amigen (C£A) and human cho•·ionic gonaclou·opin
(hCG) are useful. In O\'lll)' eighty per cem are ptimary
and 20% at·e secondat)' from u1e breast, colon, stOmach
and uterus. Risk of malignanc)' increases with age. Bilateral
wbectomy or h)-sterectomy •-educes the tisk of O\'<ll·ian
cancer, if tl1e theory of mutagen ascending u1e genital u-act
is correct ('la ble :36. 1).
New Histological!)' ovarian tumours have wide vatiations.
They are grouped as follows:
l. Epet.hilial Ovarian Turnou t'S: 80-90%
2. Germ Cell Tum o urs: 10- 15%
3. Sex Cord Tum ours: 5%
4. Metastat.ic Tumours: 5-8%
5. Unclassified Tumours
Table 36.1 Risk Factors for Ovarian Cancer
Age - between 45 and 60 years
Nulliparous Of of low parity
Woman with previous PCOS, Of on tamoxifen
High-calorie, high-fat diet
Genetic predisposition BRCA-1 and BRCA-2 gene mutation
Late menopause
Family history of breast and gastrointestinal cancers
Multiple cycles of ovulation Induction
459
460 SHAW'S TEXTBOOK OF GYNAECOLOGY

Non epithelial ovatian tumours: These include malignan-

cies of (i) genn cell origin, (ii) sex cord su-omal cell origin,
(iii) metastatic cancers and (iv) rare malignancies such as
lipoid celltLunours, sarco mas.

EPITHELIAL CANCERS OF THE OVARY

Sevelll)·five per cem of epithelial cancers are of the serous
histo logic t)pe, about 10% are mucinous and 12%-15% are
endomeu·ioid. Brenner wmour, clear cell carcinomas and
undifferenti ated cancers account. for I% or less each. Ead1
tumour type has a histologic pauem similar LO a pan of the
upper genital tract, e.g. serous or papillary (Figs 36.1-36.3)
pauern resembles the lining of the fal lopian tube, mucinous
tumours have lining r·esembling the endocervical glands and
t11e endometdoid tum out'S have a pauern resembli ng Lhe
endomeu·ium.
As much as 50% of benign serous epitl1elial tum o urs
undergo secondary maligna nt change, but o nly 5% muci-
no us cysts undergo ma lignant tra nsforma tio n.

Figure 36.3 (A) Brenner tumour nests of transitional type cells

within a fibromatous stroma. (B) Clea- cell: Tumour cells a-ranged in
a papillary and glandular pattern with moderate to abundant clea- to
eosinophilic cytoplasm, vesicular nucleus with prominent nucleoli
Rgure 36.1 Bilateral papi llary ova-ian carcinoma. and hob nailing. (Courtesy: Dr Sandeep Mathur. AIIMS.)

Ten to twemy per cent of these wmow'S are of low malig-

Rgure 36.2 Serous carcinoma of the ovary. Tumour cells
arranged in papillae and nests with marked nuclear atypia and
the presence of stromal Invasion. (Courtesy: Dr Sandeep Mathur,
All MS.)
n am potential ( LMP) and arc labelled as borderline tu-
mo urs (Grade 0). T hey tend to re main co nfin ed to tl1e
ovaries for long and predomi na ntly occ ur in t11e premen o-
pa usal age groups (30-50 )'Cars). T hey are with a
good prognosis. Five-yea r surviva l is 90%. In conu·ast, inva-
s ive cancers are often seen in wo men aged 50-70 years, and
they spread rapid l)'·
CRITERIA FOR DIAGNOSIS OF BORDERLINE TUMOURS
(SEE ALSO CHAPTER 34 ON OVARIAN TUMOURS)
• Epitl1elial proliferation witl1 papillary formations and
pseudosLrali ficatio n.
• Nuclear atypia and increased mito tic ac tivity.
• The absence of Lrue sLro ma l invasion.
• Borderline wmours can be either epithe lial o r mucinous
vatiel) (Fig. :l6. 1).
These tumours a t-e d escri bed in the chapter on Ov:uian
Tumours. Only serous and mucinous epilhelialtumo ut'S fall
imo this group of borde dine O\oarian wmout'S.

Rgure 36.4 (A) Mucinous tumour of ovary. (B) Mucinous cystadeno-
carcinoma of ovary: Ovarian cyst lined by a single layer of mucinous
cells. (Courlesy: [) Sardeep Matll.lr, AJIMS.)
NONEPITHELIAL MAUGNANCIES OF THE OVARY
Nonepithelial malignancies of the ovary accou nt for 10%-
20% of a ll ma li gna ncies of the ovary. T he details of th ese
types are as foil ows:
Omn cell are de rived f ro m th e primo rdial
germ cells of tJ1e ov<uy These in c lude:
• Dysgermino ma (refe r to C hapte r 35; Fig. 36.6 )
• Te ra to ma; (a) ma wrc, dermo id cyst, (b) immaLUre- solid /
qstic and (c) monode nnal temtomassuch as s truma ovarii,
carcino id, mixed and o tJ1ers (Figs 36.5 a nd 36.8)
• Endodermal s in us tu mo ur (Fig. 36.7)
• Embryonal carcinoma
• Polyembryoma
• Choriocarcinomas
• Mixed fonns
GERM CELL TUMOURS
DYSGERMINOMA
D)'Sgenninoma are tJ1e commonest germ cell wmours of
ovary. They account for 15-50% of all genn cell wmours.
CHAPTER 36 - O VARIAN MALI GN ANCIES 461
Figure 36.5 (A) Immature teratoma. (B) Immature teratoma: Tumour
composed of mature elements (hyaline carlilage, glandular lining) as
well as immature neuroectoderm.
They are mostly seen in young adolescent g irls, occasio n-
ally tJ1ey may be seen in association with pregna ncy. T h ese
tum o u r are fema le co unterpart of seminomas sam e in boys.
Most of these tu mo u rs do not p rod uce a ny wmo u r m a rker,
e leva te d levels of LOll a nd alkali ne p hospha te
may be see n in mos t of tl1 csc tum o urs. In 10-15% cases o f
d ysgermino ma low level of I ICC may be no te d. Most o f th e
tum o u rs a re uni la te ra l b u t in 15-20% cases may be bi la t-
eral. ln most cases tum o ur size is be twee n 10-25 e m, rare ly
tumo u r can a tta in la rge size. This tu mo ur has p ropensity to
dissemi na te b)' l)•mp hatic spread. In 5% of g irls with d ysger-
mi noma external gen ita lia may be ambiguo us. Dysgermi-
noma can also occur in dysgenetic gonads, especially if
chromosomal pattern is '16XY. At laparotomy tumo u r is
found to be well and capsulated in most cases. At c u t sec-
tion twnour is predominantl) solid with few C)'Stic areas.
The LU1der microscope tumour consistS of large cells ar-
ranged in groups of aheolar fashion. L)1nphocytes and
giam cells are diffuse I) present among tumour cells. Pres-
ence of large dark staining nucleus with clear C)'Stoplasm
and I) mphoq lie infiltration of fibrous septa is diagnostic of
d)'Sgerm i noma.
462 SHAW' S TEXTBOOK OF GYNAECOLOGY
Rgure 36.6 (A) Ultrasound appearance of dysgerminoma of the
ovary showing solid t umour w ith mixed echogenlc ity. (B) CECT image
of germ cell tumour of ovary showing a solid tumour w ith intact t hick
capsule.
Figure 36.7 Endoderrnal sinus tumour of ovary.
D)•sge rmin omas are highly rad iosensiti ve (tho ugh radio-
the rapy leads to future infe rtili ty). The)' a lso respond well to
chemo th erapy witho ut ime rfe li ng with fu tu re fe tt ility and
therefo re chemotherapy is prefeHecl.
Figure 36.8 (A) Solid teratoma of the ovary. (B) Teratoma of ovary
showing mesodermal (hyaline cartilag e and smooth muscle} and en-
doderm al (Intestinal epi thelium) elements. No Immature component is
seen. (Courtesy: Dr Sandeep Mathur, AIIMS.)
ENDODERMAL SINUS (YOLK SAC) TUMOUR
9 AFP , d- ldntitypsin
Endodermal wmour ahJ10ugh a rare tumour is t11e
second most commo n genn cell Ltuno lll·. It is thouglu
LO originate from a multipotent embryonal tissue as a
res ult of selective differentiation o f yo lk sac su·uctttres
(Fig. :HI.9 ). This explains wh y the tumo ur is rich in AF Ps
and alp ha-1-a m iu-ypsin. In most cases this tumo ur tend to
be unila te ra l. Histo logically, the tu mo ur cha rac te ristically
p rese nts with pap illary proj ec tio ns co mposed of a ce ntra l
co re of b lood vesse ls e nveloped by immature ep ithe liu m.
Intracell ula r and ex tracellular hya li ne drop le ts are pres-
e nt in all tum o urs, Schiller-Duval bodies. The AF P con-
tent can be stained by immunoperoxiclase techniques.
Most of th ese patients at·e children or )Otmg women, pre-
se nting with a bdomina l pain a nd a pelvic mass. T he tu-
mo urs a t·e kn own to g row rapidl y. AhJ1 o ugh considered LO
be hig hl) ma lignatl l, L11ey respo nd LO chemotherapy witll
good survival rate .
CHORIOCARCINOMA
Rarely see n in a p ure form, ge nera II)' choliocarcinoma is a
pa tt of a mixed germ cell turn o ut: Its origin as a terawma
ca n be confi rmed in prepuber tal girls, when the possibility
of its gesta ti onal origi n can be defini tely excluded. T he
wm out'S are very vascul ar.

Rgure 36.9 Yolk sac tumour: Tumour cell s arranged in a retic ular
pattern in a loose, hypocellular stroma (Courtesy: Dr Sandeep Mathur,
AllMS.)
Hiswlogicall )'• the tumo ur shows a d imo rp hic pop ula-
tion of syncy ti otrop hoblasts and C)' Lo u·ophoblasts. It se-
cretes large q uantities of hCG hormone, which forms an
ideal tumour marker in the d iagnosis and management of
tl1e wmour. The tumo ur is high ly ma lignant, and metasta·
sizes by bloodstream to the lungs, brain, bones and otl1er
viscera.
EMBRYONAL CELL CARCINOMA
Embl')onal cell carcinoma is a rare wmour accounting for
about 5 % of all genn cell wmours, and occurs in prepu·
benal girls. It elaborates both AFPs and cho•;onic gonado-
Lropins. It is associated with the S)lnpwms of precocious
pubeny and menstmal irregula•·ities. It is highly malig-
nanL The condition may be associated witl1 fever due to
torsion, ruptu1-e and haemorrhage.
CUNICAL FEATURES OF GERM CELL lUMOURS
Of all ovarian tumou•'S 10-15% are genn cell wmours. Most
of these tumou i'S are malignant except mature C)'S tiC tera-
toma. The incidence of ma lignam germ cell tumours is
lower in Ca ucasian whi tes, b ut threefold higher in Asians
and Afro-Americans. Man)' of these secrete b ioc hemical
substances whi ch are used as wm o ur marke •'S; fo r example,
embryonal ca rci nomas (A FP, hCG), endode nn al s in us tu·
mo ur (AF P) and cho ri oca rcino ma (hCG) . D)'Sgermino ma
and p ure germi nomas do not secre te these markers, but
secrete lactose de hydrogenase.
Al tl1ough dysgerm inomas are highly radiosensitive (though
radiotl1erap)' leads to fuLUre infertili ty). They also respond
equally well to chernOLherapy. In young patientS use of d 1emo-
tl1erapy is desirable for preseni ng fmure fenility and ovarian
fi.mction.
SEX CORD STROMAL TUMOURS
Sex cord stromalwmours are ei1J1er benign or malignant.
The benign wmours a•·e desc•·ibed in Chapter 35. These
account for about 5%-8% of all ova•·ian malignancies.
This group of ova•·ian neoplasms is derived from the sex
CHAPTER 36 - OVARIAN MALI GN ANCIES 463
Figure 36.1 0 Arrhenoblastoma. (Courtesy: Dr Sandeep Mathur,
AIIMS)
cords and th e ovarian stroma or mese nc hyme. T hese
tu mo urs are composed of var ious combina tio ns of cells
consisting of 'female cells' (gran ulosa, theca cells) a nd
'male cells' (Serwli, Leydig cells) as we ll as morpho logi-
cally indifferent cells (Fig. :lii. IO). They are also called
mesench)'lnomas. The tumours of eli nical imerest are the
following.
GRANULOSA CELL TUMOURS
GramLiosa cell wmours secrete oestrogens. Depending on
the age of tl1eir appearance, t11e) ma) caLLSe precocious
pubeny. Menomeu·o•·rhagia and episodes of abnonnal uter-
ine bleeding (AUJ3) are not uncommon in women of child-
bearing age and postmenopausal bleeding in elderly
women. Endometrial hyperplasia occu•'S in 25%-50% of
patients, and endomeLrial ca•"Cinoma occu•'S in about5% of
cases. Theca cell tumour is more oesLrogenic and more
likely to cause endomeu·ial cancer. A g•-anulosa cell tumour
secretes inhibin, a marker for this tumour. Often u1mour
has component of granulosa cell tumour and tl1eca cell tu-
mo ur. Hence, tl1ese tumotu'S are also called as Theca Granu-
losa Cell Tum o w:
ANDROBLASTOMAS OR ARRHENOBLASTOMAS
(SERTOLI-LEYDIG CELL TUMOURS, Fig. 36. 10)
An d rob lasto mas or arrhenoblastomas occ ur com mon l)' in
the tl1i rd and fo mtl1 decades of life. Th ese tu mo urs are very
rare and acco unt for 0.2% of all ovarian neop lasms. T hey
secrete androgens and cause clefeminiza tion followed by
masc ul inization. The women experience o ligomenorrhoea
followed by amenon·hoea, Oattening of the breasts, acne,
hirsutism, enlargement of t11e clitoris and finally a change
in voice. On removal of t11e tumour, all t11e above changes
reverse except voice change.
UNCOMMON OVARIAN CANCERS
Uncommon ovarian cancel'S comp•·ise only 0.1 % of all ovar-
ian malignancies. The chief representative t)pes in this
subgroup are lipid or lipoid cell tumour, sarcom a of the
464 SHAW'S TEXTBOOK OF GYNAECOLOGY
ovary and chorioepithelioma. The li pid cell variety arises
from u1e adrenal co rtical cell rests that reside in the vicinity
of u1e ovary. These wmours are often benign or of low-
grade malignanC). The) may be witll virilization,
obesit). h) pertension and glucose into lerance.
Ma lignam mixed mesodermal sarcomas are rare tu·
mOlii'S of tlle ovat'). The) occur in posunenopausal women.
The tumours are \et') aggressive and metastasiLe early. Che-
motherapy offers u1e best hope.
SARCOMA
Ovarian sarcomas are rare. Many wmours labelled as sarco-
mas have been misdiagnosed histologically and are in real-
ity granulosa cell tumours or anaplastic carcinomas. Sarco-
mas arise most fr·equenuy after menopause, particularly in
multiparae. They give rise to multiple metastases. Rh abdo-
myosarcoma of the ova ry has also been described.
METASTATIC CARCINOMAS
Ovarian metastases a re co mmo nl y from the prima ry growth
in u1e gasu·o intestinal u·act, notably u1 e pylo tUs, colon and,
rarely, the small bowel; tJ1ey occasionally occ ur from u1e gall
bladder and pancreas. They may also occ ur in late carci-
noma of the breast, as see n in 30% of all a ULopS)' material
from breast cance r: Carcino mas of the corp us ( 10%) and
cervix ( 1%) also metasLllSize to the ovary owing to the close
relationship o f their lymphatic dra inage. Carcinoma of the
corpus is 10 times more like ly to metastasiLe to tl1e ovary
Ulan t11e cervLx. The reason for tJ1is is t11at u1e ova rian lym-
phatics drain Ule corpus directly, whereas u1 e cervical me-
tastases tend to b) pass u1e ovarian lymphatics and travel by
way of the h)pogastric and aortic glands. About 20% of
clinical I) malignan L ovarian wmours are secondary deposits
from pr·imat') growtlu elsewhere. Two fonns of secondary
carcinoma of tlle 0\'3 r')' are recogniLed. ln u1e firsL, tl1e
growth cor·responcls in its histologywitllthe primarygrowtll.
Dissemination to Ule ovar·ies takes place eitller by implanta-
tion fi·om metastases wiu1in the peritOneal cavity or by ret-
rograde lymphatic spr-ead. Both ovaries are replaced by
solid carcinomas and multiple secondary deposits are usu-
all y disseminated over UlC peritoneum. A curious feature is
u1at the ovarian tum out'S are much larger Ulan u1e other
secondary deposits, which is explained by assum ing u1at the
ovaries offer a much be tter e nvironment for Ule growth of
malignan t cells tJ1a n tJ1e o tJ1e r intrape rito neal viscera.
T hese secondary ova rian ca ncers have the following fea-
tures. T hey are solid wiLh itTegul ar surface, and nearly al-
ways bi lateral. Asc ites is co mmo n a nd o tJ1e r obvio us perito-
neal metastases are present, notab ly in the omemum which
is often rep laced by an e nonn o us solid malignant p laq ue.
The method of ova ria n infilLraLion is either by surface im-
p lantation or by reu·ograde lymp hatic penneation. Both
meu1ods are probably operaLive, and histological examina-
tion is rarely ab le to reveal u1 e route u1rough which tl1e
metastases occ un-ed.
The second t) pe of secondary 0\'3rian carcinoma is tl1e
Kruken berg tumour.
KRUKENBERG TUMOUR
This L) pe of tumour should be diagnosed on I)' if it confonns
to the following pattem. Krukenbe rg tumours are almost
bilateml. They ha,•e smoou1 surfaces which may be slightly
bossed; U1ey are freely movable in tJ1 e pelvis (Fig. 36. 12).
There is no tende ncy to form ad hesions wil11 neighbouring
viscera and tl1ere is no infil tratio n UHough l11e capsule. The
tLunOLtr retains the shape of the normal ovary and has ape-
CLLiiar solid waX) consistenC) although cystic spaces due to
degeneration of the growth are common. Histologically, the
tumour has a cellular or myxomatous stroma amongst wbich
are scattered large signet-ring cells. These cells are ovoid in
shape with a granular C)tOplasm and the nucleus is com-
pressed against one pole of the cell so that tlle outline oftl1e
cell resembles a signet l'ing (Fig. :36. 11 ). The tum out'S are
secondat·y growtll in Ule 0\>ary and most often at·ise from a
primary carcinoma of the stomach (70%), large bowel
( 15%) and breast (6%). The Krukenberg tumour outstrips
the pl'imary growu1 in si.te, and unless u1e histOlogy of the
tumour is known, Ule case may be regarded as one of
primary malignant ovatian ca rcinoma, parti cularly as the
tumo urs are usually freely movable \\1thout obvious intra-
peritoneal metastases. The tumoun; almost certainly arise by
re Lrograde lympha ti c spread ; the ca rcino ma cells from
the stOmac h to tJ1e superior gastric lymphatic glands wh ich
a lso rece ive the lymphati cs fro m tlle ova ry. Re u·ograde lym-
phatic spread can be demonstrated in ea rly cases when
carcinoma cells are fo und infilLraLing the ova ry by way of
the lymp ha tics in Ul e med ulla.
COINCIDENT CARCINOMA OF THE OVARIES AND THE
BODY OF THE UTERUS (SYNCHRONOUS CARCINOMA)
Cases of coincident carcinoma of the ovaries and tl1e body
of u1e uterus are known. In some cases, 1J1e growtl1 is pri-
mary in tl1e bod) of the uterus and forms seconda ry depos-
its in tlle ovaries. ln ou1er cases, u1e primary growtl1 is in
tlle ovaries and secondaq deposits reach u1e cavity of tlle
uterus eiu1er b) l)mphatic penneation or b)' reu·ograde
spread tllrough tlle fallopian wbe. Another group of cases
is well-recogniLed in which u1e O\>arian carcinomas are his-
tOlogically different from u1e carcinoma of the body of u1e
uterus. Any postmenopausal bleeding associated wiu1 an
ovarian tumour should suggest the possibility of a coinci-
dent endometrial carcinoma, and this possibility always
demancls the remo,>al of u1 e uterus as well as u1e ovarian
Figure 36.11 Microscopic appea-ance of Krukenberg tumour showing
signet ring appea-ance of cells.

Rgure 36.12 (A) Ovarian fibroma showing a solid tumour. (B) Histo-
logical appearance of Fibroma: Tumour comprises fascicles of spindled
cells with miid nucle..- atypia Few collagen bundles are seen between
the cells. (Crurtesy br (8): Dr Sardeep Mathu-. All MS.)
tumours. In case it becomes difficult to make o ut cyLO
primary wmours these cases are labelled as Synchronous
carcinoma.
METASTASES IN THE UTERUS
Advanced carci noma of the ovari es becomes adherent to
tl1e surro unding su·uctures so that the uterus is directly in-
filtrated by tl1e growth. The peritoneal surface of tlle tltenlS
is also infilu·ated in so me cases by ca rcinoma cells dissemi-
nated over the peritoneum. In rare metastases form
in tl1e e ndom etrium as a result of ca rcinoma cells passin g
along tl1e fall opia n wbe in to the cavity of the uterus. In
some cases of ca rcinoma of the ova ri es, seco ndat) ' deposits
are formed in tl1 e vaginal walls, and s uch metaStases corre-
spond to those fo und in cases o f cho rioepitllelioma and of
carcinoma of tl1 e bod)' of the ute rus, when metastases form
by reu·ograde lymphatic spread.
Direc t spread of th e tumours occ urs in the pouch of
Do uglas, paracolic gutter, subdiaph ragmatic o n tl1e right
side. liver and peritoneal lining.
SPREAD BY WAY OF BLOODSTREAM
It is rare for carcinoma of the ovaries to spread by 'vay of the
bloodstream. but with vet) malignant wmours, metastases
ma)• be disseminated in this wa)'· ll is therefore important to
obtain a chest radiograph in a ll cases witll malignant ovar-
ian tumow-s.
CHAPTER 36 - OVARIAN MALI GNANCIES 465
LYMPHATIC SPREAD
The regionall)1ll ph a tic glands of the ovaries are tl1e para-aortic
and t11e superior gasuic which are impalpable clinically. Some-
times. t11e malignant cells read1 the mediastinal glands when
t11ey may ttlcerate into the pleural cavity and cause pleural effu-
sion. Sometimes. secondal) deposits may be found above tlle
left da,icular region. where tlle) have an·ived via tl1e main lpn-
phatic ducts in the mediastinum. Once t11e peritoneum is in-
volved, pel\ic I) mph nodes ,,;n be infilu-auxl \\itll metastaSeS.
METASTASES IN OPERATION SCARS
It is not uncommon after the removal of malignam ovarian
tumours for metastases to fonn in the opet-ation scar and to
spread to t11e adjacent skin. Th is may be more comm o n with
lapat·oscopic sut-ger-y.
BILATERAL CHARACTER OF OVARIAN TUMOURS
Seventy per cent of primary ova ria n ca ncet-s are bilateral,
whereas nea rly a ll seconda t) ' growths are b ila teral. Both
ovaries may be invo lved in 16% ben ign tum o urs. Even with
mali gnant ovarian tum o urs, the two ova ri es are involved
simultaneously by tl1e disease and the invo lvemem of o ne by
secondat)' de posits from the o ther is exce ptional. Witl1 sec-
ondary ovarian carcin omas, if the invo lvement is by retro-
grade l)•mphatic spread, o ne wou ld expec t both ovaties to
be involved simultaneo usly. Similar may be the pathogenesis
when implantation of ca rcinoma cells th e cause of devel-
opment of seco ndat-y deposits in tJ1e ovaries.
The most important of malignam ovarian ru-
mours are tl1ose which fonn on the peritOneum and lead to tl1e
development of large tLUnours in tJ1e omentum. The secondat-y
deposits of carcin oma of t11e O\aries rarely involve tl1e liver, be-
cause t11e ov;u·ian vessels belong to the S)Stemic S)Stem and not
to t11e portal system like t11ose of the inteSijne and stotnadl.
CUNICAL FEATURES
T he clinical featut·es are usually nonspecific in early stages,
t·esulting in late diagnosis in 70% cases. A woman witl1 ma-
lignant ovarian tumour is usually a post menopausal woman
of low parity. A fam il y history of breast or ovarian U11nour
may be releva nt.
early satiety
Initiall y, tl1e woman is asymp tO mati c. Initial symptoms
are in tl1e form of full ness of abdomen after meals, altera-
tio n in bowe l hab its o r vague pain abdome n. T hese symp-
toms often make woman LO visit ge ne ral physician or gastro-
e nterologist or a surgeo n. This results in de lay in d iagnosis
of carcinoma ova t)' in ea rly stages.
T he malig nant ova rian wm o urs a re often bila teral, so lid
and presem with asci tes. The benign tum o w· tl1at ca use as-
cites (Me igs syndro me) are ova tian fibro ma (Fig. 36.I3),
Brenner tumo ur and rarely granulosa cell tumo ur. The n.t-
mo ttrs are ofte n fixed in tJ1e late stage and inl111pe riLOneal
metastasis may be palpable abdominally.
The vaginal examination ma) reveal fixed nodules in tl1e
pouch of Douglas, apart from adnexal masses felt separate
from tl1e uterus.
Unilateral nonpitting oedema of tJ1e leg, pleural effusio n
and enlar-ged lh er are suggesti,·e of the advanced stage of
the disease. Peritoneal tubm:ulm.is mimics t)Varirm cmu:er with
raued Q\-125.
466 SHAW'S TEXTBOOK OF GYNAECOLOGY

INVESTIGATIONS

The investigatio ns to confi nn th e diagnosis and nature of

the tLunoLu· are desc rib ed in the chapte r 35. Fo llowing inves-
tigations are co mmo n I) do ne to diagnose ovarian cancer.

• UltraSound shows a solid tumour with echoge nic or cystic

Rgure 36.13 Krukenberg tumour of b oth ovaries. The t umour has
an intact capsule and surface free of all adhesion.
SCREENING FOR OVARIAN CANCER
The re is no satisfacto ry sc ree ning fo r ovarian malignant
twnour. CA-125 and ulu-asound have low detection rates
in pickin g up the tumour (Table 36.2). Howeve r, a high-risk
woman sho uld be unde r obse rvation. A pa lpa ble ovary in a
me nopausal wo ma n is like!) to be malignant and sho uld be
investigated .
ln a wo man with famil) histOI) o f ovluian or breast cancer,
sa ·eening o f ova.-ian cance r·should be cani ed out by perioclic
ul traSow1d for O\'lUies and CA-125.
areas, a thi ck capsule "ith papillar) ' proj ectors and a thick
septwn measwing more than 5 mm in a malignant twnour.
The other O\'llry may be enl arged or bilateraltwnoursseen.
An endomeuiallining more than 4 mm in thickness with
papillary projections in a woman is seen in
a feminiL.ing twn our and if endometri al secondar·ies are
present. Except in Meigs syndrome, ascites is characteristic
of a malignant tWllOur: 3D ulu-asound is useful.
• Tissue marker-s mentioned ea rlie r suggest the histOlogical
natu re of th e as well as decide th e d ura ti o n of
postoperati ve chemo th e rapy or need fo r rad io therapy.
CA-125 is raised in e pitJtclial tum ours.
• CT a nd MRl ind icate the exte nt of tlte urm o ur sp read.
• Bariwn meal, barium enema and breast exa mination are
required when me tastatic uun our is suspected. X-ray of chest
and liver scan are req uired to detect metastatic growtJ1.
• Doppler ul u·aso und showing a low pulsatile index less
than 1 and a resistance index less than 0.4 suggest ma lig-
nancy. In a benign LUmo ur, b loocl now and vasc ularity is
from the pe riphery to the ce ntre. In a malignant tumour,
neovascularity is initiated in the ce ntre of the tumour.
• D&C is required if the wo man deve lops posunen opausal
bleeding.
• Tissue marke r-s.
• CEA more than 5 ng/ mL (no rma l 2.5-5 ng/ mL) is
repon ed in e ndome u·ioid, Bre nner lllmour, mucinous
tum our, coloni c, live r, breast and lung metas tasis.

Table 36.2 FIGO St aging for Carcinoma of the Ovary: 2014

State 1: Tumour Confined to Ovaries
lA: Tumour limited to one ovary, capsul e Intact, no tumour or surface, negative peritoneal washing
19 : Tumour involves both ovari es, otherwise like lA
IC: Tumour Iimited to one/both ovaries
IC1: Surgical spill
IC2: Cap sule rupture before surgery or t umour on o varian surface
IC3: Mali gnant cell s In ascetic or peritoneal washing
Stage II: Tumour Involves One or Both Ovaries with Pelvic Extension (Below Pelvic Brim) or Primary Peritoneal Cancer
IlA: Extension and/or Implants on the u terus and fall opian tube
liB : Extension to other pelvic Intrap eritoneal tissue

Stage Ill: Tumour Involves One or Both Ovaries with Cytologically or Histologically Confirmed Spread to the Peritoneum
Outside the Pelvis and/or Metastasis to Retroperitoneal Lymph Node
lilA: Positive retroperitoneal lymph node only
lilA 1: (0 Metastasis < 10 mm (iQ Metastasis> 10 mm
IIIA2: M icroscopic extrapelvic peritoneal involvement - p ositive retroperitoneal lymph node
1119: Macrosooplc extrapelvic, peritoneal metastasis > 2 em - positive retroperitoneal lymph node, extension to capsule of liver/spleen
Stage IV: Distant Metastasis
IVA: Pleural effusion with positive cytology
IVB: Hepatic and/ or splenic parenchymal metastasis, metastasis to extra-abdominal organs (inguinal lymph node, lymph node
outside abdomen)

Source: FIGO gtidelnes.


• CA-125 is a glycop ro te in surface antigen raised in 80%
epitl1elial wmours, but is no t very specific, as it is also
raised in abdomina lwberculosis and endomeu·iosis as
well. It is normal in 50% Stage I epithelial carcinoma.
Some have observed raised CA-1251evels, 18 montllS to
3 )ears before clinical detection of malignam ovarian
tumours.
• AFP, hCG, B/ 701<, placental alkaline phosphatase and
lactase deh)drogenase ( I000 U/ L) are the tissue markers
for germ cell tumours. lnhibin is raised in granulosa cell
tumour. B/ 70K is a gi)COpnnein raised in 60% epithe-
lial wmours (abO\e II kU/ mL), but also seen in liver and
renal failure. The tissue markers are useful dm·ing che-
motll erapy to decide the response and tl1e duration of
tl1erapy in postopet-ative follow-up. Recently CA - 19.9
and 1-1£-4 are being uti lised as tum our marker·s for mak-
ing diagn osis of ova ri an ca ncer.
• Fine- needl e aspiratio n cytology (FNAC) a nd ascitic fluid
cy tology yield a hi gh false-nega tive repo rt.
• Cf and MRJ di agnose de rmo id, e ndome ui osis and ex-
te nt of spread of ova ri an malignancy as well as assess
lymp h node invo lvement. Because tl1ese on l)' p ick up
l)' mph nodes e nlarged more than 1 em, some employ
l)' mphography if Cr a nd MRI give negative l)'mph node
involve ment, because lymphography can p ick up nodes
as small as 5 mm.
• Oebul king surge ry is un dertaken even in the ad-
vanced stages, so diagnostic la pa roscopy has lost its
importance.
SURGICAL TREATMENT OF CARCINOMA
OVARY
MANAGEMENT Of EPITHELIAL OVARIAN CANCER
Most patients need a combined modali ty of treaunent, maxi-
mum possible debulking sUJ·gery followed by chemotl1erapy.
ln most cases, surgery is the initial step in tl1e management,
it provides opportunity to know stage of tl1e disease, exact
spread of the disease and also helps in removing maximum
possible amount of the disease fro m abdomen and pelvis.
Such a surgi cal procedure is called debulking surgery (cyto-
reductive surgery). Prognosis depends on amoun t of residual
disease left at the end of cytoreductive surge t)'· Following
are the standard steps fo llowed whi le operating a case of
carcinoma oval)'.
STEPS OF SURGERY FOR OVARIAN CANCER
l. Open abdomen by vertical mid li ne incision.
2. Obtain ascetic fl uid for cytology. If asc ites is absent peri-
to neal washings a re obtained by ins tillin g 200 mL of
saline in pelvis a nd asp irating this fl uid with a dispos-
able syri nge.
3. Evaluate exte nt of disease: By careful itlSpection of all
pelvic and abdom ina l organs U)' to make o ut extent of
the disease. Make special efforts to feel live r surface, sub-
diaphragmatic area, stomach, splee n, small intestine,
large bowe I. surface of bladder and tl1 e pouch of Douglas.
4. Obtain small pet·itoneal biopS)' from subdiaphragmatic
area, tight and left paracolic gutters, surface of bladder
and tlle pouch of Douglas.
CHAPTER 36 - OVARIAN MALIGNANCIES 467
5. Perform total abdo min al hyste rec to my with bilateral
salpingo-oophorectomy.
6. Perform intracolic omentectomy.
7. Obtain lymph nodes from pelvic and paracolic area for
sampling.
8. Remove an) otl1er structure which may be invo lved by
tlle disease.
9. At tlle end of surge t) make a careful note of tumour
whi ch is left in spite of maximum possible surgical effort
(Residualwmou r).
CONSERVATIVE SURGERY FOR EPITHELIAL OVARIAN
CANCER
On r-are occasion if one finds cancer limited to one or
botl1 ovaries in a young patient who is desirous of preg-
nanc y in future, a consetvative surgical approach in
the form of unilateral salpingo-oophorectomy or bilateral
salpingo-oophorecto my with prese rvation of tl1 e uterus
can be carried o ut. Such patie nts if re ma in d isease free
for 2 )'ears or more during fo llow- up ca n be allowed to
a uemp t pregnancy spontaneo uS!)' o r by IVF app roach.
INTERVAL DEBULKING SURGERY
On occasions whe re a newly diagnosed case of carcinoma
ovat)' is found to have advance d isease and i.s considered unfit
for anaestl1esia on account of a coexisting cardiac, respiratOt)'
or other disease, tl1ese patients are managed by ini tially giv-
ing three cycles of chemothe t-apy ( Paclitaxe l + Carboplatin)
at tl1e tl1ree weekly intervals followed by debulking surgery.
Such a surgical procedure is called ' in te rval debulking sur-
gery'. Bysud1 an approach, ofte n general condition of patients
improves. ascites reduces and she becomes fit for anaestllesia
and SLu·get). A patient managed b) tllis approach gets remain-
ing chemotl1et-aP> (tJu·ee C)cles) after smget) '·
SECONDARY DEBULKING SURGERY
lf a treated case of carcinoma O\>ary develops recun-ence,
she can be managed by a second operation witl1 tll e aim of
removing recurrences. However, witJ1 wide spread t-ecur·
t·ences treatment with tl1e second-line chemotherapy is usu-
all y the preferred approach.
PROGNOSIS
Ovarian cancers are o ne of th e most le tJ1al wmours. In spite
of max imum possible surget) ' and che motherapy, a great
majority of women ex pe ti e nce recurre nces and may die
subsequen tly of disease rec urrences. AltJ1ough rec urrence
rates depend on stage of disease at d iagnosis, s urgical pro-
ced ure and chemo th erapy, but up LO 80% pa tientS experi-
ence recurrences within 3 years. Fo llowing Table 36.3 shows
stagewise 5-)'ear surviva l rates.
CHEMOTHERAPY FOR OVARIAN
CARCINOMA
After initial surgical management almost all cases need 'adju-
\'lllll chemotllemp) '. On I) patients who can be kept o n
follow-up b) avoiding postoperative chemotherapy are the
o nes who had Stage Ia disease. Patients who were t-eponed w
have 'bot·derline O\'lltian malignanC)•' on histopatllology are
also kept on follow-up only without gi,·ing any chemotl1erapy.
468 SHAW'S TEXTBOOK OF GYNAECOLOGY

been tested in ovarian ca ncers a nd is being tried in other

Table 36.3 FIGO Staging and 5- Year Survival Rate tumours also (breast cancer). Drug is initially given
in Carcinoma Ovary
weekly for 20-21 C)cies, but can be exte nded up to
Staging 5 year Survival Rate 22 weeks. At present, high cost of u·eaunem with bevaci-
ZLUnab prevents itS routine usage.
Stage 1: 90%
Ia: 94%
lb: 92% FOLLOW-UP OF EPITHEUAL OVARIAN CANCERS
lc: 85%
Cases of epithelial ovatian cancers u·eated b)' surge•) ' and
Stage II: 70% chemotherapy are seen at regular interval of 3 montl1s for
IIa: 78% initial 2 >ears and subsequently e' ery 6 month for next
lib: 73% 3 >ears for any t-ecun·ences. Clinical examination and serum
Stage Ill: 39% CA-125 evet)' 3 months help in detection of recurrences.
lila: 59% Imaging swdies are catTied out in case of any suspicion of
lllb: 52% recun·ences.
lllc: 39%
Stage IV: 17%
GERM CELL TUMOURS OF OVARY

Ge tm cell tum o uts of the ovar)' comprise 5%-10% of ali

DRUGS USED FOR CHEMOTHERAPY
In the past, several chemOLhe rapy drugs either give n s ingly
or in combination have been ttied with va riable success
rates. Current!)' most common!)' used combination of drugs
in t11e u·eaunentof epithelial ovarian cancers is Paciit.axei +
Carboplatin. These drugs are given intraveno usly every
3 weeks for six cycles. Doses and side effectS of these
two dntgs are given below:
Paclitaxel: Dose 175 mg/ m2, intravenously over 3 hours.
Main side effect: eurotoxicity.
Ct•rboplatin: Dose is calculated b) area under curve (AlJC)
which is generall) taken as 5--6. However, in suqjectS witll
compromised renal function a smaller dose is given.
Side effectS: ephrotoxicity, bone marrow suppression.
ovarian ma lignancies. The)' te nd to a tise from germ cells
with the ovary. AILI1ough Llle)' originate from t11e ovat)', tl1 ey
differ from epithelial ovarian ca nce rs in many respects.
Most often these tum o urs are seen in )'Oung ado lesce nt
girls, it is rare to find t11ese twnours afte r t11e age of25 years.
Most of these tumours are usually fast growing and highly
malignant, )'et witl1 tim e ly diagnosis and appropriate surgi-
cal managemem good o utcome can be expected. Current!)'
postoperative management of L11ese patjentS witll chemo-
therapy in the form of BleOm)Cin ELOposide-Cisplatin (B£P)
has almost ensured cure for these wmours. Witll effecli\'e
and time I) chemotl1erap), most of these young girls can be
expected to resume Llleir normal menstrual function and
achieve reproducr.he outcome in the fonn of nonnal live
birtllS.

OTHER CHEMOTHERAPY REGIMENS STAGING SYSTEM

l. Paciitaxel 80 mg/ m2 every weekly + Carboplatin eve•·y
tlu·ee weekly.
2. Paclitaxel 60 mg/ m2 + Carboplatin AUC-2 given weekly.
3. Docetaxel mg/ m2 + Carboplatin AUC 5-6 every
tl1 ree weekly.
NEWER DRUGS FOR TREATMENT OF EPITHEUAL
OVARIAN CANCER
In case patient is found to be platinum resistant, fo llowing
newer drugs can be used:
l. Topotecan 1.5 mg/ m2/ day X 5 days
2. Pegyiated ii posomal doxorubicin (PLD) 50 mg/ m2 orally
X 28 days.
3. Gemcitabine 1000 mg/ m2 on clay I , 8 and 15.
4. Nanoparticle albumin bound Paclitaxe1 (Nai>-paciitaxel)
5. ELOposide 50 mg/ m2 orally X 2 1 days
6. Trabectedin 1300 mcg/ m2over 3 hours every tllreeweekly.
7. Bevaci.wmab (Avastin): It is an anti-angioge nic ' Human
Monoclonal Antibod) to VGEF (vascular growth endo-
tllelial factor)'. It is not chemotherap)•, but addition of
tllis agem to tl1e standard chemotllerapy helps in im-
proving result of chemotherapy. This new approach has
For staging of germ cell tumours of the ova t) ', same stag-
ing system as given by International Federation of Gynae-
cology and Obstetdcs(FIGO) of ova ri an cancer (20 14) is
followed.
PREOPERATIVE WORK UP
In additi o n to co mm o n!)' done investi ga ti o n such as hae-
mogram, c hes t X-ray, imaging of abdo me n by uiu·asound
a nd CT / MRI; a pane l of tests including hCG, AFP a nd
LDH are cond ucted. T hese in vestiga tions he lp in kn ow-
ing t)•pe of germ ceil wmour. R.1ised AFP is noted in yo lk
sac tumo urs, raised hCG points towards choriocarci-
noma. Raised LOl-l is noted in dysgerm inomas. A combi-
nation of tumour markers, when raised, poin tS LOwards
t11e possibility of embryo nal care inoma or mixed germ
cell tLUtlOUr.
SURGICAL MANAGEMENT
Surge•)' is the first line of treatment in most cases of ov:u;an
germ cell tumours. Majot·it)' of cases are )Otmg girls, so pres-
enoation of Ll1e utet·us and nonnal O\'llt) ' or O\'llt·ian Lissue is
desirable. 'v\l'ith a careful approach and surgical efforts it is

always possible to preserve normal-looking ova rian tissue in
one or both ovaries.
SURGICAL STEPS
Same surgical steps are followed as described for epithelial
ovarian cancers.
l. Vertical micUine abdominal incision.
2. Peritoneal washings/ ascites fluid for C)l.ology.
3. Exploration of alxlominal and pelvic organs.
4. Unilateral with preservation of
the uterus and normal-looking ovarr
5. Pelvic and para-aortic lymph node sampling.
6. omentectomy
7. Removal of any other wmour mass in the abdomen
CHEMOTHERAPY
Al l patie nts with germ cell tumo urs of ovary need postop-
erative chemo tllerap)' witl1 th e exce ption of Stage Ia dysger-
minoma. Bleomyc in-l.!: toposide-Platinum (BEP) regimen as
given below is tl1e best regiment for germ cell tumours
of ovary.
BEP Regimen
Bleomycin 15 mg i. v. on day I, 2
Etoposide 100 mg!m2 on clay 1-5
Cisplatin 20 mg/ m 2 i.v. on day 1-5
Follow-up: All treated case of ovarian genn cell tLunours
are followed b) three montJ1l) by clinical examination,
tumour markers for initial 2 )ears.
SEX CORD STROMAL TUMOURS
Sex cord stromal tumotas are uncommon. They comprise
3%-5% of all oval"ian tumours. They can occur in any age
group. These wmours by virtue of excess production of
female sex hor·mones or male sex h onnones are easy tO
diagnose. They mostly are small sized (5-15 em) and tend
to grow slowly. In most cases, surge r)' alone is the treatment
except tl1 ose which have metastasize or are rec urrent.
Their symp toms ma)' vary depend ing on the age group in
wh ich they occ ur. Granu losa cell tumours whi ch are associ-
ated witl1 excess prod uction of oesu·ogen may cause preco-
cious pubert)' in )'Oung premenarc hal girl; it may ca use
mens u·ual irregulariti es such as menorrhagia, in a woman
in a reproductive age and cause posunenopausal b leeding
in women with excess production of inh ib in A Similar!)',
male honnone-producing sex cord tumours (Sertoli-
Leydig Cellwmours) may cause features of defeminil.ation
followed by masculinization in the form of breast atrophy,
d1ange in voice, amenorrhoea, hirsutism and cliwromeg-
aly. Lf stLSpected diagnosis is easily made based on levels of
sex hormones and imaging.
STAGING SYSTEM
Asimilarstagingsystem as given for epithelial ovarian cancers
is used. In most cases, disease is to ovary.
CHAPTER 36 - OVARIAN MALIGNANCIES 469
SURGICAL TREATMENT
SLLI'ger)' remains the cornersLOne of u·eaunent. Removal of
ovary harbouring tumour will suffice in most cases. However,
in case of bilateral tumours or tumours witl1 spread tO other
su·uctures an operative procedure on 1!1e lines of epithelial
ov;uian cancers is can·ied out in t11e form of tOtal alxlominal
hysterectom) witl1 bilater"al and in-
fracolic omentectomy.
CHEMOTHERAPY
Eru·Jy stage cases are usually kept on follow-up and do not
require adjuvant chemotJ1erapy. However, for the ad-
vanced disease and for rectwrences chemotl1erapy ca n be
considered. Both regimens (J>aclitaxel + Carboplatin) and
BEP have been used. However, a response to chemoth er-
apy varies and is not as good as for germ cell tumours.
Prognosis: Most patients have ea rl y stage d isease a t diag-
nosis and have good prognosis. However in tl1 e advanced
disease and recurrences prognosis is co mpromised.
FALLOPIAN TUBE CANCER
Cancer of the fal lopian tubes is rarest of a ll gen ital tract
malignru1cies. More often the fallopian tubes are invo lved
by extension of disease from ovaries or uterus. Primary
carcinoma ofthe fallopian tube is uncommon and accounLS
for only 0.3% of all cancers of t11e female genital l!'act,
though metastatic growths from t11e uterus, ovaries and gas-
u·oimestinal l!'act are common.
The tlLmour is bilateral in one-tl1ird of cases \\11en it re-
sembles a pyosalpinx or tuber-cular lesion. The tLUnour is often
atl adenocarcinoma tl10ugh chor·iocarcinoma may develop in
a tubal ectopic pregnancy or in a wbal mole. The tumour is
highly malignamand spr-eads rapidly tO tl1e SLUTOLUlding areas,
and via lymphatics to tl1e pelvic or·gans. Ver)' often, Lhe tumour
is in the advanced stage when diagnosed and mostly it is diag-
nosed only on a histological study after tl1e surgery.
The distal portion oftJ1e tube is t11e common site of cancer.
Staging of fallopian tube carcinoma (FIGO)
Stage Description
0 Carcinoma in (limited to tuba l mucosa)
I Growth limited tO fa llopian tubes
lA Growth li mited to o ne LLtbe witJ1 ex tension into
the subm ucosa and/o r muscularis b m noL
peneu·ating th e serosal surface; no asc iLes
IB Growtl1 limited to both tubes wi tl1 ex tension in to
the submucosa and/ or muscularis b uL not
peneu·ating t11e seros;1l surface; no asc ites
!C Tumour either stage lA or IB witl1 tumo ur exten-
sion through or on to t11e wbal serosa; or wit!1
ascites present containing malign am cells or
positi\e peritoneal washings
II Growtl1 imoh ing one or botl1 fallopian tubes witlh
pehic extension
!LA Extension and/ or metastasis to t11e utenLS at1d/ or
ovaries
C<mlinued
470 SHAW'S TEXTBOOK OF GYNAECOLOGY
liB Extension to other peh'iC tissues
IIC Tumour eilher stage IlA or liB with ascites
present comaining malignant cells or with
positive peritOneal washings
Ill Tumo ur involves one or both fa llopian tubes with
peritoneal implams o uts ide th e pelvis and/or
positive retroperitoneal or inguina l nodes; su-
perficial liver me tastaSis eq ua ls stage Ill; tum Otll'
appears limited to u·ue pelvis but with histologi-
cal!}' pt·oven malignant extension to the small
bowel or omentum
IIlA TlUnour grossly limited to the U'\le pehis \lith negative
nodes but \lith histologically confinned mia"OSCopic
seecling of abdominal petiLOneal surfuces
IIIB Tumour involving one or both tubes with
histologicaU}' confirmed implants of abdominal
peritoneal surfaces, none > 2 em in diameter;
l}'mph nodes are negat.ive
IIIC Abdom inal impla ms >2 em in d iameter and/or
retroperitoneal o r inguinal nodes
IV Growth involving one or both fa ll opian tubes with
distant metaStases; if ple ural effusion is present,
there must be positive cytology to be stage IV;
parenchymal liver metaStases equals stage IV
STAGING
Ere:t. classification ofthe fallopian tube cancer is as follows:
• Stage 1: The tumour is limited to th e mucosa and muscle.
• Stage llA: The serosa is breached, b ut tJ1e tumour has not
spread to o tJ1 er organs.
• Stage liB: The tumour invades the pelvic organs.
• Stage Ill: Metastasis outside tJ1e pelvis, but within the
abdominal cavity.
• Stage IV: £xtraabdominal metaStaSis is presenL Para-
aortic lymph nodes are itwoh,ed in tJ1 e ad,oanced stages.
CLINICAL FEATURES
The tumour occ ttrs in menopausal women, 50% of t11ese
women are nulliparous. The early symptom is a watery dis-
charge per vagin um, wh ich may a t Limes be amber coloured.
Sooner or later, postmenopausal bleeding develops. A lu mp
ma}' be too sma ll to be felt on cl inical exa minat.ion. Pa in
is a late symptom. A fallopian tube carcinoma may be
suspected in a woman witJ1 a persistent excessive vaginal
discharge whet·e pap smear shows abnonnal cells, but evalu-
at.ion of cenrix and endomeu·ium does not reveal any abnot·-
mal area, In such a siwat.ion, t11e presence of a small ad-
nexal mass should strongly raise possibilit}; a rare situation
of tJ1e fallopian tube carcinoma. In most cases. diagnosis
of the fallopian tube carcinoma comes as a sttrprise
at laparotomy being conducted for a diagnosis of ovarian
pathology.
DIFFERENTIAL DIAGNOSIS
The condition is often mistake n for uterine or ovarian
malignancy, and tubet·culat· adnexal mass.
INVESTIGATIONS
The clinical diagnosis is clifficult and often missed.
• Pap smear: The adenomatOt.LS cancer cells are very rarely
see n and Pap smear scree ning is unreliab le.
• Uterine cure ttings are negative in postmenopausal
b leeding so also hysteroscop ic exa minati on. Negative
cureLLings in posunenopausal b leeding sho uld arouse tJ1 e
suspicion of tJ1 e fallopian tube maligna ncy.
• Laparoscopy shows adnexal mass.
• UIU'asound showing an adnexal mass in a posuneno-
pausal woman with posunenopausal bleeding suggest.ing
tubal cancer.
• Dopple r flow velocity shows low-resistance blood flow.
• Sometimes serum level of CA-125 is raised in adeno-
carcinoma.
MANAGEMENT
Surgical staging is important. In operable cases, surgery is
s imi lar LO tJ1at of ovarian malignancy and consists of h)'Ster-
ecto my, bilateral salpingo-oophorecLOmy, pelvic lymp h node
sampling and omentectomy.
Postoperat.ive radiotllet-apy, chemot11ernpy and progestogen
honnonal tJ1erapy are often required.
PROGNOSIS
Prognosis is poor and overall 5-year cure rate is 25% .
• Stage I survhoal is 60%.
• Stage II survival is 40%.
• In tl1 eadva ncedstage,sunrival is 10%.
KEY POINTS
• Epithelial O\oarian tumours are the commonest tu-
mours, and accoum for 80% of a ll O\<arian malign am
tumours.
• Borderline epilhelial tumours with low malignam
potent.ial occur in younger women, and respond well
to t11e consenoative St.trgery.
• Germ cell wmours of ovary prod uce uunour markers
such as hCG, AFP and LDH making d iagnosis eaS}'·
• The common ma ligna m tumo urs in adolescents are
d)•sgerminoma, teratoma, emb ryona l tumours and
granulosa cell tumour. The conservat.ive surgery fol-
lowed by chemot11erapy yields good results and re-
tains fert.ility potential in young women.
• Primary SUI-gery followed by postoperathe chemo-
tllerap} is the cornerstone in the managemem of epi-
tllelial ovarian malignam tumours. ll}Sterectom}, bi-
lateral salpingo-oophorectom} and omentectom} are
t11e standard surgical procedure. Some include I} mph-
adenectomy as well.
• Chemot11erapy (Paclitaxel + Carboplat.in) is most
preferred regimen given tluee wee kly for six C}'cles.
• In an advanced stage, a 3-weekly co urse of chemo-
tll erapy fo llowed by debulki ng surgery has improved
t11 e outcome and survival rate.
 CHAPTER 36 - OVARIAN MALI GN AN CIES 471

4. A 10-year-old girl is brought witJ1 abdominal pain and a

• A woman with gen ita l cancer also needs g uidance in
lwnp felt during the last I mo nth. Disc uss th e differen-
nuLrition, pain re lief and pS)Chological support.
tial diagn osis and ma nage me nt.
• ln case of bilateral O\'aria n malignam wmo urs in
5. Sho rt no tes o n:
)OLmg wo men , conservatio n of the uterus will enable
• Teratomas Kruke nberg wmo ur
pregnane> b) OOC) te do no r a nd IVF. • Borde rl in e ovarian lll mo u r
• PET and Cf impro' e th e earl) diagnosis in detecting
location and recurrence o f the tumo ur, and assessing
the response to chemotherap).
• The gold standa•·d is a bdominal h)'Sterectomy and SUGGESTED READING
bilateral salpingo-oophorectomy \lith omenteCtomy in
Bonnar J (ed). Recent At.l\"ance. in Ob>tetrics and C)o..aecology, Paul
the early a nd opera ble cases of ov:u·ian cancer. Oebulk- Donnellan and o.,,;d Fennelly. In: Recent a.:h -ances in o' -arian cancer.
ing and chemothera py prolong life and duration of 20: 179. 1999.
remissi on. Bon narJ (ed). R<.>cent in Ob;,tetrics and CynaecolOf.'Y 16: 357,
• Prima•) ' fallopian tube can cer is very rare and is diffi- 2005.
Duncan J , Shulman P. Yearbook of Obstetrics, C)n aecologyand Women's
cult to differenti ate fro m ova ri an and en domeLrial IJ<:".thh 2010.
cancers clinicall y. Prognosis is poor. Jon ath an S C)"1ccologic O n cology, Berek and Ilackers.l2: 530,
201 5.
Studd J. Progre.s in Q b, tctrics In: P Nonnan,
P Schwan z. Proph ylactic ooph orectom y in BRCA carrier Vol 17: 369,
2007.
SELF-ASSESSMENT
1. Descti be tl1e eli nical fcawres of ma lignam ovatian tumours.
2. Discuss the manageme nt of malignan t ovarian tumo ur.
3. A wo man presents with postme nopausal
b leeding, abdo minal pain and a lu mp in th e lower abdo-
me n. Disc uss the d iffe re ntial diagnosis and management
 Vulval and Vaginal Cancer

Cancers of the Genital Trod 472 Key Points 480

Cancer of Vulva 472 Self-Assessment 480
Vaginal Cancer 478

CANCERS OF THE GENITAL TRACT Table 37.2 Common Gynaecologic Cancers

and Breast Cancer in Southeast Asian
Genital u·act cancers are important in gy naecology because Countries
of the high mortality, morbidit)' and shonenin g of lifespan Canc er India Pak istan Bangladesh Sri Lanka
in women. T he detection of the preinvasive and microinva- Site (ASR) (ASR) (AS R) (AS R}
sive stages and the near- ! 00% surviva l by the conservative
sw-gery now adds LO the success story of genital u·act cancers. Cervix 30.7 6.5 27.6 28.8
Altl1ough breast cancer predominates in t11e developed Corpus uteri < 1.5 5.8 < 1.5 <1.5
countries. genital tract cancers remain t11e main kiUers in
developing COlUl tries, including India. Ovary 4.9 9.8 3.3 5.1
Table shows tllat cancer of the cervix holds the Breast 19.1 50.1 16.6 19.3
plime position in de, eloping countries, followed by mat of
Others < 1.0 < 1.0 < 1.0 <1.0
me utems, oval"), vuh<a, fallopian LUbe and vagina in that
order of frequenC)• and fonns a major healm problem de- ASR, age-stand<l"dzed rates per 100,000 female population.
spite it being potentially pre-•emable.
Burden of g)lltJecologic a11d bre(IS/ Cflllt:I'YS i11 Sott/he(ISt Asia:
Nandakumar A et al. (2000) reviewed the cancer burden cancers in women. Fortunately, both mese cancers are ame-
amongst women living in the Indian subcontinent. Their nable to early diagnosis and cure.
findings have been bl'iefly shown in Table 37.2 for a quick
comparison.
Table 37.2 shows that cancer of the cervix continues to CANCER OF WLVA
be the leading cause of ca ncer in our subcontinent. Breast
cancer co mes up as th e seco nd most common cancer, Cancer of t11 e vulva is a rare emit)' and accoun tS for I %-5%
except in Pakista n, where breast ca ncer leads the list of of all gen ital u·ac t ca ncel'S. In developing countries inci-
dence is lower as co mpared LO ri ch counu·ies.
Malignan tlltm Oui'S of t11e vulva are grouped as fo llows:

Tab le 37.1 Inc idence of Genital Tract Cancers 1. Preinvasive lesions-intraepithetial

In Developed and Developing Countries cancer usual type VIN and
Developed Developing Differentiated VIN lntraepithelial
Bowen disease carcinomas
Organ Countri es Countries
Paget disease
Cervix 60% 80% Microinvasive
Melanoma in situ
uterus 25%-30% 5%
Ovary 10% 10%-15% 2. Invasive lesions
Vulva 4%-5% 1%-5% • Squanlous cell carcinoma- mosL common 90%
• Melanoma I %-5%
Fallopian tube 0.3%-0.5% 0.3% • Adenocarcinoma I%
Vagina 0.2% 0.2% • Sarcoma 2%
• Rodem ulcer or basal cell carcinoma I%.
472

The vulva can also occasionally be the site of metaStatic
cancer. Cancer of Lhe vulva and Lhe cervix may coexist in case
it is caused by papilloma virus. Most of these malignant lesions
are located on Lhe labia majora. In 5% of cases, the lesions are
amlltifocal. and are seen in )Otanger women below 40 years.
A single lesion is seen in older women.
PREINVASIVE LESIONS
INTRAEPilHEUAL VULVAL NEOPLASIA (VIN)
Definition
lntraepithelial vulval cancer is defined as a cellular abnor-
malit)' limited 1.0 the epithelium of the wlval skin, exclud-
ing the keratinit.ed layea: The cancer cells are restricted by
tl1e basement membrane and do not spread to tl1e dermis.
His topathological characteris tics
• T he presence of acanthosis
• lntraepi th eli al pea rl formation a t th e re te pegs
• Inflammatory reac tion in the derm is
Classification
The classification is comparable to that of preinvasive carci-
noma of the ce rvix.
ln 2004, tl1 e International SocieLy for the Study of Vulvo-
vaginal Disease officially divided VIN imo two types:
(i) Usual type YIN, which is related LO human papilloma
virus (H PV) infection.
(ii) Differentiated YIN, which is unrelated LO HPVinfection.
The term VI I is no longer used, because of lack of repro-
ducibilit) of histopatholom and difficulty in differentiating
from tlle nonnal cases, and VI 2 and Vl 3 are simply called
Vl . ln )Oung patients, it is related to HPV and tl1ere are 90%
chances of a-ega·ession and 10% progress, whereas in elderly it
is associated witl1 lichen sclerosis and higher chances of pro-
gression to invasive cancer.
It is, howevea; important to remember tl1at invasive cancer
need not ahvays be preceded by preinvasive lesion and it can
develop de novo.
Incidence
A rise in tl1e incidence of VIN in the rece nt times is attrib-
uted to greater awa re ness of its e xistence, better diagnosis
and tl1 e longer s urviva l of woman beyond the age of
70 years, whe n the ca rcinoma of t11e vul va prevails. T he in-
traepithelia l cancer also inc reasingly affec ts women yo unger
tllan 40 years, who are often affec ted b)•sex ua lly transm itted
diseases and viral infections suc h as HPV (70%-80%) and
herpes simplex virus II (HSV). H PV (type 16, 18, 31, 33) as
well as smoking predisposes one to cancer. Type 16 is the
most common and is present in 60%-90% of cases.
Aetiology
l11e aeuological factors are similar 10 those of vulval dystro-
ph) (see Chapter 25 on Benign Diseases of the Vulva), and
tl1erefore it is not surprising to see the lesions of VlN
amongst tl1e dysu·ophic aa·eas.
Chronic vulval irritation, immunosuppressive condilions
such as pregnancy, HIV infection and smoking suppress the
CHAPTER 37- VULVAL AND VAGIN AL CANCER 473
immune system and predispose t11e patient to VIN lesions.
Condyloma, sexuaBy transmitted diseases and dystro phies
are the other risk factors. Poor nutrition and hygiene, and
local moisture are the contributing facLors. The associalion
witl1 carcinoma of Lhe cervix and breasL cancer in the same
woman indicates tl1e common aetiological factOrs.
Fift>• per cent of VI Cll.lt'!> lwvt' 5eqtumti£tl or concomiumt neo-
plasia in the lmuw gmital tract, l!!>j>l'rially ctmct!T of the ceroix.
The Vl lesions aa-e observed in relative!)' )Oung women
below 40 >ears. Obesity, diabetes, chronic prua·itus and der-
matitis are often linked to this disease.
Histology
A loss of polarity, and stratification and d)•su·ophic changes
are confined to the epidermis, and t11e basement mem-
brane remains intact.
Clinical Features
Man y earl y lesions may re main as>•mptomatic for a long pe-
riod, and VLN l is not visible macroscop ica ll y. Pruritus may
be tl1e only symptom in t11 e earl>• s tage. It may be mistake n
and treated for funga l infec tion. Late a; soreness, dysuria and
dyspareunia deve lop. The preexisting le ucop la kia, condy-
loma and d)'su·ophic areas may now s how whiLe, or red, flat
warty or papular les ions, single o r multi ple wiLh we ll-defined
edges. Multiple widespa-ead lesions are more common in
yo unger women, and occ ur in 5%-25% of cases. Some de-
velop pigmentation. The lesions mainly affect tl1e labia ma-
jora, but may also be seen over the peaineum and perianal
regions. The cliL01is and labia minora are not spared. The
inguinal glands are not palpable (Figs 37. 1 and 37.2).
Investigations
lt is impossible to diagnose VI and differentiate it from
d)'su·ophies without a biopsy. Exfoliative C) tOIOg)' does not
>ield satisfactory a-esults because of keratiniL.ation and poor
exfoliation of cells. Colposcopic study too does not alwa)'S
show punctuation, mosaic and abnonnal vascular pattem, if
tlle skin is hype•·u·ophied and thick. Application of K-Y
jell>• improves visualit.ation of the vasculature of ski n.
Five per cent acetic acid causes white areas and staining tl1e
37.1 Basal cell carcinoma (Source: From Rgure 8-30. Cinical
Gynecologic Olcology. In: lrwa5Ne Cancer of the Vulva, 2007 .)
47 4 SHAW'S TEXTBOOK OF GYNAECOLOGY
Rgure 37.2 Squamous cell carcinoma of vulva with groin metastasis.
area wi th I % to lui d ine blue marks abno nna l areas royal blue,
thus enabling selective b iopsies from the dark-stained areas.
Excisional b iopsy of a localized lesion picks up VI N. Colpos-
cop)' and Pap smear oflhe cervix are also requi red to rule o ut
concomitant preinvasive cancer of the cervix.
Proctoscopy and anoscopy may be requi red, if the peri-
anal region is invo lved in the lesion. This will show the ex-
tension into the anal wall. Vaginal and Pap smear become
mandatory in the diagnosis as well as in the treatment of
these m ultifocal lesions.
DNA stud) is useful so far as a ne uploidy is concemed.
Aneuploid) strong!) suggests the possibility of VI progress-
ing to in vasion and should be tremed, whereas euploidy in
young women can be observed o' er a period of 6 momhs,
with a hope of regression.
H uman papilloma viniS 0 A detection combined with
C)'l.Oiogy impi"O\eS the detection teSt tO 95%.
Vulvoscopy defines a vascular pauern, but is not so clear
because of keratinit.ation. Condyloma which does not re-
spond to treaunentshould be investigated for VLN.
Management (Tobie 37.3)
T he purpose of u·eating VIN lesions is threefold:
• To relieve the symptoms of pruriws and so reness.
• To prevent ca ncer deve loping in the area. Five to ten per
cent V!N Ill to umcer within 8 years.
• To avoid m uti lati ng surgery and sex ual dysfunctio n in
yo ung women; rad ical vu lvec tOm)' is m utilati ng and
causes gen ital disfigurement and dyspareun ia.
The u·eatment is the refore based on the age of the
woman, sexual activity, site and extent ofVIN and grading.
With more young women developing V!N, there is a ten-
dency to shift from the earlier radical approach to a very
conservative management with success of 90%-94%. How-
ever. a long follow-up is required to wmch for recurrence
and progression to invasio n.
The management is as follows:
l. Young women with multiple focal lesions and showing
euploidy o n 0 A study may be observed for up tO
Table 37.3 Management of VIN
Observe young women with multiple lesions and HPV positive
for 6 months. Persistent lesion requires treatment.
Excision
Wide excision
Skinning vulvectomy
Ablative
C02 laser
Photodynamic therapy
Surgery
Simple vulvectomy in older women and in Bowen disease
Medical
Local application of 5% testosterone
cream, Fluorouracil (5-FU) mainly for local recurrence
• lifelong follow-up
6 months, beca use suc h lesions ofte n disappear by
then. T h is occ urs mo re com mon ly in yo ung wome n who
develop V!N d uri ng pregnanC)', d uring a n immun osup-
pressive period and fo llowing viral infec tio n, especia lly
HPV 16, 18.
2. With uni focal lesio n, wide excision of the lesion going
2 em be)•ond the margin is found adeq uate and vulvec-
tomy is not warranted. The skin edges can be approxi-
mated with or without underm ining the excised margins.
Local recurrence is the risk to be watched for. Excision is
performed with a knife, ca ute•) or laser.
3. Persistent VIN and VIN Ul req uire excision, skinning
vuh-ectomy (Rutledge and Sinclair) wi1J1 a split-skin graft
LO avoid disfigurement of the imroiuiS and dyspareunia.
Skinning vulvectOm) is desirable, if the involved area is
laser ' <apo•it.atio n (Townsend) or laser
excision, Cl) osurge•)'. application of diniu·ochloroben-
£ene, 5% testosterone cream a nd corticosteroicls are also
consen<ative treatment, but they do not guarantee recur-
rence or im<asion and need a lifelong follow-up. Laser
therapy avoids pain and scar formation without disfigure-
ment; the cut heals in a few weeks. Periurethral and
pe.-ianal lesions are, however, not amenable tO laser, and
require excision.
Cryosurgery up to a de pth of 2 mm can cause extensive
slo ughing. l'rophylact.ic HPV V(ICcillii is now available.
Photodynamic therapy (PDT) uses a w mo ur p hotosens i-
ti zer 5-ami no-levulin ic ac id (A lA ) combined with no n-
therma l lig ht of an app roplia te wave le ngth to gen erate
oxygen-ind uced cell death. Q uick healing and minimal
tissue destmc ti on are its advan t.ages.
Conservative therapy t/t(lt invfiSiVI' lesion should be
excluded">' multiplii or adequate
4. Elderly women should be dealt wil11 by simple vu lvectomy.
A lifelong follow-up is required in all cases.
Follow-Up
RecLLn·ence around the excised lesio n or fresh recurrence
occurs in 20%-30% of cases. Five to ten per cem of cases
progJ·ess to invash e cancer in 8 )Cars, after which invasion
is less likely, unlike that in ca•·cinoma in situ of the
which may take 10-15 )Cars to cJe,·elop to ill\<asive cancer.
Pap smear, colposcopy three to six monthly and later

yearly wi ll be requ ired. Rec urrent tu mour is treated wir.h
5-Fluorouracil.
Bowen Disease
Bowen disease is an intraepithelial carcinoma of the vulva. It
presents as a slow-growing hard reddish induraLed patch.
lniliall). it is well-ciret.tmso·ibed, with a dry or eczematous
sw·face. This vet-rucoLLS lesion rare!) metastasizes. Pruritus is
the main complainL The biopsy reveals t)pical pt;ckle cells
imading the epidennis. The presence of giant cells and corps
ronds is a charactetistic of the lesion. The vagina and the
cenrix may also show similar lesions in the colposcopically
directed biopS)'· The u·eaunent consistS of simple vulvectom>'·
Paget Disease
A rare exu-amammary disease, Paget disease, is comparable to
intrad uctal carcinoma of the breasts, beca use the apocrine
sweat glands are involved. 1L occ urs in a posunenopausal
wo man as a sharply dema rcated and sli ghLiy elevated white
indw·ated or eczemato us lesion and ca uses p mritus. T he bi-
opsy reveals the charac teristi c large, pale, vacuolated cells in
th e epidetmis (Fig. :37.3). Peri anal and perineal areas are
rare!)' invo lved. Paget's ce lls are adenoca rcinomato us m ucus-
secreting cells, round cells with pale cytoplasm and vesicu lar
nuclei. Mi tosis is rare. Un like Paget disease of the breast, the
w1derl)•ing carcinoma is reported in only 20% d ue r.o adeno-
carcinoma of Bartholin's gland. In the perianal region, ir. is
associated with adenocarcinoma of the an us. It is imponanr. to
search for the underl)ing malignancy which may be involved
in 30% of cases. The treaunent is local excision or vulveCtomy,
if no under!) ing lesion is detected. With lesion,
u-eallllent is as of invasive cancer. RadiotheraP>• is employed
for women unfit for surge•). but a prolonged follow-up for
t-ecun·ence is obligatOI)! Local and systemic 5-FU and bleomy-
cin are also uied. The tumour recurs in 20% of cases.
Microinvasive Cancer
Microimrui'e melanoma is rare and detected only histo-
logically.
SujJerjida/J:y vrdval c<mcfr (microimasive - SIVC) is
defined as a single lesion measuring 2 on or less in the m axi-
m um diameter with a depth ofim>asio n notgreatenhan 1 m m.
Figure 37.3 Paget disease of the vulva. (Source: Da'Jid Dabbs, Uni-
IIE!rsity of Pittsburgh School of Meclcine, Department of Pathology.)
CHAPTER 37- VULVAL AND VAGIN A L CA NC ER 475
It represents Stage lA of tJ1e FICO classification. Multip le foci
even of deptl1 less tl1.·tn I mm do not fal l under tl1is classifica-
tion. Avoiding radical surgef) while maintaining tl1e same sur-
vival rate has 1-educed tl1e surgical morbidity of extensive
1)1nphadenectom) and improved sexual and general quality of
life. A sentinel 1)1nph node mapping and accurate staging is
tl1erefo1-e vef) necessat). \\'ide excision or vulveCLomy is done.
When the l)mph nodes are involved, surge•)' is bette•·
than radiation for groin l)lnph nodes. However, radiother-
apy yields beuer sun ivai rates for peh,ic I) mph nodes.
INVASIVE CARCINOMA OF THE VULVA
EPIDEMIOLOGY
Vulval cancer accounts for 2%-4% of all mal ignancies of tl1e
female genital u-acL T he women are generall y elderly, in the
sixth or seventl1 decade of life. T hi rty per cent of cases are
older than 70 years, and 40% of cases are between tl1e age of
60 and 70 )'Cars. Increasing number of lesio ns are now seen in
younger women, and most of them suffe r fro m sexuall)' trans-
m iLLed di seases such as l=IPV and HI V infectio n. Smoking is
also a risk factor in these )'Ottng wo men. Howevet; o nl)' 2% of
cases are )'Ounger tJ1an 30 years. Null ipa r(H.LS and women of
low parit)' at-e disposed to vulval cancec Vulval cancer is assoc i-
ated wi th cervical and ovarian c;1ncer in 20% of ca..ses. T his may
be related to viral infection in tJ1e gen ital u·act in tl1e former
and low p;uity a11d older age group in tJ1e ov;uian cancer.
AETIOLOGY
The causes are the same as those of in situ carcinoma. The
lesion associated with VI and at) pica! dystrophy often pro-
gJ·esses to invashe cancer. VI however does not always
precede invasive cancer as is seen in cervical cancer. Squa-
mous cell carcinomas account for 90% of all vulval C<UlCers.
CUNICAL FEATURES
Eighty per cent women complain of pru•·itus, \ulval swelling,
lwnp or an ulcer. The lump may be papular, raised pigmented
area. The ulcer has often an even.ed ma•·gin. The su•Tounding
skin ma)' be fissut-ed, cracked and indurated. Leukoplakic or
dysu·ophied area may be present, and tJ1ese may be single or
m ul tifocal. T he lesion is more commonly encowlte•-ed over
the labia majora (70%) , but tJ1e clitoris and pe tineal a1-ea may
be involved. T he an terior two-tJ1irds of tJ1e vulva is usual ly in-
volved . T he lesio n is single in 98% of cases, and multi ple le-
sio ns am see n in o nly 2% of cases, in elderly wome n.
T he ulcerati ve lesions b leed, and ca use offensive vulval
disc harge. Pain is a la te feature of t.h e d isease. Whe n tl1e
ure tJ1ra is invo lved, the woman complains of dys uria and
mictu rition d ifficul t)'· When the anal area is affec ted, rectal
S)•mp toms in the form of rectal bleeding and painful defeca-
tion develop. The ingu inal lymph nodes may or may nor. be
palpable. A woman may be diabetic, hypertensive or obese.
DIFFERENTIAL DIAGNOSIS
(i) Tubercular or S) ph ilitic ulcer
(ii) Elephantiasis vulva
(iii) Soft sore
(iv) L)'Inphogranuloma
STAGING
Refer to Table :n. 1.
476 SHAW'S TEXTBOOK OF GYNAECOLOGY

Iliac
Table 37.4 Staging of Vulval Cancer (AGO 2009)

Stage 1 Tumour oonfined to the vulva

( turator
lA Lesions s2 em in size, confined to the vulva or Deep
perineum and with stromal invasion st.O mm",
no nodal metastasis
IB Lesions > 2 em in size or with stromal invasion
> 1.0 mm•, confined to the vulva or perineum,
with negative nodes
Stage II Tumour of any size with extension to adjacent
perineal structures lower urethra, one-
third lower vagina, anus) with negative nodes

Stage Ill Tumour of any size with or without extension to

adjacent perineal structures (one-third lower
urethra, one-third lower vag ina, anus) w ith
positive lnguino-femoral lymph nodes

lilA (0 With 1 lymph node metastasis (2:5 mm), or

(10 1-2 lymph node metastatls(es) (< 5 mm)
IliB Ol 2 or more lymph node metastases (2:5 mm),
or
(10 3 or more lymph node metastases (< 5 mm)
IIIC With positive nodes with extracapsular spread Rgure 37.4 Lymphatic drainage of the vulva.
Stage IV Tumour Invades other regional (two-thirds upper
urethra, two-thirds upper vagina), or distant
structures. Lymphatics of the clitoris drain directly int.o ll1e pel-
IVA Tumour invades any of the following : vic lymph nodes. The regional I) mph nodes are assessed
by MRI and PET. The invo lvement of ll1e lymp h nodes
IVB Any distant metastasis induding pelvic lymph nodes
depends on the site of the lesion, iLS size a nd deplll of
"The depth of 1nvasion is deli ned as the measuemert of the invasion.
tumour from the ep!thelal-stromal junction of the
most superfidal dermal paplla to the deepest poir1 of invasion. INVESTIGATIONS
Diagnostic investigations include following:

• Punch or excision biopsy depending on the siLe of the

SPREAD OF THE TUMOUR
The tumour proliferates mainly by following:
(i) Di rect spread to the a4j11cent organs
(ii) Lym phatic spread
(iii) Haematogenous spreild rare
Pan·yJ ones was tJ1e first to desc ribe the lymphatic spread
tha t occ urs in a syste ma ti c ma nner. At first, tJ1e supe rficial
inguin al nodes a re invo lved through lymph ati c e mboli, but
la ter lymph ati c channel pe rmeatio n occ urs causing lym-
phatic blockage and leg oedema. T he malignancy spreads
to deep nodes a nd via tJ1 e gland of Cloq ue t (uppermost of
the femoral or tl1 e lowermost of the external iliac gland) to
t11e extemal iliac glands, obturator and common iliac nodes
in tl1e adva need stages.
Laterally placed tumours rarely spread to the contralat-
eral inguinal glands, but centrally located lesion involves
t11e lymph nodes of tJ1e opposite side in 25% of cases and
this is because of crossing of I) mphatics in t11e midline.
L) mph nodes not clinicall) suspicious may show metasta-
sis in about25% of cases.
Inguinal I) mph nodes a•·e involved in 10% in Stage I, 30%
in Stage II, 70% in t.age III and 100% cases in Stage N.
See Fig. :l7. 1 for I) mphatic drainage of the ' 'ulva.
lesion.
• C)Stoscop)' if uretlua is involved.
• Anoscopy and proctoscopy if the perianal area is in-
volved.
• X-•·ay of chest and bones.
• CT and MRI scans for lymph node metastasis.
• Lymp hograp hy is supe rior to cr sca n and can detect
metastasis in tJ1e lymp h nodes 2-5 mm in size, whereas
CT can pick up metastasis on I>• if it is more tJ1a n I em.
Restrictin g unnecessa ry lymph node dissection reduces
the s urgical morbidiq• in ea rly ca ncer. Howeve•; LO do this,
determination of tJ1 e ex tent of primal')' lymp h node (se nti-
nel) invo lvement is neceSSi\1')'· Lymphatic mapping and
sentinel node biopsy (froze n sectio n) before or d urin g sur-
gery help in carrying o uL an adeq uate surgical proced ure
will1 good prognosis.
Mapping is done by:
• An inu-aoperative intradermal u-uectio n of blue dye
amund the tumour (Fig. :l7.5); a detection rate of 100%
is reported.
• Labelling tissues with 1-adioacti'e tmcer and localiat.ion
with a handheld detector.
• L)mphoscintigraphy has also a 100% detection 1at.e.

Rgure 37.5 A picture showing Infiltration of methylene blue dye into
the subdermal tissue of the tumour to facilitate sentinel lymph node
identification.
Microin vasive vu lval cancer S1.a ge lA is app licable on ly
to a single lesion of squamous cell carcinoma up to 2 em
in size and less than I mm invasion below the epitl1elium
with no evidence of vascular space invasion and lymph
nodal involvemenL Adenocarcinoma and melanoma are
not included in this group of tumours, because of their high
propensit) for nodal involve me m. Microinvasive LUmours
can be treated b) local excision with a margin of 2 em be-
yond tl1e lesion, pro' ided the sun·ounding skin is not dys-
trophic. Lf it is d) u·ophi c, vulvectOlll)' is recommended
because of the possible recurren ce of cancer in the dystro-
phic tissue. Multiple foci do not come under this classifica-
tion and more radical surgery.
Treahnent
TI1e traditional u·eau11ent by radical vulvectomy with bilateral
lymphadenecLomy of inguinal, femoral and pelvic nodes, as
described by Way and Taussig in 1935, has undergone a radical
modification in the rece nt )'ea t'S. This is based on the observa·
lion of high prim;uy mortali ty of radical surge•)', a high per·
centage of nega tive lymph node invo lvemem and satisfactOry
5-)•ear cw·e raLe wiLJl the conservative app roach (Table 37.5).
Besides, im,asive ca nce r encountered in )'Oungwomen has also
Table 37.5 Results of Treatment and 5-year
Survival Rates for Cancer of the Vulva
FIGO Staging 5-Year Survival Rates
Stage I 90%
Stage 11 80%
Stage Ill About 50%
Stage IV About 15%
Total About 60%
CHAPTER 37- VULVAL AND VAGINAL CANCER 477
Fig ure 37.6 (A) Radical vulvectomy specimen of carcinoma of the
vulva. (B) Post vulvectomy reconstruction.
welcomed this cotlSCrvati'e su•·ge•)', Lhere is a multidisciplinary
approach for Lhe treaunent and it should be individualized
(Fig. 37.6).
The factors to be considered before individualizing tl1e
surgical treaunent are the general condition of tl1e woman,
stage and site of the tumour, wmour histology and diffe•·en-
tiation. The surget)' is now performed with a separate groin
incision rather than extensive skin incision over a wide area
which is mutilating and diff1cuiL to heal. Primary mortality
of surge•)' is 1%-5%.
Stage I. Stage ! A- Ulleral lesions can be dealt with by
simple partial vulvectomy with a margin of at least 2 em
beyond the growLh, o r unilateral vulvectomy, accompanied
by ipsilateral inguinal node dissection . If the frozen sec tion
reveals the absence of involvemenL of glands, nothing more
is required. This is because, in Lhis case, 1.he conu·alateral
lymp h nodes are invo lved in o nly 0.4% and extensive sur-
get)' will not improve survival, but add to morbidity. Ipsi lat-
eral lymph node involveme nt demands contralateral re-
moval of inguinal glands. The pelvic lymph nodes are
removed onl) if the gland of Cloquet (femoral) shows
malignant cells. Ahe rnativel), a woman is subjected to post-
operative radiation. in place of e xtensive node dissec-
tion. A cenu-al tumour requires bilateral inguinal node
dissection.
Stage 11. Radical/modified radical vulveCLomy and bilat·
eral inguinofemoral l)mph node dissection. If tl1ese are
478 SHAW'S TEXTBOOK OF GYNAECOLOGY
positive, pelvic node dissection or postoperative radiother-
apy is required to th e pelvic nodes.
l fLhe wmour is more than 11 em in size, poorly differenti-
ated or it is a me lanoma or adenocarcinoma, nothing less
than radical vuh ectOm) and bilateral lymphadenectOmy
with pelvic node dissection are required. A separate vulval
incision and two groin incisions are e mplo)ed.
Stnge m. Mega,oltage rad iotherapy 4000-5000 rad O\'er a
pe•·iod of 5 weeks causes sl11inkage and at times the tOtal
disappeamnceofthe tumour. Local excision of the shrunken
tumour is then adequate and eliminates the need for exen-
teration operation. Loca l recurrence can be dealt with b)'
chemotherapy. Forty per cent survival and 30% recurrence
have been reponed.
Stnge IV. It is u·eated by d1emot11erapy or radiot11erapy.
Anal involvement is satisfactorily treated wit11 infusion of
5-FU and mitom>•cin·C, followed by radiot11erapy 3000 rad,
over 3 weeks. Local excision of residua l tumour may be re-
quired. Chemotherap)' avoids exenteration operati on with
its assoc iated high mona !it)' and morbid ity. Fifteen per cent
5-year surviva l is reported. Other chemotherapy agents used
area as fo llows:
• Bleom>•cin 5 mg days 1-5
• Metho u·exate 15 mg da)'S 1-4
• Tmstuzumab 4110 rng days !).7
This regime is administered weekly for 6 weeks.
BARTHOLIN's GLAND TUMOUR
Bartholin's gland tumo ur is a rare unilateral tumour, com-
mon!) an adenocarcinoma, and carries a poor prognosis.
Radical vulvectom> is the treatment of choice.
VULVAL SARCOMA
Vuhoal sarcoma is a rare tumour which occurs in younger
women (Fig. :l7.7). Treatment is local excision. MetaStaSis is
common. The p•·ognosis is poor.
VULVAL MELANOMA
Malignant melanoma accounts for 3%-5% of all vuhoal tu-
mours. lL occurs at all ages, and may develop in a mole or
occur de novo. The lesion is pigmented a nd presents as ei-
tller nodular or superficial spreading tumour. The edges of
t11e lesion are ofte n and freq uently ulcerate and
Figure 37.7 Sa-coma of the vulva.
bleed. The u·eaunent is managed by vu lvectOmy and bilat-
eral node dissection. Postope rative radiotherapy may be
reqLtired Prognosis is poor.
RODENT ULCER
This uncommon lesion presents as an ulcer which keeps
invading the deeper tissues of the vulva. Biopsy shows basal
cell carcinoma. It is locall) malignant and responds well to
local excision.
PERSISTENT CANCER (RESIDUAL)
Persistent cancer is one whi ch develops witl1in 6 months
of primary treatm ent. Local excision with \\ide margin is
required.
SECONDARY GROWTH OF THE VULVA
Secondat-y growt11s of the vulva are metaStases from chorio-
carcinoma, endomeu·ial and ova ri an ca nce r. They are
treated by radio therapy or chcmo t11e rapy.
Distal metastati c growths arc rare. T hey are treated with
radiot11erapy and chemo tlt erap)'·
Fifty per cent recurrent growths are seen at the local site
within 2 )'Cars of prima•-y trcatmem, and occur witl1 large
growt11s and l)•mph node invo lvement. The)' are u·eated by
exenteration operation, radiotherapy and chemo therapy.
Rewmmt growth.!>. Rec urre nt growtlts occ ur in 30% of
cases within 2 years. Local rec urrence is seen in 75% cases.
Lymph node and distal metastasis are rare. If the growth is
small, local excision with a wide margin over 2 em is ade-
quate; otlterwise, radiotherap) or chemotherapy is em-
ployed as palliative treaunen L
Exenteration operation with removal of bladder/ rectum
with vulvectom> is ve11 rare I) perfo rmed t11ese days.
PROGNOSTIC FACTORS
Prognostic fuctOI'S are tlte sit.e of t11e grading, his-
tOlogy, lymph node im·ohrement and immune status of the
woman. Groin node status is the best prognostic predictOr.
When the lymph nodes are not involved, 5-year swvival
is 90%. Lymph node involvement diminishes tlte survi,oal
rate proportionate to t11e number of lymph nodes involved.
VULVAL CANCER IN YOUNG WOMEN
Vulval imraepithelial neoplasia is mostly encoumered in
young women. Using barrier co ntraceptives and maintain-
ing h)•giene can reduce the transm ission of HPV infection
which normally ca uses VIN. 8\ dy d iagnosis and conserva-
tive therapy can cm e th e d isease, avoid mutil atin g surgery
and improve the survival rate. II PV vaccine can prevent
malignanC)' in tJ1ese cases in future.
VAGINAL CANCER
Primary vaginal cancer is a rare cancer acco tmting for less
than 0.2% of all cancers in women. It occurs in elderly women
often older tJ1an 70 >ears when sexual acaivity has genemlly
ceased. Unfonunatel), onl) about o ne-t11ird of the patientS
have regional disease at the time of diagnosis; t11erefore, late
diagnosis is not un common (Fig. 37.8). An LLilusual tumour
clear cell adenocarcinoma was seen in )Oung women who
were themselves exposed to diet11) lstilboesu'OI (DES) in utero.

Rgure 37.8 Carcinoma of t he upper-third of the vagina removed by
extended hysterocolpectomy.
Rgure 37.9 Carcinoma in a case of prolapse. (Source: From: Sen-
gl.4)ta et al. Gynaecology br Postgraduates and Practitioners, 2rd ed.
Elsevier, 2007.)
H owever, such cases arc fast disappearing with withdrawal
of the drug. C'..ancer of th e ce rvix , bladder and urethra,
vulva and lower bowel may spread LO involve the vagina.
MetaStaSes from ca nccr ofLhe ute rus, ova ry a nd trophoblas-
ti c tum o ut'S have bee n known LO occ ur in the vagin a.
Cancer over a d ec ubitus ulce r in pro lapse is a lso known to
occ ur (Fi g. 37.9).
CLINICAL FEATURES
Vaginal cancer is generally asymptOmatic in itS earlier stages.
The usual complaints are the presence of watery discharge, or
postcoital bleeding; the lesions may be diffuse, raised velvety
patches bleeding on touch, a whitish pateh or ulcer: Cytology/
Schiller's iodine test/colposcopy and biopsy help settle t11e
diagnosis. The lesions are often multifocal and in the upper-
third of the posterior wall. The extent of spread may be deter-
mined b) combined vaginal and rectal examination. Diffuse
spread ma)rimolve the w·ethra and bladderamer·iorlyand t11e
large bowel posteriorly when urinary and bowel spnpwms
may occur. Cancers may a rise de novo in )Ounger women
CHAPTER 37 - VULVAL AND VAGINAL CANCER 479
Table 37.6 Vaginal Cancer Staging
Stage 0 Vaglnallntraepithelial neoplasia (VAIN)
Stage I Carcinoma limited to the vaginal wall
Stage II Carcinoma extending beyond the vagina, but not
extending to the pelvic side walls
Stage Ill Carcinoma extends up to the pelvic walls
Stage NA Carcinoma extending beyond the true peMs/or
involving the bladder and/or rectum, or evidence
of distal metastasis
Stage NB Spread to the distal metastasis
exposed to DES in utero, whe n the upper o ne-third vagina is
involved, following trophi c ulcer'S in women wit11 procidentia,
foll owing prolonged and neglected use of ring pessar) ' fo r
prolapse or as spread fro m othe r pelvic o rgans. VinJs infec-
tio n may be a causati ve facLOc
lL may also d evelop >•ea rs later foll owing rad ia tio n for
cancer of th e cervix.
T he lesion is sq ua mous cell carc inoma in 90% cases,
rare l)• adenocarc inoma a rising from vagina l adenosis in
)'Oung girls. The wmour in th e u pper vagin a drains in to
pelvic lymph nodes and that in the lower part drains in to
inguinal lymp h nodes (Fig. :l7.5 ).
Vaginal intraepithelial neoplasia (VAJN) is rare, and al-
ways progresses to invasive cancer.
STAGING
Refer to Table :l7.6.
DIAGNOSIS
Suspicious areas of plaque/ white patch should be
to Schiller's test and colposcopic biopsy. All gross lesions
such as nodule, papule, ulcer or mole should be biopsied.
Local application of oestrogen in old women enhances a
colposcopic view. Colposcopy is d ifficult on account of a
large vaginal area, multiple lesio ns and vaginal folds.
MANAGEMENT
PRETREATMENT WORK-UP
Compl e te histOr)' and exa m ination, WBC, urina l)•Sis, blood
s ugar es tim a ti on, li ver function tes t (LIT), renal function
test (RFT), chest radiograp h y, t::CG, cystoscop)\ p roc toscopy
and bari um ene ma may be req uired. CT and MRI are done
for a nodal study.
TREATMENT
VAIN. It is treated with loca l e xc is ion biopsy, COt laser
and local application of 5-fluorouracil cream. Electrocau-
tery ru1d c r1 otherap) are best avoided. Invasive cancer is
u·eated wit11 local radiotherap), Wertheim hysterecwmy
with total colpectOm), or exenteration operation for the
advanced cases irwoh'ing bladder/ bowel. O verall
is 30%-10%. Creation of neovagina is required in young
women.
480 SHAW'S TEXTBOOK OF GYNAECOLOOY

Treati ng a decubitus ulcer and proper care of

a ring pessary in a prolapse can avoid cancer of vagina.
SarromEt. Sarcoma botr")Oides is a rare tumour seen in
children.
This tumour arises in l11e mesenchymal tissues of tl1e
vagina and in rare cases, in the cervix before the age of
2 )Cars. It presents as a haemon-hagic grape-like po lyp o r as
a flesh)' mass and consists of rhalxlom)oblasts with vacuo-
lated C)'LOplasm, myxoedema a nd su·oma with fusifonn cells.
The tumour spreads b) local infihratio n. lymphatics and
bloodstream.
£xami1Uttio11 is done under anaesthesia; biopsy confirms
tl1e diagnosis. CT and M R1 indicate its spread.
Trt!(t/mmt. C he mothe rapy wil11 VAC (vincristine, adriamy-
cin and cyclop hosp ham ides) is the gold standard in treating
tlus u.unour. Othe r drugs used are cisplatin, actinom>•cin,
cyclop hosp ha mide and ifosfa mide.
St.u·ge•")' is li mited to l11e local resid ual twno ur. Intersti-
tial rad iati on is used in the advanced stage.
KEY POINTS
• Prein vasive ca ncer of vulva (V LN) is caused b)' human
papilloma virus in )'Oung women.
• VIN is usua ll y a multifocal lesion in young women, but
a single lesion in older women.
• In )Oung wom en , 90% reg•·ess, 10% progress to inva-
sive cancer within 8 )Cars. Careful follow-up is recom-
mended.
• VI in older women invariably progresses to imasive
cancer and should be treated b) \uhectom>'·
• The conservative surget")' ablative as well as local wide
excision is adequate in )Oung women. Simple vulvec-
tOmy should be performed in elder!)' women. Follow-up
is necessa•")'·
• Radical \llhe cLOmy is required if tl1e regional lymph
nodes are imo hed.
• Prognosis depe nds o n the l) mph node in,olvemem
which in tum depends upo n the site. sue and depili
of ll1e lesio n.
• Vaginal cance r is rare a nd difficult to diagnose in its
early stage.
• Radical surger) is usuall) required. Radiotherapy is
palliative in the advanced stages.
SELF-ASSESSMENT
I. A 55-year o ld woman prese nts wi th a vulva l ulcer. Disc uss
the diffe renti al d iagnosis and manage men L
2. Disc uss the manageme nt ofv1 Jva l cancer Stage l.
3. Disc uss the manageme nt ofv1 Jva l cancer Stage U.
SUGGESTED READING
BonnarJ (ed). Recem Ath-.-lllC<'> in Ob>tctrics and Gynaccology Vol I 7:
223, 1992.
Bonnar J (ed ). VIN. Recent Adv Ob>t.cl Cyna<.'COI 1998; 20: 167.
Duncan J, Shulman P: Ye-.;rbook of Ob>t.c trics. GynaecoiOj,')' and
Women's llealth 1989; 417:7, 2010.
jonathan S (ed). On co log)•. Berek and I JackeTS. I 3:560, 2015.
Studd]. Role of ,;nl>e> in 10 oncology: I n: AB
et al. Progress in Ob>tcLric> and C rnaccology Vol 12: 403, 1996.
 Gestational Trophoblastic
Diseases
Hydatidiform Mole .48 1 Recurrent Molar Pregnancy .488
Invasive Mole .483 Coexis6ng Molar Pregnancy .488
Placental Sile Trophoblastic Tvmovr .483 Choriocorcinomo .489
Persistent Trophoblostic Disease .488 Key Points .493
Treatment of Persistent Trophoblastic Disease .488 Self-Assessment .493
Perforating Mole (Chorioongiomo Destrvens) .488
Gestational u·ophohlastic diseases (GTDs) comp tise a vari-
ety of biologically interrelated conditions wh id1 form a
clinical spectrum from a benign partial hydatidifonn mole
at t11e one end to the highly malignant choriocarcinoma
at t11e other witJ10ut an) precise line of demarcation.
This specu·um extends from a very early pregnancy (hyda-
tidifotm mole) to )Cars afte r t11 e pregnancy is over (chorio-
carcinoma).
Trophoblastic tumours ma> be categoriLed imo tJuee
broad gro ups ("Iahle :38. 1):
I. Hydatidiform Mole: It may be a complete or a partial
mol e. The tumour sometimes invades the wall of the
uterus and the surrounding su·uctures, when it is called
an invasive mole (chorioadenoma destruens).
2. Persistent trophoblastic disease (P1D), also kn own
as residual u·ophoblastic disease (RTD), incl udes the
invasive mole.
3. Ch oriocarcinoma: T his is U"ttl y a malignant tum our. It
co ul d be a nonm eL<'\Sta tic trop hoblastic d isease ( NMT D)
or a metastati c trop hoblas ti c disease (MT D) .
Metastati c wm our ma>' be of low o r high risk.
Table 38.1 Classification of Trophoblastic Disea ses
1. Molar pregnancy
Partial
Complete
2. Persistent or residual mole
Invasive
Placental site
3. Choriocarcinoma
Nonmetastatlc
Metastatic: Low and high risk metastatic
HYDATIDIFORM MOLE
INCIDENCE AND AETIOLOGY
The incidence of t11e disease is higher in t11e Eastern coun-
tries t11an in t11 e West. i ts geographical distribution is as fol-
lows: in the UK and t11 e USA I :2000 to I :3000, India and tlle
Middle-East 1:160 to 1:500, China 1:150, Philippines 1:173,
and indonesia and Taiwan 1:82 pregnancies. Likewise, t11e
malignam potential of t11is disease is higher in Southeast
Asia, where it is as high as 10%- 15% compared to 2o/o-4% in
the Western counu·ies. Some immigrantS from Southeast
Asia to a developed country lose tll e potential to develop
h)datidiform mole once they settle down in the new environ-
menL This proves t11 at t11e conditi on is not racial, but may be
t·elated to geogt-aphical and environm ental influences.
Vitamin A, 1)-cat·otene and folic acid deficiency in t11e diet
are also implicated in t11e occun·ence of trophoblasti c disease.
Women belonging to blood gro up A are suscep tible to
thi s disease, but th e reaso n is not kn own. Ve ry young and
wo men o lder than 40 )'Cars are pro ne to iL Repeat molar
pregnancy occ urs in 2%- 10% of cases. In co ntrast to a com-
p lete mo le, mate rnal age and nuu·itio n do no t appear to
infl uence the incide nce of a partial mo le.
A mo le is conside red partial if there is coexisting preg-
nanC)' and it is labelled as co mp le Le mo le when there is no
evidence of normal pregnancy. Comple te mo le is far more
common UlaJl p;u·Lial mo le.
The diagnosis of co mplete and partial moles is based
on morphological, histological and karyotype findings
(Table 38.2).
PATHOLOGY
A complete h)<latidiform mole resembles bLUlches of grape-
like vesicles, pearly white in colour and u-anslucem, contain-
ing watet)' fluid (Fig. :l8. 1A and B). The vesicles vary in size
481
482 SHAW'S TEXTBOOK OF GYNAECOLOGY

Tab le 38.2 Features of Complete and Partial M o les

s. No . Features Complete Mole Partial M ole

1. Fetus Absent Present, malfonned or IUGR

2. Fetal vessels Absent Present

3. Hydropic changes Diffuse and placenta not present Focal

4. Trophoblastic hyperplasia Marked M ild to moderate

5. level Very high Comparatively low

6. Karyotype 46XX mostly and paternally derived 69XXY

7. Malignant potential 15%- 20% Rare

R gure 38.1 (A) Hydatidiform mole. (B) Specimen of hydatidiform mole from a 43 yr old woman. (Source: From Figl.l'e 31-2. Plljsiobgy in Ctild-
bearing. Elsevier. 2005; Figl.l'e 16·22. NiCholas Vardaxis: A Textbook of Pathology. Elsevier. 2010.)

from a few millimeu·es LO 2-3 em in diameter and are auad1ed
to the main stalk by thin pedicles. A few haemon·hagic areas
are seen in between the bunches. The fetus, amniotic sac and
t11e placenta are conspicuously absenL The size of t11e mole
depends on t11e duration of pregnancy and clegene1·ation.
Histologi call y, t11e disease is dla racterized by (i) hydropic
degeneration and swelling of the villous su·oma, (ii) absence
of villo us b lood vessels and (iii ) proliferati o n of both syncito
and cyto trop hoblastic e pithe lial. The vesicle demonstrates
irregul ar proliferation a nd pleomo rphism of epithelial cells
whose nuc lei are h)'pe rchro matic and ac tive !)' mitotic. The
villous Sll1ICture is, we ll preserved and identifiable.
Irrespec ti ve of u·ophoblastic cell proliferation, it is the pres-
erva tion of a villous strucwre that determines the benign
nature of th e trophob lastic disease (Fig. 38.3).
l n a very early pregnancy, it is difficu lt to d ifferentiate
between a molar pregnancy and a missed abortion. Histol-
ogy of products of conception alo ne can identify molar
pregnanC). ln complete mole mostly karyotype is 46XX and
botJ1 sex chromosomes are paternal in origin.
A partial mole resembles the placenta, but contains a few
vesicles on its maternal surface. A fetus is identifiable in this
case. One of the twins may be a mole and anot11er a nonnal
fetus. Even an ectopic p1·egnanC)' has been repon.ed to con-
tain a molar pregnancy. In a partial mole, some or most of
the villi appear normal. The fetus most often shows gross
malfo1·mation, inu-auterine growth retardation (JUGR) and
in utero deat11. Very few live babies have been bom in a case
of partial mole. The fetal blood vessels are seen on ulu-a-
souncl scan. Kat-yotype is usuall y 69XXY.
T he average gestational age wh en a partial mole is diag-
nosed is at a later date than that fo r a complete mole; it
co uld be in tJ1 e second uim este r or as la te as around
24-26 weeks of pregnane)'· The e nlarge me nt see n in a com-
p le te mo le is rare ly obse rved in a partia l mo le, a nd it may be
of a normal s ize or smaller fo r Lhe gest.atio na l pe1i od on ac-
count of inu·auterine feta l growtJl retardation. ILrare ly me-
tastasizes and does not. req uire prop h)'lactic ch emo tJ1erapy,
as the level of human chorionic go nadotropin (hCG) is
comparatively low (< 10,000 IU). Despite this, follow-up is
necessary, as choriocarcinoma may, in rare cases, follow a
panial mole.
The uterine wall is h)'Pertrophied in a hydatidiform mole
as in a pregnane) and is lined b) a Lhick decidua. The ova-
ries contain tJ1eca lutein C)SLS in 60% of cases, and l11e cystS
are usual I) 6-8 em in siLe and tend to be bilateral. Rare com-
plications of a torsion of Lhis ovarian cyst a nd haemoni1age
into the cyst necessitating lapa,·otom)' have been reponed.
Features of complete and partial moles have been
described in '!able :l8.2.
 CHAPTER 38 - GESTATIONAL TROPH OBLASTIC DISEASES 483

INVASIVE MOLE
Some h)datidifonn moles (about 5%-10%) are invasive
moles that im-ade the wall of the ute•·us, burrow imo the
m)omeu·ium and, in some cases, even perforate Lhrough the
uterus imo either the pe.-itoneal ca,•ity or the broad ligamem
when dangerous intemal haemon·hage may ensue. It should
be emphasi£ed that, though behaving as locally malignant,
the im-asive mole does not kill b) distal metastasis and, mere-
fore, cannot be considered a cancer. The relative proportion
of invasive moles to the benign noninvasive type is in the re-
gion of I: 12. The invasive mole occupies an imermediate
position between a benign hydatidiform mole and a malig-
nant choriocarcinoma ( rahle :38.:3).
An invasive mole is li ke ly to be mistaken for a choriocar-
cinoma, b ut histologicall)' there is one distinguishin g Rgure 38.2 Perforation of uterus by hydatidiform mole.
feature -an invasive mole will show evide nce of ch orio nic
villi, whe reas in a chori oca rcino ma, all eviden ce of villous
fo •mati on is lost. Trop hoblastic wm our di agnosed up to
6 months fo llowing an abortio n or a mo le is often an
mo le, b ut tumo ur d iagnosed later t11 an 6 mo nths is
us ually a cho riocarcinoma. £ igh ty percent of hydatidiform
moles resolve following trea tment in t he form of evac uation
of uterus, 15% pe•'Sist as pei'Sistent or resid ual mole an d
5% develop into choriocarcinoma.
lm'liSive or pe1'Sistent mole is diagnosed clinicall y by per-
sistem vaginal bleeding and pain following evacuation of a
h)datidiform mole, but more often by follow-up wilh ulu-a-
sound scan and se.-ial 13-hCG levels (persistently raised
level). Chemotherapy is ttsually effective, but hysterectomy
may be required to conll'ol bleeding if perforation occurs
(Fig. 38.2).

PLACENTAL SITE TROPHOBLASTIC TUMOUR Figure 38.3 Histology of Molar pregnancy.

It constitllles I% of all trophoblastic diseases. Placental site

trophoblastic wmour arises from tl1e placental bed tropho- tl1is reason, !3-hCG level is low and serum lwman placental
blast and invades t11e myometrium. It follows a fui J.. lactogen (I-I PL) levels are high.
teml norma l del ivery in 95% of cases, altho ugh in rare
cases, it may follows a mo le (5%). hCG levels are lower than
AETIOLOGY OF GESTATIONAL TROPHOBLASTIC
those observed in choriocarcinoma, and rare l)' exceed
DISEASES
2000-3000 IU/ L. Most of tl1ese tumours run a benign
co urse, ma ligna ncy being rare. T his tum our con tains mainly T he ca n be see n in wo me n betwee n 18-50 years of
cy to u·ophoblasts witll few o r no syncyti otrophob lasts. Fo r age, may be mo re co mmo n at ex treme of repro-
ducti ve life. T he incidence is hi gher amongs t wo men be-
lo nging to t11 e low socioecono mic gro up subsisting o n a
poor ri ce d iet and vita min deficiency. Diet defi cie nt in pro-
Table 38.3 Spread of Choriocarcinoma
tein, folic acid a nd iron, and environmental factors are in-
Lungs 80% X-ray chest, CT criminated in the aetiology. Folic acid is essemial for t11 e
cell ular metabolism of rapidly growing cells, and it is hy·
Vaginal metastasis 30% Speculum exam ination,
pot11esized that its denciency in the diet predisposes to ab-
normal trophoblastic prolife1-ation.
Pelvis 20% Pelvic examination, The cyLOgenic swdy of a h)datidiform mole displays
ultrasound, CT typical chromosome patterns. A complete mole is com-
Uver 10% Ultrasound, CT posed of 46XX, and all the chromosomes are of paternal
origin. The phenomenon is known as androgenesis, in
Brain 10% CT, which tlle empty O\ Lllll is fertili£ed by a haploid sperm
Gastrointestinal Rare Ultrasound, which t11en duplicates after meiosis to produce 46XX.
kidney, spleen The chromosomes in the ovum are either absem or inac-
Livated. l nfrequentl), when 46XY chromosome panem
484 SHAW'S TEXTBOOK OF GYNAECOLOGY

Types of Trophoblast ic I
Di seases

I Partial mole
1

Persistent mole Invasive mole (ir>Jades

(coofined usually l o uterine wal. Raised [}-
end omelrium. Raised hCG)
hC G in follow-up)

choriocarcinoma I
within 2 years

l 1
Placental site
trophoblastic
r Choriocarcinoma ]
disease

Rgure 38.4 Types of trophoblastic diseases.

is detected, it is h) pothesi.t:ed that two spenns have

fertili.t:ed an empty ovum which itSelf is lacking chromo- Table 38.4 Symptoms of GTN
somes. The partial mole demonstrates triploid karyotype
(69 chromosomes XXV). Amenorrhoea
Irregular bleeding per vaginum
Expulsion of structures
CLASSIFICATION (Fig . 38.4) Features of hyperemesis
• Features of thyrotoxicosis
are 1wt rrliable {fllide5 /fJ futnm dinical behav- • Asymptomatic but diagnosed on ultrasound
iour of the tunwur well lhfr<tjJf'ut.ir dPtifiOilS. In persistem
in vasive wmo ur, the tissue m ay not be available for histol-
ogy, as previous sur·gical ma nage ment by hysterectomy is Metasta ti c di sease limited to tJ1 e pelvis o r lungs
now re placed by che mo th era p)'· • No signifi ca nt prior chemo tJ1e rapy
WHO has tJ1erefo re reco mm e nded the cl inical classifica- B. High risk
ti on of gestationa l tro pho blastic (GTN) as follows • Ow·ation of tJ1e disease from term ina tion of pregnancy
(Tab le 38.'1): to initiatio n of chernotJ1erapy more tJmn 6 rnontJ1s
• H igh se n un hCG level - 50,000 rn lU/ m L or more
l. Benign GTN Brain and live r me tastasis
A. Hydatidijim11 nwle Metas tatic ch oriocarci noma followin g a term preg-
Complete nancy
Partia l
B. Other
SYMPTOMS AND SIGNS OF GESTATIONAL
Placenta l site trophoblastic disease
In vasive and persistent trophoblastic disease
TROPHOBLASTIC DISEASE
ll. Nonmetastatic mal ignant G TD: Choriocarcinoma A woman witJ1 a complete mole presentS witJ1 ame norrhoea
lll. Metasta tic malignant GTD of less tJ1an 24 weeks' gestaLio n, tL$ually 3--4 montllS.
A. Luw risk 1 O\\adays a number of cases are diagnosed on tl1e basis of
Du ration of disease from tennination of pregnancy ultrasound done in earl) pr-egnanC)'· A histOI')' of vagina l
to initiatio n of chemo tJ1erapy less than 4 montllS bleeding and alxlominal pain is present in 70% of cases. The
Pretreaunenturine hCG level less than 1000 IU / vaginal bleeding may be slight and imennittent or pro-
24 hours or serum 13-hCG 40,000-50,000 miU/ mL longed Profuse haemon·hage occurs usually with the onseL
 CHAPTER 38 - GESTATIONAL TROPHOBLASTIC DISEASES 485

of spomaneous expulsion, but b•isk haemontJ.age COMPLICATIONS OF GTN

abortion is not tmknown. The passage of vesicles is rarely
• 1-l)pe remesis gravidarum and Pil-l
observed ex.cept when the woman is aborting. Prolonged or
• Haemorrhage and anaemia
heaV) bleedmg leads to anaemia. The abdominal pain is be-
• Infec tion
cause of abortion, concealed haemo•,.hage, sudden disten-
sion of Ule uterus in rare cases, perforation. H)•peremesis • Thyroid storm - 3%
is reported in about 30% of PrcgnanC)•-induced hyper- • Embolizati on wiili ac ute p ul monary insufficiency and
tension (PLH} before 24 weeks is noted in one-u1ird of the coagul ati on fa ilure- 2%
Thyrotoxicosis resulting in supraven u·icular tachycar- • Uterine perforation- spontaneous but more commonly
during sucti on evacuation
cha, dyspnoea and raised T3 and T 4 levels is seen in 3% of
cases and is because of u1e fact that subunits of both thy•·oid- • Delayecl - 1'-ecurrent mole and cho•·iocarcinoma
stimulating hormone (TSH) and hCG share a similaJ· su·uc-
tu•-e. One per cem of women are asymptomatic and t.he INVESTIGATIONS
condition is suspect.e<l by palpating an undul)' enlarged SERUM 13-hCG
Lately, wiili routine ult.rasound screening perfonned
This condition is characte•·ize<l b) marked elevation of
m earl) pregnancy, more asymptomat.ic cases are being diag-
serum hCG values. These values mar often exceed 40,000-
nosed and t.reated before bleeding occurs (Table 38. 1).
100,000 miU/ mL.
The symptomatic patient may look pale and ill, and she may
be febrile. The uten.IS is larger u1an wou ld be expected from Serum 13-hCG level is very high in a complete mo le, but
t.hc calctJated elate of gestation in 70% of cases. ln 15% of u1e is not ve L)' much raised in a pania l mo le. A se rum level of
cases, Ule ute 1ine size corresponds to Ule peliod of gestation, more than 40,000 miU/mL as de te rmined by rad io immu-
and in Ule remaining 15%, it is smaller Ulan expected because noasstl)' is reponed. For d iagnosti c purpose, ulu·aso und
abortion or a pan.ial mole. The uten.IS feels doughy sca n alone is confirmative, quick and a safe procedure.
?f
Hom1onal as5a)'S are now main ly confined to pOSU11olar and
m consiStenC)' because ofu1e absence of amniotic fluid. Exter-
postch emotherapy follow-up. HPL is low in a complete
nal and imemal ballouemem cannot be elicited and me fetal
hea•t cannot be heard on u1e Doppler. Ov;uian ilieca lutein mole, but raised in a pan.iru mole, pulmona•)' metaStaSis
and place ntal site tumour.
C)SLS. more man 6 em and bilateral are often present, but may
be d1fficult to feel becatLSe u1e enlarged utertLS occupies most Urinaq hCG, though common!) LLSed in ilie past, is not
as reliable as serwn hCG.
of u1e pelvis. ll1e cervix feels soft as in a no•mru pregnancy.
Serum hCG levels are raised. Hydatidiform mole LISLtally leads FETAL HEART DETECTION BY DOPPLER
to abo.rtion between the third and sixu1 monu1s of pregnancy.
Ultrasound remains the most re liable investigation to diag-
A parual mole often presents wi th oligoh)•dramnios, intrauter-
ine growu1 retarded fetus or ma lformed fellls as detected on nose the hydatidiform mole. T he auscult.ation of fetal heart
uluti.Sound scanning, during Ule second uimeste •: Few vesicles by Dopple r can rule o ut a comple te mo lar pregnancy. T he
may be seen in u1e placenta on ult.rasound scanning. absence of a fetal heart goes in favour of a mo lar pregnancy.
ULTRASOUND
DIFFERENTIAL DIAGNOSIS Ultrasound examination shows u1e 'snow-storm' appear-
MISTAKEN DATE ance in u1e uterLLS and t.he absence of fetal shadow in a
Undue enlargemem of u1e utertLS may be becatLSe of u1e pa- complete molar pregnane)' (Fig. 38.5). In a partial mole, u1e
tient stating u1e wrong date of her last mensuuru period fetus (malf01med or 1UGR) and place nta are visuali£ed.
(LMP). ll1e fetal pans are palpable. lt.rasound scan reverus a The placenta shows scattered cysts.
fetus and ult.rasonic fetal mau.uity con-esponds to Ltterine size. Ultrasound scanning is also required during u1e follow-
up LO see if u1e corp us theca C)'St regresses in si.te and to
MULTIPLE PREGNANCY
Ult.rasound scanning will reveal mu ltip le pregnancies as a
ca use of uterine size bigger u1 an peliod of gestation.
ACUTE HYDRAMNIOS
Acute pain, sudden enlargement of u1e uterus and slight
bleeding mar simulate a hydatidiform mole with concerued
hae morrhage. Ult.rasOund scan will re,eal h)'dramnios, a
fetus and pe•naps muh..iple pregnancy with which acute hy-
dramnios is commonly associated.
FIBROID WITH PREGNANCY
A uterine fibroid may conu·ibute to undue enlargement of
the uterus in pregnancy. The presence of fetal parts and
fe tal heart establishes u1e diagnosis of a normal pregnancy.
Ulu·aso und scan will show a fibroid in addition to a fetus.
THREATENED ABORTION
Ulu-asonic study distinguishes a norm al pregnane)' from a Figure 38.5 Ultrasound scan shows 'snow-storm' appearance
mol ar one. of a mole.
486 SHAW'S TEXTBOOK OF GYNAECOLOGY
detect persistent mo le, invasive mo le and development of
choriocarcinoma. The me tastasis in the liver can be picked
up on ultrasound scan. Doppler ulu·asound shows abnormal
vascularization.
Chest X-ray is done to rule o ut lung metastasis. Cf scan
is required in liver and brain metastasis and sometimes to
detect pulmona11 metastasis if d1est X-ray is nonnal.
In the earl) stage of pregnanC)', combined ullrasound
scanning and se•·um 13-hCG estimation improves the diag-
nostic accuracy.
TREATMENT
When a woman comes in the process of abon.ion, vesicles can
be identified amongst the pnxhtClS passed. Blood should
be transfused if required and inu-avenous oxytocin drip of
10-20 tmitS or more in 500 m L of5% gl ucose shoul d be set up.
Su rgical evacuation with a suction evacuati on machine (as in
medical te nn ina tio n of pregnancy (MT P]), using no. 8-10 Kar-
man can mJa, red uces tJ1e blood loss in tJ1e sponta neous expul-
sion of a mo le. A d igital explora ti on or a gentJ e curettage will
remove an>' remnants of chorioni c ti<>sue. T he evacuation
can be assisted b)' adm inisu-ation of in u-aveno us Methergine
0.2 mg. Completeness of evac uation can be confinned by
simultaneous ulu·asound. The operation can be associated
conside1-able blood loss wh id1 can be minimized by fast
evacuation an oxytocin d •ip running and i.v. Methergine,
tl1e evacuation can be completed witl1 minimal blood loss.
Witl1 the availabilit) of ultrasonic facilities and routine
screening in earl) pregna nC), a molar pregnancy is now di-
agnosed before a spo ntaneous abortion begins. Ln sud\
cases, termination of h)claticliform mole should be done
tmder a planned and co ntrolled situation tLSing a suction
evacuation machine. An incompl ete evacuation of chori-
onic tissue will cause the hCG levels to remain elevated and
ime1-fere with the proper follow-up of the patienL Besides,
it will cause continuotLS bleeding. NuwndtJ)'S, ITUlll)' prefer to
evacuate a mole 1111der tlflmsollic guidtmCP to msure annplete
evacuation mul to <Jvoid uterine j)('rfomtioll. This also avoids a
repeat check cureuage 7-10 clays later, as was practised
earlier. One hunch·ecl micrograms Rh ami-D globin should
be given to an unimmunizcd Rh-negative woman tO prevent
isoimm tmization in subsequent pregnancies.
Cervical ripening with prostagland in is effec tive in dilat-
ing th e cervix p ri or to evac uatio n. Prostagland in vaginal
pessary (400-600 meg) for ripe ning tJ1e ce rvix o r cervical
gel (Cerviprim e con tain ing 0.5 mg d inoprostone,
may be warranted in a few cases in whom ce rvical dila tion
with a metal d ilator may be undes irab le o r d ifficul t because
of a tight cervical os. A sudden unexp lained collapse du ring
evac uation is atu·ibuted to excess ive b lood loss or because of
massive dissem inated inu·avasc ular coagulation (DJC) or to
massive pulmonary emboliz;\tion by t11e molar tissue lead-
ing to acute pulmonary hypertension and cardiac failure.
Hysterectomy is generall) not required except for itS pro-
phylactic value in preventing choriocarcinoma in patients
older tl1an 40 >ears and who have co mpleted their family. It
mtLSt be reme mbered , however, t1lat hyste recwmy, while
preventing development of local cho•·iocarcinoma, does not
obviate tl1e need for ca•·eful foiiO\NIP becatLSe a metastatic
LUmour can still develop in the distal organ. With the pres-
ent-day management of h)datidiform mole, tl1e mortality
because of a molar pregnancy is very low. Death is invat·iably
associated profuse hae morrhage. Hypenhyroidism and
congestive cardiac fai ltu·e are seen in 3% of cases. The patient
may recover from a molar pregnancy but develop metastasis
in tl1e ltmgs. brain and liver at a later date. Whether it is a
benign or a malignant metasta tic lesion, haemorrl1age in
th.is lesion can catLSe sudde n death. Postabortal anaem.ia
and sepsis are not un common.
Choliocarcinoma d evelops in 2%-10% of cases following
evacuation of mole. As t11e •·isk of development of chorio-
carcinoma remains for initial 6month to 2 years a woman
who had a molar pregna ncy requires careful follow up.
Medical tenninati on with prostaglandin alone is not
desirable because of the .-isk of pulmonary emboliLation,
and surgical evacuation is needed following cervical dilata-
tion. ln a partial mole, however, medi cal termination is tl1e
method of choice.
FOLLOW-UP AFTER EVACUATION OF HYDATIDIFORM
MOLE (Fig. 38.6)
Fo llowing evacuati on hyda tid iform mole 10-14% people de-
ve lop persiste nt gestati onal Trop hoblastic disease. T here is no
marker to decide whic h molar pregnancy will proceed to cho-
riocarcinoma. Histo logical feaUires alone do no t provide a
reliable cl ue to tl1e future be havio ur of tJ1e mole and its pro-
gression to carcinoma. Therefore, tJ1e therapeutic decision in
the follow-up should not be inn ue ncecl by hi.stO iogy. However,
fiblinoid deposition in the tissue does suggest host's favour-
able immunological respo nse. Folknlf-upfor l-2years remains the
onl)• option for ddecti11g e(lrl)• clwriocarcinOITUI. Duling tl1is peliod,
an effective method of contraception should be practiced.
Serum hCG rema.ins th e best test to know statLLS of tl1e disease.
All patientS should be kept unde r careful observation for
1-2 rears because cholioca•·cinoma, if it occurs, develops
this period of evacuation of the mole.
A method of deteCLing persistent moles and develop-
ment of choriocarcinoma is by estimating the hCG level
in the serum and urine. Normally, the Lest becomes negative
in about 6-8 weeks' tim e following evacuation of a molar
1 .ooo.ooo-l--l--l--l--l--1--l--l--+---+--+--+-+---l
- I-
r-
100,0 00 r-.. Normal regression curve otl
Jl-HCG poslerior 1-
.
1.000 I \
100-1-- !-"'-!1.. . . 1- .J--1--1--t--+-+-+---l
I- t-I- t ......_N...:
II l
,:1 f
I
2 4 6 8 10 1112 13 14
Weeks posterior
Figure 38.6 Postmolar follow-up showing normal curve.
 CHAPTER 38 - GESTATIONAL TROPHOBLASTIC DISEASES 487

Hydat idiform mole diagnosed 1

Partial mole Complete mole
• Medical termination of • Surgical evacuation
pregnancy and lollow up • Cervical softening with mlsoprostal
• Allow pregnancy to followed by surgical evacuation
continue if pregnancy • Evacuation followed by chemotherapy
Is advanced with a • Hysterectomy in elderly women and lollow up
liw fetus. • Avoid pregnancy lor 2 yrs by using a contraceptive
• Follow up with serum --hCG

+
+ 1
Persistent
trophoblastic
disease
[ Invasive
l Choriocarcinoma
l
• Chemotherapy
• Hysterectomy
• Choriocarcinoma
• Evacuation and • Chemotherapy • Chemotherapy
lollow up • Hysterectomy
• Chemotherapy • Partial resection
and lollow up In pertorating mole
In women

+
( Chemotherapy ) • Hysterectomy
• Lobectomy
• Brain surgery
• Radiotherapy

Figure 38.7 Management of hydatidiform mole.

pregnancy. The patient is called at weekly intervals for this
test. Once the test becomes nega tive, the patient is followed
up monthly a ncl 3 month I)' in the fir'St year a nd 6 month!)'
in the seco nd year. Radioimmunoassay techniques have
revolutionized tJ1 e follow-up of patie nts witJ1 molar preg·
nancy (Fig. 38.7).
Pelvic examinatio n is clone to detec t any vaginal metasta·
sis, and to assess the uterine size. T he size of any ovarian cyst
and reduction in its size are notecl. A rad iograp h of the chest
is take n to ru le out lun g metastasis at baseli ne, afte r 3 months
and subsequenU)' when needed . Pe rsistent uterine b leeding
calls for a detailed evaluation and curettage should only be
done if retained tissue is suspected and t11 e ct.u·ettage are sent
for histopathological examination to detect chorioc;u·cinoma.
Pe lvic ultrasound scan can detect residual or locally invasive
tLUnour as we ll as tJ1eca lute in ovarian cySL.
Pregnane) should be avoided preferably by barrier
methods for at least I )Car (preferably 2 years) as a fresh
pregnane) wou ld interfe re with the h CG levels. lnu-aute r·
ine device and progestogen-on!)' pills cause irregula r
bleeding and are best avoided. Combined o ral pills can be
offered once the 13-hCG level becomes undeteCLed. Oral
combined pills lower the luteiniLing hormone (LH ) level
and, thereby, the h CG level and can ca use misinterpreta-
tion of results.
Pregnancy sho uld also be avoided for I year after stoppage
of chemotJ1erapy beca use of tJ1e teratOgeni c effect of dn1gs.
Beca use histopathology of molar tissue does no t give a
clue as to in which pati e nt molar pregnancy will progress to
choriocarcinoma, proph)•lactic che mo therapy has been
used in tl1e fo llowing siwati o ns:
• High-risk case, i.e. a ve ry young wo man and a multiparous
woman older tJ1an 40 years who hysterectomy.
• A patient with an initia l very high level of hCG, where the
initial siLe o f uterus was more tJ1 an 16 weeks' size.
• If a woman ca nnot come for tJ1e fo llow-up, prophylactic
chemotherapy is better than no follow-up.
A partial mole has a ver) low malignam potential
and does not requ ire dlemotJ1erapy. All tll e same, the
woman needs a follow·up in tJ1 e same manner as a
complete mole. The hCG level should rewm to nonnal
witJ1in 6-8 weeks.
Prophylactic chemother-apy compr·ises administration of
methotrexate or acti nomycin-D.
488 SHAW'S TEXTBOOK OF GYNAECOLOGY
Routine prophylactic chemotherapy in a ll patientS is
not advocated because 80% of molar pregnancies resolve
following evacuation. If chemotherapy is prescribed for all
molar pregnancies, 80% would be exposed to unnecessary
morbidit) and toxic it) of the drugs.
Some recommend chemotherapy during surgical evaCLt-
ation of a molar pregnane) and it is disctLSSed as follows:
• Actinom)cin-0: i.v. 12 meg/ kg dail)' for 3 clays prior to
evacuation and 2 days after
• Methou·exate: 15 mg orall)' dail)' for 3 clars prior LO
planned evacuation and 2 da)S after
• Out·ing evacuation, 50 mg methotrexate i.v. drip lasting
for 3-4 hours
Use of oral methou·exate may be associated with
severe oral/gasu·ointestinal tract (C IT) ulceration ; intra-
muscular route is the preferred route for adm inisu·ation of
me thotrexate.
T his is expec ted to reduce th e risk of p ulm o nary emboli
and d isse mi na ti on.
Prop hylac tic h)•SterectO m)' is not reco mme nded today,
because (i) it is not often req uired, (ii ) it does not avo id
fo llow-up and (iii ) fo llow-up with 13-hCG levels is effective
and decides tJ1e co urse of subsequent management
Because of 2%- LO% inc idence of rec wTent mole, it is
necessary to perfom1 an ul u·aso und scan in subsequent
early pregnancies.
PERSISTENT TROPHOBLASTIC DISEASE
PTD is diagnosed when during follow-up at least three
weeki) values of hCG show persistence of 13-hCG level or a
rise. About 15%-20% of women with a h)dalidifonn mole
show persistence of the tumour in the uterus following
surgical e\oacuation. Persistence of theca IULein cyst, conlin-
ued \oaginal bleeding and plateauing or raised level of hCG
in serum or urine clul'ing the follow-up are suggestive of the
persistence of chorionic tissue. The International Federa-
tion of Gynecology and Obsteu·ics (FICO) 2002 uitel'ia of
PTD are as follows:
• The plateau of hCG levels of fou r readings over 3 weeks
• A rise in hCG level of I 0% or more over 3 weeks
• Detec ti on of hCG at 6 mon tJ1s
• Persistence of irregul ar vaginal bleeding
Careful fo llow-up and hCG monitoring are the keys to
ide nti fying PTD:
• Pelvic ul u·aso uncl scan will detec t PTD in the genita l tract
• Chest X-ra)\ brain Cr scan and liver scan will p ick up meta·
static growth. Negative chest X-ray does not ru le o ut lung
metastasis; CT scan can detect an occ ul t lesion in the lung.
TREATMENT OF PERSISTENT
TROPHOBLASnC DISEASE
Once diagnosed, treaunent is chemotJ1erapy:
• Methou·exate 0.5 mg/ kg i.v. or i.m. daily for 5 clays -
repeated evety 2 weeks until hCG is undetectable
• Methou·exate 1.0-1.5 mg/ kg i.m. or i.v. on days I, 3, 5
and 7 witJ1 folinic acid 0. 1-0. 15 mg/ kg i.m. on alternate
clays (tJ1e course is repeated every 2 weeks as long as
reqttired)
• Actinom)cin-D 10-12 meg/ kg i.v. daily for 5 clays every
2 weeks if methotrexate is contraindicated (liver damage)
or fails, and in high-l'isk cases
• EtOposide (VP-16) - 200 mg/ m2 dail) for 5 clays ot-ally
eve f)• 2 weeks in high·•·isk g•·oup or i.v. over 3 hours
Haemoglobin percentage should not full below 8 g,
white cell count not less tJ1an 3000/ mm 5 and platelet not
less than 100,000/ mm 3 • Blood transfusion will be required
if the blood parameters full below the c•itical levels. Raised
serum glutamic pyruvate u-ansaminase (SGPT), semm
gl utamic oxaloacetic u-ansaminase (SCOT) and alkaline
ph osph atase levels indicate liver dysfu nctio n.
PERFORATING MOLE (CHORIOANGIOMA
DESTRUENS)
Perfora ti ng mo le was treated by hysterec tomy in the pasL In
a )'Ot.tng woman wishi ng to conserve fertili t)', pa n.ial resec-
tion of th e uterus and newer techn iques to con u·ol bleeding
by occl usive instruments and ligation of utetine/ interna l
iliac ligation have now been successfully done. rhe
risk of uterine rupture should be \\'lltched d uring subse-
q uent pregnancy, and elective caesarean section is often
advocated. Postsurgef) chemotherapy may also be required
for a residual tumour.
RECURRENT MOLAR PREGNANCY
Recurrent molar pregnancy is reponed in 2o/o -l 0% of cases,
with as many as nine consecuti'e molar pregnancies as
reported by ·w HO in 1973. Following two molar pregnan-
cies, the risk of recwTent mole rises to 28%. A woman with
one molar pregnancy faces 20 times tJ1e risk of suffering
another molar pregnancy and choriocarcinoma. It is tftewfore
maudntory to fJeifonn an ultmwnic in tlzis womnn in
Sl.tbseqnent mrly fJregulllil)'.
In a rare case wi tJ1 recurrent molar pregnancies, preg-
nancy with her husband sho ul d be avoided. Instead, in vitro
fertili za tion witJ1 a donor sperm is the op ti o n LO avoid no t
o nly subseq uen t molar pregnancy but a lso tJ1 e risk of
choriocarcino ma.
COEXISTING MOLAR PREGNANCY
Coexisting molar pregnancy with another uterine preg-
nancy is reported in 1:10,000 to 100,000 pregnancies. In the
vast majority, the fetus shows gross su·uctural and genetic
anomalies. and 30% terminate in inu-auterine fetal death.
Tenninalion of pregnane) is therefore recommended. In
rare cases, if the fetus pro,es normal b) uiU'aSonic scanning
and genelic stud). pregnane) ma) be allowed to continue,
but hCG monito•ing has no value du•·ing pregnancr Vaginal
delivery is possible. Placental site tumour does not respond
to chemotherapy and requires hysterectOmy.
 CHAPTER 38 - GESTATIONAL TROPHOBLASTIC DISEASES 489

CHORIOCARCINOMA

Choriocarcinoma is rare, but it is one of the most malignant

tumour arising in the bod) of the uterus. The nongesta-
tional choriocarcinoma appears as pan of a genn cell
gonadal neoplasm, both in males and in females. The na-
ture of choriocarcinoma can be identified by DNA SLlldy of
the tumour. ln nongestational cho•·iocarcinoma, D A is of
matemal o.-igin, whereas in molar pregnancy choriocarci-
noma, D A is of paternal origin.
ln a woman, this neoplasm follows a pregnancy, 50% of
cases follow evacuation of a h)datidifonn mole, 25% follow
an abortion and 20% follow full-tenn pregnancy, whereas
5% follow exu-aute.-ine pregnancy. The malignancy may ap-
pear many years after a full-tem1 pregnancy or an abortion.
However, in most cases it develops with in next 2 years of
a molar pregnancy. The long peliod that elapses between
tJ1e pregnancy and the develop me nt of choriocarcinoma
makes tl1e clinica l suspicion of ma lignancy ratJ1er difficult.
A primary cho rioca rcino ma aris ing in tJ1 e place nta during
pregnancy that led to fe tal met.ast.asis in tJ1 e liver has been
reponed.
Abom4%-10% of mo lar pregnancies develop choriocar-
cinoma, witJ1in 2 years. Posunolar GTD may be an invasive
mole or cho.-iocarcinoma, but nonmolar GTD is always a
d10riocarcinoma.

INCIDENCE
Chol"iocarcinoma exhibits a geographical distribution very
similar to that of a h)datidiform mole. TI1e incidence in tlhe
UK and tl1e USA is of the order of I :50,000 tO I :70,000 preg-
nancies, and it is 10 times more common in SoutJ1eastAsia.
An older woman witJ1 high pa•·ity and belonging to a low
socioeconomic group runs a high •·isk of developing tl1is
malignancy.

MORBID ANATOMY
To the naked eye, the growLh appears as a solid purple
friable mass. The majority of p•·imary growth arises in the
body of tJ1 e uterus and develops fi 1'St within the endometrial
cavity (Fig. 38.8). 1n suc h cases, the growth projects in to the
cavity of the uterus, qu ick!)' ul ce ra tes and causes a blood·
stained di sc harge, which la te r becomes offensive and pun1·
lent as tl1e growth becomes infec ted and necrotic. T here
may be periodic episodes of fresh hae morrhage. Growths of
tJ1is kind superficially resemb le placental pol)'P• but chorio-
carcinoma always infi ltrates the wa ll of t11 e uterus, whereas
a p lacental polyp us is clearl)' demarcated from the myome-
u·ium and can be easily detached. Ch oriocarcinoma does
not necessarily develop p•imarily in the endometri um, and
it is not uncommon for the growtJ1 to stan in the myome-
trium in the deeper tissues of the uterine wall. Primary
d1ol"iocarcinoma of the uterus may erode tl1rough into the
broad ligament or periLOneal cavity and cause profuse
bleeding. or it ma) cause enlargement of the uterus to such
a degree that the fundus of the utenLS reaches upwards LO
tJ1e level of t11e umbilicti.S. Metastasis occurs early and dis-
semination usually occu•'S by way of the blooclstream. Ones
which can be detected easil)' are Lhose found in Lhe lower
Figure 38.8 Chorioca-clnoma of the uterus. (A) The t umour has in·
filtrated the myometrium and presents as a polypoid excrescence
into the cavity of the uterus. It Is, therefore, readily diagnosed on ex-
ploratory curettage. (B) Patient came wit h massive Intraperi toneal
haemorrhage. (Courtesy: Dr Narayan M Patel, Ahmedabad.)
thi rd of tl1e vagina and ;u L11e vu lva. Such metastases form
p urp le haemorrhagic projections eithe r into t11e vagina or
aro und the vaginal orifice. Their appearance is characteris-
tic and pathognomonic of choriocarcinoma. These metasta·
ses are imeresting patJ1ologically, for t11 ey are comparable to
the vaginal metastases sometimes found with carcinoma of
the body of the uterus and malignant ovarian tt.unours.
Such metastases are produced by retrograde spread along
the venous d1annels of the vaginal plext.LSes of veins. TI1e
general metastases probabl) develop early, t11e growth dis-
seminating b) wa) of the bloodstream. Mulliple metastases
may fonn in t11e lungs and haemoptysis (Fig. 38.9).
Vaginal metastasis fonns in 30% of cases. Deposits are fre-
quently found in the kidneys, b•-ain, spleen and liver, but
when the dissemination is widespread, almost any organ
490 SHAW'S TEXTBOOK OF GYNAECOLOGY
Figure 38.9 Mult iple 'cannon ball ' metastases In lungs from chorio-
carcinoma.
IllS)' be affected and large emboli ma)' ge t lodge in th e large
aneries oftl1e S)'Stemic circulation. Th e most common sites
of mewtasis are lungs (80%), brain and liver ( 10% each ).
Less common sites are err, kidne)', spleen, genital t:J·act and
t11e l)'mph nodes (10%). In advanced cases, tl1e parame-
triLun ma)' be extensive I) infiltrated witJ1 growtl1. Invasion of
t11e ovaries is usuall) b) the wa)' of the bloodstream. Ovarian
C)'Sts of the theca lutein C)St are found in about 9% of cases
( fable :38. I).
The histological appearance is vel")' t)'Pical. S)11C)'lium,
C)'lou·ophoblast and degenerated reel blood cells constitute
ilie growth. The cells are acti,·el)' growing and show sud1
malignam charactel"istics as t) pi cal mitotic division and ana-
plastic changes. In some areas, the cells are translucem or
vacuolated and ma)' resemble cleciclual cells. No evidence of
chot·ionic villi can be detected, ilie growth consisting solely
of embl")'onic S)'nC)'tium, C)'tOtrophoblast and degenerated
blood cells. The absence of vi lli must be stressed as a diag-
nostic featw·e which sepa•·ates the ma lig nant choriocarci-
noma from the benign and invasive mole in which villi are
demonsu·able. This is because the trop hoblast grows in s uch
ex tensive colu mns as to complete!)' obli tera te t11e villo us
pattern. T he other d is ti nguishing fea wre of malignanc)' is
in vasio n of the uteri ne wa ll b)' trop hoblasti c cells, with de-
su·uction of muscle tiss ues acco mpa nied b)' necrosis and
haemorrhage (Fig. :38.10). The pri mitive infilu·ating p rop-
erties of the emb t)'Onic C)'tOtrophoblast are retained in
choriocarcinoma so that vesse ls are eroded and local hae m-
orrhages are produced, which cause the t)'p ical macroscop i·
cal appearances. As a res ult of erosion of vessels, the growth
penetrates into the S)'Stemic blooclsu·eam, and generalized
metastases are apt to develop early.
There is clinical evidence t11at mewtases may regress
after tl1e removal of t11e prima•) growth but this is rare. The
radi<>g1-aph of lw1gs presents the haemon·hagic metastasis
as a 'cannon ball' (see Fig. :38.9), whereas, in realicy, iliey
IllS)' be only 1.0nes of haemot-rhage. It may also present
a woolly appearance because of diffuse haemont1age. It
must be remembered that 1>aginal nodules resembling the
Figure 38.10 Choriocarcinoma: sheets of t umour cell s showing
marked nuclear pleomorphism. A blphaslc pattern with mixture of
cytotrophoblastic and syncytlotrophoblastlc cells Is seen. (Courtesy:
Dr Sandeep Mathur, AIIMS.)
mewwes of choriocarcinoma can occur with benign hyda-
tidiform mole and even norma l pregnancy, accord ing to
Magn us Haines. This concept of benign trop hoblastic em-
bolism must considerabl)' innuence our th inking on the
question of spontaneous regression of tl1e so-called malig-
nant metasLaSes in choriocarcinoma. Choriocarcinoma, as
with h)'datidifonn moles, shows high levels of in the
urine and serum.
SYMPTOMS AND SIGNS
These are dependent on the site of growth. Persistem or
irregular utet·ine haemorrhage following an abot·tion, a
molar pregnancy or a normal delivery should ahl'li)'S raise
the suspicion of choriocarcinoma. The bleeding is
usuall)' profuse, but sometimes there may be only blood
stains. An offensive vaginal discharge develops when
secondar)' infection supervenes; p)'rexia and cachexia
will be the accompanying symptoms. When amenorrhoea
occnrs, it of a very high letx'l of hCG Sel'reted IJy the
tumunr. T he perforation of the ute rus wit h intraperito-
neal hae morrhage s imul ates an ectOpic p regnane)'. T he
o th er S)' mpw ms ma)' va t)' depe nd ing upo n C)'LO metasta·
s is. Dysp noea and haemopt)'Sis a re no ti ced with lu ng
metastasis. Th e appea rance of ne uro logical S)'mp to ms
s uch as hem ip legia, epilepS)', headac he and visua l distu r-
bances s uggests brain metastasis.
On examination, a vaginal metastasis appears as a bluish
red vasc ular tumour wh ich bleeds easil)' on w uch . Th e
uterus ma)' be enlarged. The theca lu tein C)'St in ovar)' are
palpable in some cases. The liver and brain metastases are
often seen in cases witl1 lung metastasis.
DIFFERENTIAL DIAGNOSIS
• Botl1 postdelivel') and postabonal retained placental
tissue or placemal pol) p cause secondat)' postpartum
haemonilage (PPH). Histopathology of curettings will help
to diagnose chol"iocarcinoma. However, the diagnosis can
 CHAPTER 38 - GESTATIONAL TROPHOBLASTIC DISEASES 491

be missed if Lhe growLh is in the myo metrium. 13-hCG

level in se rum a nd th e urine will establish the co rrect di- Table 38.5 FIGO Classification of Gestational
Trophoblastic Diseases
agnosis. Ulu·asound and CT scans are useful to determine
spread of the d isease.
Stage I Disease confi ned to the uterus
• Whe n cho riocarcino ma develops ma ny years later follow-
ing a pregnane), iiS clinical d iagn osis is difficult to ma ke. Stage II GTO extends outside of the uterus but is
Irregular bleedin g mandates curettage which will reveal limited to the genital structure
the cause of bleeding. Ultrasound will reveal the ute rine Stage Ill Lung metastasis with or without genital tract
growth. involvement
• lnua pe•·itoneal hae mon·hage following spontaneous
uterin e perforation b)• the tum our growth may simulate Stage rv Other metastasis
ectopi c pregnan cy. The treaun em is laparotomy in botl1 IVA No risk factor
---------------------
these conditions wh en tlle u·ue nature of tl1e lesion IVB One risk factor
becomes obvious.
• Pulmonary Metastasis. The pulmonar y symptoms may IVC Two risk factors
resembl e pulmo nar y w berculosis. The ' cannon ball' Risk factors:
-----------------
metastaSis is typical of a malign am lesion.
1. Serum c hori onic gonadotropin
• Brain Metastasis. The ne urological symptoms point
(hCG) level > 100,000 miU/mL
towards a brain lesio n. T he elevated hCG level in the
serum or preferab l)' in ce rebrospinal flu id (CSF) and 2. Duration of disease > 6 months
Cl'/MRI sca n wi ll esLab lish t11 e diagnosis.
Note: Lately. risk factors are not Included in staging.

When tl1e metastasis develo ps more than 1 year following

abortion, diagnosis o f chorioca rcinoma becomes difficu lt
Think of cho riocarcino ma if a yo ung woman develops neu-
ro logical sympto ms with a history o f past abortion or preg-
nancy, in s uch cases esLimate !3-hCG leve l in CSF, serum.
STAGING
Disease is staged into four stages (Stages I-IV) b)' F1GO. FLUi.he r-
more. to risk score t11 e disease, a WHO risk scoring syStem is
commo n!) usecl Refer to 38.5 and 38.6.
DIAGNOSIS
The d iagnosis is based on clinical fea tures and histOlogical
evidence when availa ble. Serum !3-hCG level, X-ray of lungs
as well as CT scan of lungs and brain, and ulu-asound scan of
liver and pelvis help in establishing th e correct diagnosis.
PET is empl oyed in difficult cases witl1 unusual symptoms
and signs.
TREATMENT
CHEMOTHERAPY
One of the biggest uiumphs of medical scie nce is effective
chemotherap) in ch oriocarcinoma. Histapatllological evi-
dence may not be available in every case, especially in invasive
and metastatic tumo LtrS. !3-hCG is a very specific marker, so
tlle d1emotl1eraP> can be ad ministe red based on tl1is alone.
Unlike otl1er malignant lesio ns, the u·eaunent o f chorio-
carcinoma is mainly chemotlle rap)', fo r both local and dista nt
metastases.
The most effeCLh·e chemothera peuti c agent is metllo-
trexate, a folic acid an tagonist. It is a mixtLU·e of4-amino-1 0-
methyl folic acid and related compounds. This drug inter-
feres with tl1 e fonn ati on of nucleic acid and mitOsis in tlle
malignant cells and there by arresLS t11 e growth. The staging
decides whetl1 e1·single o r multiple drug therapy is required.

Table 38.6 Modified WHO Prognosti c Scoring System

Prognostic Factors 0 1 2 4
Age (years) < 39 > 39
Antecedent pregnancy Mole Abortion Term pregnancy

Interval (months) <4 4-6 7- 12 > 12

Pretreatment hCG (miU/mL) < 1()3 1Q3- 10' 10'- 1OS > 10S
Size of tumour (em) <3 3-5 >5
Site of metastasis Lung Spleen, kidney Gl liver Brain

Number of metastasis 1-4 5-8 >8

Previous failed chemotherapy Single drug 2 or more
Low risk- <1•6, high risk> 6
492 SHAW'S TEXTBOOK OF GYNAECOLOGY
Methou·exate is given orally 5 mg five times a day for
5 days earlier but was associated with significant C IT side
effects. It is now given b) intramuscular/ intravenous injec-
tions. To reduce side effects with the use of methotrexate,
therap) is usual!) given on days I, 3, 5 and 7. On alternate
days (da)S 2. '1, 6, 8), injection folinic acid is given. The
course of chemotherap) is repeated at intervals of I 0-I4 days
depending on the blood picture and side effects of the drug.
The patient should completely recover from any toxic side
effect before the second course is Started. These courses are
continued until complete regression of the pt·imary tumour
and all metastases are achie,ed - indicated when three con-
secutive weekly radioimmuno<lssa)S for hCG in serwn are
negative. Thereafter; one more course is administered. This is
done because even cannot detect (3-hCG
level below I mlp/ m L, and the last course hopefully destroys
any minute trophoblastic tissue that mi ght have been left
untouched
Me th otrexa te has the following side effec ts: (i) ulcerative
stomatitis and gasu·ic haemo rrh age; (ii ) s kin reaction;
(iii) alopecia; (iv) bone marrow depression, leading to
anaemi a, le ucopen ia a nd agra nu locytOsis; and (v) liver and
kidne)' damage.
It is advisab le chec k on haemoglobin, wh ite cell co unt
and platelet count and carry o ut liver function tests, kidney
function tests and rad iograph of chest before instituting this
chemotherapy. Metho u·exate is conu·aind icated in liver
disease. To avoid or to reduce toxicity, 'folinic acid rescue
regime' is recommended. This regime consists of citrovo-
nun factor (folinic acid ) 15 mg inu-amuscularly and metho-
trexate administered o n alternate days, so that one course
of u·eatrnent lasts for a total of I 0 days.
COMBINATION CHEMOTHERAPY REGIMEN
Combined chemothet-apy is recommended in high-risk
cases. A ,oa,·iety of combinations of chemothempeutic agents
are being used, such as (i) methotrexate, actinomycin-0
and cyclophosphamide (MAC) and (ii ) methotrexate, acti-
nom)•cin-0 and addamycin (MAA). The number of courses
depends on the sever·ity of the disease and response of the
patient.
Bagshaw treated cases with a combinatio n of etoposide,
meth otrexate and ac tinomycin-D a nd claimed equall y
good resu lts with less side effects. All aULh ors agree that it
is more effec tive to trea t the hi gh-risk cases with com-
b ined therapy ab initio than to treat the m with combined
th erapy on ly afte r a fa iled atte mpt with a single agent.
Current!)' EMA-CO regime n is the most co mmo nly used
combination che motJ1 erapy regimen in tJ1 e management
of high risk.
The course is repeated eve•)' 2 weeks depending on
recovery from toxicity.
MAC treaunent co mprises the combination of methotrex-
ate 50 mg i.v.• actinomyc in-D 0.5 mg i.v. and cyclophospha-
mide 250 mg i.v. dail) for 5 da)S and repeat every 3 weeks
( fable :38.7).
The place mal site u·ophoblastic disease is often resistant
to chemotherap). and hyste rectomy is recommended
In bt-ain and lung metastases, previous treaunent
radiothet-apy is now replaced by che mothet-apy, because
Table 38.7 MAC Regimen and EMA-CO Regimen
(A) MAC Regimen
Day 1-5 Methotrexate 1mglkg
Day 1-5 Actinomycin-D 12/ug/day
Day 1-5 Cyclophosphamide 3mg/kg
(B) EMA-CO Regimen
Day 1 Etopocide 100ng/m2 iv infusion over 30 min in 200ml
saline
Actinomycin - D : 500/IJQ iv stat
M ethotrexate 100mg/m> iv over/2hr
Day 2 Etopocide 100mg/m2 iv infusion over 30 min
Actinomycin - D 5001Jg/iv stat
Folinic A cid 15mg im x 4 does every 12 hr
Day 8 Vincristine (On covin) 10mg lv stat
Cyclophospham ide 600mg lv Infusion In saline
*Next course repeated after 2-3 wks.
the resui ts ru·e good a nd rad io th e rapy causes exte nsive
fibrosis.
MetJ1ou-exate 12.5 mg can be inu·a rhecally at
every 2-4 weeks' interval until hCG level becomes negative.
Newer d rugssuc h as Taxol, t)'J)Otecan and ge mcitabine
(a ntimetabolite) have been used in resistant cases. Gem-
citabine I250 mg/ m 2 o n da)S l-8 wiLh cisplatin is
effective.
Rarel)'• leukaemia has been reponed with tJ1e use of
Etoposide se,•e t-al ) ears late.-.
SURGERY
Surgery is mrely indicated in the managemem of chotiocar-
cinoma.
H)Stet-ectomy is indicated in tJ1e following conditions:
• High-tisk cases older th an 40 rears, multiparous
• Chemothempy ineffective/chemotJl et-apy •-esistance
• Haemorrhage beca use of ute rin e perforation
• Large-sized growtJ1 in the ute rus
• Whe n placenta l site u·op hoblasti c does not
respond to chemo tJ1e rap)' and hysterec to my is the only
solutio n
Hysterecto m)' is us uall y fo llowed b)' chemothe rapy.
T here is no need to re move th e ova ries as ova rian metasta-
s is is rare and can be effec tive ly trea ted by chemotherapy.
Hysterectomy reduces th e number of chemoth erapy
cow·ses.
Role of radiotllempy is limited to only ac ute bleeding
from vaginal metast."l.Sis, brain and live r metastasis. The post-
radiotJlerapy fibrosis is tJ1e disad,oantage.
A solitaJ') lung metastasis can be dealt witJ1 by tl10racot-
omy a11d lobectom). CraniotOm) is t-arely resorted to in a
solitary brain wmour.
The role of high dose chemotJlet-ap)' wiLh autologous
bone marrow u-ansplant is being explored.

Table 38.8 Management of Metastasis
Vagina Vaginal pack for bleeding, avoid excision,
chemotherapy
Lungs Chemotherapy, Lobectomy if the growth is
localized or resistant to chemotherapy
Liver Chemotherapy, Radiation
Brain Chemotherapy
Intrathecal chemotherapy
Surgery
Radiation
CEREBRAL METASTASIS (Tobie 38.8)
A focal lesion detected b)' CT/MIU can be excised to pre-
venL haemorrhage in tJ1e wmour and dea tJ1. A large lesion
is trea ted with rad iation given in a dose of 30 Gy in 10 frac-
ti ons 5 clays a week for 2 wee ks along with EMA/ CO and th is
yields 80% response. Liver metastasis sho uld rece ive whole-
organ rad iation over 10 days in a dose of20 Gy.
Lobectomy is required in a chemotJ1erapy-resismnt case.
FOLLOW-UP OF A CASE OF CHORIOCARCINOMA
Serum 1)-hCG is done every week till it becomes negative.
Once negative it is •·epeated eve•]' 2 weekly for 3 momh,
tJ1ereafter every month for one year and t11en 6 montl1ly for
•-est of life.
PROGNOSIS
Overall cure rates in recem years have been excellem witl1
chemot11erapy alone, and surge•] ' is undertaken only in se-
lective cases described earlier. With chemotllerapy, 100%
success has been claimed in low-•·isk group (J Lewis, 1980)
and 90% success in high-risk group. A successful pregnancy
has followed treatment with chemo t11erapy. However, it is
for the patiem not to conceive for 2 years after the
drug u·eaune nt is The lifelong follow-up ofthe woman,
however, should be e nco uraged.
KEY POINTS
• Trop hoblastic d iseases comprise a spectn.1m of clinical
cond itions va•]•ing from hydati d iform mo le, in vasive
mole and choriocarcinoma.
• Hydatid ifonn mole is more prevalen t in Sout11east
Asia, d iagnosed cli nicall y and confirmed by ulu·a-
sound scan and •-aise<l 1)-hCG levels.
• Treatment of hydatidiform mole is surgical evacua-
tion. Six montJ1 up to two-years monitoling is re-
quired to detect persistent moles and development
of cho•iocarcinoma. Pregnancy during tllis peliod
should be avoided. Proph)lactic chemotherapy is
beneficial in selective cases.
CHAPTER 38 - GESTATIONAL TROPHOBLASTIC DISEASES 493
• Serum hCG level is tJ1e key marker in follow-up.
• Histology is not able to indicate tl1e potential of molar
pregnancy for dC\elopment of malignancy. Therefo1-e,
follo\\•up witJ1 sen.un 13-hCG is necessa•]' for 2 years.
The•-eafter, tJ1e •·isk of malignancy is negligible.
• Persistent trophoblastic disease and cho1iocarcinoma
are treated effecti,el) b) chemothempy. Surge•]' is
rare!) required.
• Choriocarcinoma and metastatic growtllS dC\•eloping
se' era! >ears after pregnane> render t11e diagnosis
difficult
• Placental site trophoblastic disease wit11 low hCG but
raised H PL Ie,el fails to respond to chemot11erapy and
req uires hysterectOm).
• Following molar pregnanC)', tl1e woman needs co un-
selli ng regarding recurrent mo le and choriocarci-
noma, and should be cow1selled for follow-up.
• Prognosis has greatly improved beca use of specific
hCG ma rke r and effec ti ve chemo tl1erapy.
• Cho rioca rcino ma is unco mm on, but highly malignant.
• Chori oca rcino ma may follow a molar pregnancy,
aborti on, te nn pregnancy and ec topic pregnancy.
• Fifty per cen t cases of choriocarcinoma occ ur following
molar p regnancy and occur within 2 years.
• T he long interval of yea1-s between pregnancy and
cho•·iocarcinoma makes tl1e diagnosis difficulL
• P1ima•]' treaunent of d10docarcinoma is chemotller-
apy and is effective in 90%-100% of cases. Surgery is
reserved for selecti' e cases.
• P•-egnancy is possible following treaunem with che-
motherapy. Howe,er, conception should be dela)ed
for 2 >ears to a'oid te•-atogenic effect on me fetus.
SElf-ASSESSMENT
I. A 25-year-old woman presents with 3 montllS' amenor-
rhoea, abdominal pain a nd vaginal bleeding. The uterus
is 20 weeks' size. How will you investigate the case?
2. How wi ll you manage a case of h)•datidiform mo le at
16 weeks' pregnancy?
3. What are the complications of h)•daticliform mo le? How
will you prevent tJ1em?
4. Descri be the clinical feawres of choriocarcinoma.
5. Disc uss 1J1e management of choriocarcinoma.
SUGGESTED READING
Dalya Alhamdan, Bignardi, CL-orgc Condous. Rct:ognising
gesr.uional lrophobla>l.ic dbca><·. In : lk'l>l PrdCiiet: and RL'Se'.trch:
Oinical Obsl<'lrics and Cyn:t<>cology, Vol 20(5): 565-573, Efse,ier,
2006.
IlK, Wong LC, 1'\g-,m JYS. In : 1l1c modem managemem of tropho-
blastic disease. Bonnar J. In: Advances in Obstelrics and
Vol 16: 1-23, OlUrchill London, 1990.
 Radiation Therapy,
Chemotherapy and Palliative
Care for Gynaecological Cancers
Radiation Therapy 494 Key Points .505
Clinical Applications of Rodiotheropy 498 Self-Assessment 505
Cancer Chemotherapy for Gynoecologic
Cancers 500
Mos t gynaecological ma ligna ncies need adj uvant u·eatment
in th e form of radiotJ1e rapy and chemo tJterapy. Advances in
tJte fie ld of radiation oncology and medical oncology have
he lped in ach ieving optima l results whi le u·eating cancer of
tJte cervix, cancer of the ovary, endometrial cancers, gesta-
tional u·ophoblastic diseases a nd other rare types of gen ital
uract cancers.
RADIAnON THERAPY
Radiatio n !Jlerap) plays an impo rta nt role in tJ1e manage-
ment of g> naecological malignancies. ItS specific curative
role has been established a nd doubt in the ma nagement
of cervical cancer, the most commonly seen g) naecological
cancer in clinical practice. Radiation treaunent may also be
curative for locali.wd endometri al cancer and when surgery
is not possible. It improves prognosis if used as adjuvant
postoperative therapy in adva nced cervi cal and endometl"ial
cancer. The scope ohadiation the•-apy has been enhanced
in tlte man agement of cancers of the vulva and vagina. ln
selected cases of ca ncer of tJt e ova ry, postoperative adjuvant
radiotherapy may be benefi cial in conu·olli ng t11e disease.
In many cases, a judicio us co mbination of rad iotherapy
and cancer chemo tJte rap)' has co ntributed sign ificantly in
im proving tlt e patie nt's prognosis and surviva l period.
Cell dea tl1 in term s of rad ia ti o n bio iOg)' is defined as the
loss of clonogenic ca pac ity or 'cell rep rod uctive potential'.
Ion izing radiation produces free rad icals wh ich d isrupt the
reproductive integrity o f DNA-prod ucing cells and thus
conu·ol cell division and neoplastic growth. Rad iation af-
fects bo tl1 normal cells a nd LUmo ur cells. However, the di-
viding mitotic cells are most vulne rable. Hence, by grading
tJ1e dose of irrad iatio n, a differential effec t can be attained
by forcing tl1 e cancer cells to differentiate and UlLLS lose
!Jle ir malignant potential, stimulating angioblastS and fibro-
blastS to grow into tJ1e LUmour cell mass, dividing tl1em into
smaller nests of neoplastic cells and, finally as tl1e connec-
tive tissue fibroblasts consu·ict, cutting off !Jle tumour cell
blood supply causing tumour necrosis. Anaplastic tumours
!Jlerefore respond beuer compared tO well-<lifferentiated
494
sq uamous cell wmo urs. Ade nocarcinoma and sa rcoma are
poor responders.
PHYSICAL PRINCIPLES OF RADIATION THERAPY
BASIC PHYSICS
Radiation physics deals witJ1 tJ1e measurement of energ>'
that is transferred from the radiation so urce to tl1e target
tissue being irradiated.
The tlt erape u tic activ it) of rad iatio n is mainly related
LO the process of ioniation. The re are two fonns of ph(}-
tons (quanta of rad iation whose e nergy is proportional tO
their fi·equenq a nd imersely proponional to their wave-
length). One fonn of ioni.t:ing 1-adiation is e lectromag-
n etic, which refers to X-l'li)'S. These sources of energy have
no mass and no electdcal charge. They are produced in
discrete quanta or photons. A second source of photon
radiation comes from the production of gamma l'li)'S
(similar to X-l'li)'S) which 1·esult from the decay of 1-adioac-
tive isotOpes.
Electromagneti c •·adi ati on witJ1 shorter wavelengtllS has a
higher frequency, he nce hi gher ene rgy. The energy pro-
duced is measured in electron voltS (eV); I eV = 1.6 X
10- 12 e rg. T he X-ray radiothc rap)' units ca n range from
50,000 eV (50 kV ) to ove r 30 mi llio n eV.
Photon radi ati on is measured in curies (Ci). One curie
is de fined as 3.7 X 10 10 d isintegrati ons/seco nd, wh ich is
eq uiva len t to tl1e disintegration of I g of rad iu m.
Irrespective of the source of elec u·omagnetic o r photon
radiation, tl1e tran smitted e ne rgy dive rges from the source
of origin and diminishes inversely as the sq uare of the dis-
tance u·ave rsed (I I d·) .
X-rays and photons can be generated a5 a result of rapidly
accelerated elec u·ons in vacuum sui lUng a target. Modem gen-
erators tl1at accelerate tJ1ese e lectrons LO a high speed mtl)' do so
in a circular fashion (betatrOn) or linearly (linear acceleratOr).
Another t)pe of rad iatio n energ>, known as particulate
.-adiation, is produced b) subatomic particles a dis-
crete mass. These panicles a 1·e de1·ived as a result of disinte-
gration of 1-adionuclides. Four differelllL) pes, name ly alpha
particles, neutrons, protOilS and elecU'OilS, are produced.
 CHAPTER 39- RADIATION THERAPY, CHEMOTHERAPY AND PALLIATIVE CARE FOR GYNAECOLOGICAL CANCERS
are high ly penetrative and have no d1arge b ut
have a large mass. They cause high-energy collisions witl1
atomic nuclei, principall) hydroge n in the tissues. The re-
sultant recoil proton loses e nergy to the surrounding tissue
by ionization. causing cell death.
Plwwm are posithel) charged panicles and can be pro-
duced directl) b) ge nerators. The high-energy beams pro-
duced are used for special applications such as the u·eaunem
of pituitary tumours.
Alplw particles (helium nucleus) have very liule penetrating
po\\er and therefore are not of much practical use.
Electrons, also referTed to as beta rays, can be produced at
different energies b)' machines for v:u·ious therapeutic uses.
RADIATION BIOLOGY
Photons (gamma rays or X-rays) act by dislodging orbital
electrons of th e tissue through whi ch they pass. Th is colli·
sion prod uces a fast elecu·on (Comp to n effec t) which th en
io ni zes mo lec ul es along its path prod uci ng secondary elec-
u·ons and free hyclr'OX)'I (011 ) rad icab. T his p rocess co ntin-
ues until the p ho ton loses all of its e ne rgy. Abo ut SO% of the
cell contains wate r; so cell ul ar rad iation damage is mediated
b)' the ionization of water and prod uction of free rad icals,
h)•drogen (H ) and h)•drox ide (01-1 ).
The free 0 1-1 radical causes DNA cell damage. The effect
may be lethal and ki ll the cell or it may be subletl1al, in whid1
case tl1e cellular DNA may undergo repair and the cell recovers.
The free molecular 01 1 radicals react with molecular oxy-
gen to fonn peroxides, which in tum ftu·ther damage t11e tis-
sues. OxylJim theTfjOTf imJXJrUmtto mlumce plwton effects. Large
tLUnours witl1 poor blood suppl) have poor photon effect in
h)poxic areas and are radioresistant R£uliation in the frTl!SimCil of
(IIWemia, infoctum am/ 5amulti!JIU' produas poor rmths.
The Idle of loss of enermr of an ioniLing particle as it
traverses a unitlengtJ1 of medium is known as linear energy
transfer (LET). In case of photons, energy tl'allSfer from an
X-ray or electromagnetic source, the LET is low; hence,
multiple tissue bom bardments are required lO achieve ale-
thal dose. In case of particulate irradiation with large pru·ti-
cles (neutrons), t11 e ionit. ation achieved is high, leading to
high LET, more intense ionilation and production of more
tOxic hydroxyl radi cals, achi eving greater lethal tissue effect
independent of tissue oxygenation.
Successful racl iothe r"iip)' req uires a good balance between
t11e dosage to the wmo ur and to that of t11 e surroundin g
su·ucLU re (radiati on to lera nce) so that least damage is in·
flic ted to tl1e no rma l tissues, whi le max imal radioeffect
reac hes the twno ur cells. The a im is to de live r a high dose
to the u unour and minimal dose to t11e no nnal tissues.
Radiosensitizers, cisplatin and &-n uorourac il, en hance the
letJ1al effect of radiation when given concomitantly. This
combirwtion wiled chemoradiation.
An important principle to re member is that a given dose
of radiation kills a co rlStant fraction of tumotu· cells; hence,
each repetitive sitting ac hieves a similar reduction of ru-
motu· cell activit).
There are four phases of a cell cycle: resting phase, RNA
and protein S)lllhesis, D A S) nth esis and cell or
mitosis. Rapidl) clh·iding cells are the most radiose11Sitive.
This explai rlS the higher respo•lSC of anaplastic tumours
compared to a well-differentiated one.
495
Fractionation of radiation treaunent pennits effective
treatment of tl1e tumour, and minimizes complications
which could result from exposure of nonnal tissues (bone
marrow. nonnal intestine) to a single large dose. The more
effective repair of normal tissue occ urrin g between treat-
ment fractio11S allows recovef) of no rmal cells which is a
therapeutic advamage.
The clinician must be familiar with the unit of measure-
me m of amoum of enerm•absorbed b)' the tissue, called t11e
rad. Rad is defined as 100 ergs of enerm•absorbed per gram
of tissue.
Lately the term gra-)' ( I j / kg) has been introduced. One
gray (Gy) is equivalent to 100 rad.
Summary
Radiation biology pr·oduces the following effectS:
• Radiation (photons or gamma rays) is u-ansferTed from
t11e rad iation source to the tissues undergoing in·adiation.
T he process of ionization occurs (Compton effec t) along the
patJ1 of radiati on. T he free racl icab liberated produce tissue
damage. Mitoti c cells are ki lled (le tJ1al effec t) or tmdergo
differen ti ati on (rendered non lethal). Pr-oliferation of an-
gioblasts and fibrob lasts breaks up the mass imo smaller is-
lands of tissue tumow·s. Finall)', the fib r-oblastsconsuictand
cause nea·osis o f tissue by way of dec reasing vasc ularity.
• The effect of traJ1Stnitted energy, ir1·espective of t11e source
of irradiation as it diverges fi-o m t11e source of origin, rapid I)'
diminishes inverse!> as t11e square of the distance travelled
• Success of radiotJ1erap) requires a good balance of dos-
age between tl1e tumour tissue and 1J1e healthy surround-
ing tissue.
RADIATION SOURCES: EXTERNAL AND INTERNAL
THERAPY
ln general, two techniques are utiliLC<I in radiation treat·
ment, brachytl1erapy (internal) and teletherapy (extemal ) .
BRACHYTHERAPY
Brachytl1e1-apy is a form of radiation therapy in wh ich t11e
source is placed close to the tumour: The application may
be in tl1e fonn of needles implanted into t11e tumour (inter-
stitial) or placed in t11e vagina, ce rvical canal or uterine
cavity (in u·acavi tary) in tande m with vaginal ovoids or use of
colpostaL
In tl1e case of cervica l and uterine ca nce r; b rac hytherapy
comprises a cen tral ute rine tandem and two ovoids in t11e
vaginal vau iL This position ing irrad iates t11e prima rr growth
as well as tl1e pamme uium and th e ob u.rraLOr lymp h nodes
(Fig. :39.1).
Preradiation preparation includes:
• Checking haemoglobin and WBC
• Rectal e nema or suppositOt)'
• Antibiotic cover
Method. Under gener-al anaesthesia, a self-retaining cath-
eter is i11Sened into the bladder. The cervix is dilated to al-
low the i11Se •·tion of t11e ute1ine tube. After i11Serting t11e
long empty d evice, two rubber O\'Oids or platinum boxes are
placed in the 'oaginal fornices. The ' oagina is then packed
496 SHAW'S TEXTBOOK OF GYNAECOLOGY

Table 39.1 Brachytherapy

Amount
and Type Number of
Technique of Radium Applications Duration

Paris Intrauterine One Five days,

technique tube 33.3 mg - each day,
two vag inal radium is
ovoids 13.3 mg removed,
c leaned and
replaced

Stockholm Intrauterine Three 48 hours

technique tube 50 mg- each with a
twovaginai gapof1week
Rgure 39.1 lntracavit..-y source of irradiation in cancer cervix. ovoids between the
50-60mg first and the
second, and
2weeks
with sterile gauze in such a wa)' that iJ1e b ladder and the between the
rectum are disp laced awa)' from th e radiation so urce. An - second and
te roposte rior and lateral X-ra)'S of the pelvis a re taken to the third
chec k the correc t position of iJ1e devices (Fig. 39.2). The Manchester Intrauterine Two 72 hours
radioactive substance is then loaded into the device b)' re- technique t ube 50 mg each at
mote control of 'afterloading technique'. It is unloaded and vaginal intervals of
when nursing medical staff enters the patient's room. This colpostat 1 week
reduces the radiation exposure to nurses and doCLors 3G-50 mg
(safety method).
Three methods are in vogue ("Ia hie ). In the Paris
the radiLUn (which is removed dail) for cleaning) is
applied continuous!)' for 5 days. In iJ1e the
radium is insened on three occasions, witl1 intervals of
7 da)'S between th e first two insertions and 2 weeks after the
last inse rti on, eac h insertion lasting 48 ho urs (Fig. 39.3). In
iJ1e Mandwster li!chnilj"ttli, two insertio ns 72 ho urs eac h are
applied at a week's interval (Fig. 39.tl).
In brachytl1erapy, various radioisotopes are used depend-
ing on tl1eir half-life (Table 39.2). In general, tl1ose witl1 a
short half-life may be placed in th e patient and left penna-

Figure 39.3 Isodose curves of a standard radium Insertion using the

Manchester techni que for carcinoma of the cervix uteri. The dose at
point A Is taken as 100%. (Source: From: Paterson R. The Treatment
ot Malignant Disease by Radium and X-Rays. Edward Arnold.)

nently (e.g. radioactive gold-198), whereas those with a lon-

Rgure 39.2 X-ray of pelvis, showing positioning of radium in a Man-
chester Insertion. Note that the central opacity between the two
ovoids Is, In fact, a space and not a third radium -containing ovoid.
(Sovoe: Frcrn: Madeod and Read, Gynaeoology. 5th ed. Ch.Jrchil, 1955.)
ger half-life are left temporarily in the patient, and removed
after a p•-escl'ibed dose of irradiation has been administered
(caesium-1 37).
During brach)'therapy, it is importa nt to achieve a unt-
form disu·ibution of radiation in iJ1e adjacent tissues to
avoid ' hot spots' whid1 can cause excessive damage to the
norma l tissues, and 'cold spotS' which can lead to under-
Lrea un ent of the tumour. in brachythe.-ap)' forcancerof the
ce rvix, iJ1e li miting fac tor to be kept in mind is point A, a
poim 2 em above Lhe lateral forn ix and 2 em lateral to the
cervical ca nal. lL is the anatOm ical location of the w-eter;
 CHAPTER 39 - RADIATION THERAPY, CHEMOTHERAPY AND PALLIATIVE CARE FOR GYNAECOLOGICAL CANCERS
A c
Figure 39.4 Di fferent methods of brachytherapy. (A) Manchester techniq ue. (B) Paris technique. (C) Stockholm techni que.
Table 39.2 Half-lives of Commonly Used Isotopes
Radlonucllde Half-Life (Days)
Gold-198 2.7
Phosphorus-32 14.3
lodine-125 60
lridium-192 74.4
Cobalt-60 5.3
Caesium-137 30
Radium-226 1620 years
hence, a dose exceeding 8000 rad should not reach this
poinl. The second should be to i•·radiate maxi-
mally poim B, located 5.0 em from the uterine axis, laterally
and at the same level as poim A, and dose is 5000 rad. This
poim represenLS the lateral pelvic wall. However, th e radia-
tion dose achieved at the lateral pelvic wa ll would be low
because of the inverse sq uare law (1000 rad) .
T he bladder and recta l mucosa ca nnot withstand ove•ir-
radi ation (rec tum : 5000 rad; bladde r: 6000 rad); hen ce, ad-
equa te pac king of the vagina and keep ing the bladder and
rec tum empty are manda to ry. Optim al safe dose depends on
th e 'radi ati o n tolerance' of tile norm al surrounding s truc-
tu res: b ladde •; recw m, intestines, live r and kidneys.
TELETHERAPY
It is a form of radiation therapy where the radioactive
so u rce is placed at a dista nce from the patient (external
t11erapy) . The source of radiation is placed at a distance
5-10 times greater than the dept11 of tl1e tumo u r tO be
irradiated, in order to achieve uniform distribution of
radiation to the tumour, and ahereby avoid the large
dose vaJ;aLions attributable tO the inverse square law.
This distance is also called source-to-skin distance (SSD).
Extemal radiotherapy inadiates main I)' the parametrium
and the pehic l)mph nodes. Brach)therapy is followed
by teletherapy OYer a pe•·iod of 4-6 weeks. In a few cases,
497
whe re th e prima ry tum o ur is large o r th e tumo ur has
distO rted the ce rvica l ca na l a nd p reve ntS the inse rtio n
of a ute rin e device, it is prude nt LO app ly te le th e rapy
fi rst (3000 rad ). T his shrinks the pri mary tumour and
enables the app lication of brach)•the rapy. Cobalt-60 and
caesium-137 are tl1e common sources of te le tl1 erapy (exter-
nal radiotherapy).
$electron reduces t11e period of application and shrinks
the tLunour quickly. Mega voltage t11erapy has tl1e following
advantages:
• Greater penetration which allows deeper tissues to be
effectivel) radiated
• Spares tlle skin effect
• Shorter treaunenttime
• o bone necrosis
• Can cover a larger field in the abdomen
Supplementary teletherapy Ill rough four or more portals
is necessary to achieve uniform and adequate cancericidal
dose or to t11e entire pelvis.
The tumou•· tissue recovers more slowly or n ot at all as
compared to the normal tissue. T herefo re, fractionated
co urse of radiotherapy (four to five tim es a week) allows
normal tissues to recover befo re the nex t dose and reduces
the LOxi city.
In pelvic racUa ti on, eac h frac tion is 180-200 cGy. In
abdo mina l racUa ti on, it is red uced to 100-120 cGy to
avoid damage to the li ve t; ki d neys and intestin es. A total of
25-30 frac tions over 5-6 weeks are adm iniste red . T his frac-
tionation min imizes t11e side effectS of rad iatio n.
INTERSTITIAL RADIOlHERAPY
In this, the radioactive source is placed directly into the
tissue tumour. It ma) be removable implantS or penna-
nent implantS which are placed in inaccessible tu-
moLU·s. such as radioactive iodine at the time of surgery.
Removable implants can be used in the vagina and cer-
vix. l l'idium-192 is the 1<1dioactive isotope of choice in
L11ese cases. As with inu'dcavity, afterloading devices
are now available as safety methods. O ther sources are
caesium-137 and cobalt-60.
498 SHAW'S TEXTBOOK OF GYNAECOLOGY

COMPUCATIONS OF RADIOTHERAPY Table 39.3 Preoperative and Postoperative

Radiation: Advantages and
Complications of radiotherapy are divided into early and
Disadvantages
late complications.
Advantages Disadva ntages
I. &trly compliwtiolls: These include:
Preoperative radatlon
• Transient nausea and vomiting; antiemetic drugs help
• Bladder ir.-i tation causing frequency; dysuria or hae- 1. Surgically undisturbed 1. Precludes accurate
matu.-ia is treated \\ith anti cholinergic drugs or chlor- tumour bed . Intact vascu· pretreatment staging of the
p•·omat.ine larity (good oxygenation) disease
• Rectal initation causing tenesmus and diani1oea (I %); 2. May facilitate surgical dis· 2. May be considered unnec·
anti ch olinergic drugs help section, allowing a lesser essary in hindsight, in
• Irritation of small intestine causing a norexia, nausea, procedure by shrinking the cases with high chances of
vomiting, di an·h oea and weight loss (5% ); octreotide is tumour cure with surgery alone
used to relieve these symptoms
3. May decrease the likelihood 3. Interferes w ith tissue
• Malaise and in·ital>ility, nervous depression and headad1e of risk of implantation or healing
• Flare-up ofsepsis, tubo-ova rian mass, pyomeu·a, perito- d issemination of viable 4. Combined therapy
nitis and septicaemia t um our cells during surgical Increases the morbidity
• Pyeli tis, pyelonep hritis and cystitis handling of t issues
• Pyrex ia
Postoperative radiation
• Pulmonary embolism
• Skin reac tion 1. Accurate surgical stag ing 1. Surgery may alter the
Megavoltage therapy redu ces these complications. kinetics of tum our
2. Late These include : proliferation
• Persistent anaemia 2. Extent of locoreglonal dis· 2. Surgery often disturbs
• Chronic pelvic pain because of fibrosis involving nerve ease accurately defined tumour vascularity causing
trunks hypoxia
• Pyo me u·a beca use o f ce rvical ste nosis
3. Choice of omitting or
• Proctitis, fo llowed later by rad iation ulcers, rectal selective use of radiation in
bleeding, rectal strictu res and occasio nally rectovaginal some patients
fistula
• Postirradiatio n ulcers in the bladder, ca using dysuria,
hae matu.-ia and vesicovaginal fis tu Ia radiosensiti£ers and potentiate the radiatio n effeet on
• Small bowel su·icnu·es, obstru Ction , ul cera tion and gut hypo xic cells. The) ha'e been used concomitant!)' 10 improve
perforatio n the results of radiotherapy. "111is is known riS chemQrtuliation.
• Colonic ul cer, telangiectasia, perforation, stricture o r
obstntction NEWER TECHNIQUES SPARING ADJACENT TISSUES
• Atropic vaginitis, fibrosis and vaginal stenosis causing Normal tissue sparing with optimal target tissue radiation is
ma•·ital discord known as 30 conf-onn al radioth erapy. RapidArc is beuer
• Ureteric std cttu·e and obstructive uropathy than 30.
• Osteoporosis and fracture n eck of the femur Intensity-modulated t-adiation therapy is being auempted.
• Disturbed psyche 30 conformal 1·adi othe ra py uses CT, MRI and PET LO
• Ovarian desu·ucti o n ca using severe menopausal symp- place th e beam of radiati o n to conform o nl y tO the target
toms and osteoporosis; this ca n be avoided by translo- area, maximi:t.e dose to the wmour a nd minimize dose to
cation of ovaries above the pelvic brim during primary the normal tissues.
surgery, or presc tibing IIIU Tomo LI1erapy and cone-beam CT also a llow precise local-
• Sarcoma reported in 8% of cases some years after ra- iza ti on of Ll1e beam to th e target tissue.
diotherap)\ as so me are suspected LObe carcinogen ic
ROLE OF PREOPERATIVE AND POSTOPERATIVE
CONTRAINDICATION$ TO RADIOTHERAPY RADIATION
• Severe anaemia Role of preoperative and posto pe rative r-adiation is s umma-
• Poor general healLll rized in Table :39.:3.
• Sepsis
• Pregnancy CLINICAL APPLICATIONS OF RADIOTHERAPY
• Prese nce of fibro ids in L11e ute rus
• Tubo-ovarian mass
CANCER OF THE CERVIX
• Uterovaginal prolapse
• Prese nee of ge nital fistu lae Plimary mdiation therap) for cancer of the combines
• Radioresistant wmou r teletheraP> with bt-adl) th et-ap). Radiatio n, like sLU·gery, is a
local therapy. IL therefore influences o nl)' the tumoLU· cells
Certain chemoth erapeutic agen tS, sudl as cisplatin, falling "ithin the 1-adiation volume. lnu-aca,'itary 1-acliation by
carboplatin, 5-FU, paclitaxel and imerferon (lFN), are itSelf may therefore not be ctn-ati'e for patientS in whom the
 CHAPTER 39 - RADIATI ON THERAPY, CHEMOTHERAPY AND PALLIATIVE CARE FOR GYNAECOLOGICAL CANCERS
tumour spread invo lves tissues beyond the effective radiation
range and tl1ose witJ1 distant metastases. Additional external
supplementary radiation to tJ1e pelvis is required to u·eat tl1e
pelvic lymph nodes. The tolerance of Lhe normal Lissues
witJ1in tl1e pelvis acLS as tJ1e limiting factor in planning radia-
tion tllerap). Cervical cancer requires a radiation dose of
6000 cG). The tolerance dose of irradiation for tl1e urinary
bladder is about 6000 cG) and for Lhe reCLum, it is about
5000 cG)•. Doses in excess can damage tllese hollow viscera
and cause radiation fistulae. The imraca,·itary radiation source
is so calculated tJ1at it does not deliver a dose in excess of
8000 cGy to tl1e point A located 2.0 em above and lateral to
tJ1e external cervical os. This point denotes the point of a·oss-
ing of tl1e ureter in tJ1e pelvis. The second point of consider-
ation is point B located 5.0 em laterally on tl1e pelvic sidewalls
where tl1e obtw-ator gland is located. The radiation dose at
point B should not exceed 4500 cGy. This is to safeguard the
bladder and rectum from overiiTadiati on. Pr«Jperative brach)'-
tlterafl)' is used in barrel-shaped endocervical growth of more
tJ1an 2 em. T his is fo ll owed "1thin a week or 4 weeks later by
WertJ1eim's hysterectOm)'· Cisplatin plior LO o r during brachy-
tllerapy imp roves tJ1e respo nse rate (Fig. 39.4 ).
Cisplatin acLS as a rad iosensitizer and is emplo)•ed as a
neoacUuvan tor concomitant che mo radiation.
Cisplatin 40 mg/ m2 i.v. given ,,1tJ1in I hour prior to radio-
tllerap)' weekly improves the response rate of me lattec
Other radiosensitizers are 5-FU, gemcitabine, paclitaxel and
carboplat.in.
Postoperative external radiotJ1erapy is required when tl1e
surgery has been incomplete or lymph nodes prove positive
for malignanC).
P1imal") radiothei-ap) is main I) applied in advanced cancer
of tlle cervix. but also preferred in Stages I and liA by some
ronaecologistS as an altemathe to We1·rneim's hysterectomy.
The cure 1-ates achieved in earl)' stages are comparable by
either metl1od. Howe,er, reali:t.ing mat radiotl1erapy causes
'aginal stenosis leading to clrspareunia, O\>alian desu·uction
"1tll menopausal S)•mptoms, and osteoporosis and cervical
stenosis causing p)omeu-a, tJ1e choice of treatment in young
women is surgery in tJ1e fonn of 'v\'ertJ1eim 's hysterectom)( ln
a few cases, radiotJ1erapy fails to in-adiate tJ1e pelvic nodes
completely, and recurrence occurs. In such cases, surgery is
preferable to repeat I'lldiotherapy, provided the woman is
su rgicall y fiL ln plimary radiotJ1erapy normally, brachytller-
apy is applied first followed b)' ex te rnal tele thempy. lf the
growth is la rge, first tele th era py is applied to shrink the
tum o ur fo llowed b)' brac h)•th erapy.
ENDOCERVICAL CANCER
ln endocervical cancer, tJ1e best survival seen when con-
comitant cisplatin weekly combined with pelvic rad iotllerapy
for 6 weeks is fo llowed by surgery. PostOperative rad iotl1erapy
is required if pelvic I)'In ph nodes prove positive for cancer.
ENDOMETRIAL CANCER
l11e importance of radiation tJ1erap)' in tl1e managemem
of endomeu·ial cancer is listed as follows:
• lt is perfonned as an acljunct to sw·gery comprising of
TAH-BSO and I) mph node sampling.
499
• By administering '>aginal radiation via colpostat, vaginal
vault recurrence drops to 2% from the previous 13%.
• The survival improves in Stages IC and ll when postOp-
erative radiotl1e1-ap) is administered to sterilize the pelvic
lymph nodes. Radiation is indicated in uterine sarcoma,
altho ugh outcome is poor.
• lt is used to treat patienLS who are unfit for surgery.
• lL helps to treat palienLS with vaginal / pelvic recun·ences.
• lt is performed for palliation in cases of nonresectable
intrapelvic or metastatic disease.
OVARIAN CANCER
The primary ll'eaunent for O\>arian cancer is C)•LOreductive
surgery( total abdominal h}sterectomy, removal ofbotl1 O\>aiies
and omemectomy). In advanced cases, maximal debulking
surgery is followed by chemotherapy in epithelial llllllOtli'S,
and most of tl1e otJ1er maligna nt ova ria n tumours. In few se-
lected cases radiation tJ1erap)' in tJ1e fo nn of ' Moving Suip'
technique is applied to para-aortic lymph nodes and abdomi-
nal metastasis. Dysgerminoma and gra nulosa cell tlUl1ow·s,
altl10ugh hi ghl y racUosensiti ve are not being routinel)' used
as advances in chemotherapy has resulted in chemo tl1erapy
being tl1e first line of u-eaunent for these u.uno urs.
ln the 'moving-suip' technique, a su·ip of2.5 em area is ir-
radiated front and back over 2 days, and tJ1e su·ip moved up-
wards, w1til tl1e entire abdomen receives radiation. Witl1 the
liver and kidneys shielded, tJ1e tota l tumour close of 2600-
2800 cGy is administe1-ed. CT and MRI are useful in detecting
para-aortic lymph node involvement p1ior to racliotl1erapy.
The earlier instillation of radioactive gold, tl1iotepa and
otller chemotherap) drugs at the end of surgery is not
widely used. because the drug needs to be even ly disu·ibuted
tO avoid imestinal adhesions. Besides, C)clophosphamide
needs to be acti,>ated in the liver before iLS effect is felL
Therefore, S)'Stemic chemotherapy is more effective.
Five )Cars survh>al mtes in ovarian cancer depend on
a nwnber of factors including residual wmow; grade of
disease and use of effective chemotJ1erapy in the fonn of
paclitaxel.Carboplatin.
VULVAR CANCER
T he aim of integra ted multimodali ty the rapy including sur-
gery, rad iation a nd possibl)' chemo radiation tl1 erapy is to
reduce the risks of loco regio na l fai lure in patientS with ad-
va nced primary o r nodal d isease, and to obvia te the need
for exenterati on opera lions in women in whom tl1e a nus or
lower ure thra wi ll be involved. The dose of rad iation given
is 4500-5000 cGy to women with microscopic disease and
6000-6400 cGy to women witJ1 macroscop ic d isease.
Preoperative radium needles (60 Gy in 6 days) shrink me
tumour and facilitate extirpation oflhe tumo tu· at a later elate.
Postoperative pelvic 1-adiotherapy is preferred to pelvic
l)"llphaclenectomy as it reduces the surgical morbidit)'· Pel-
vic radiotJ1erap) is administered only if tJ1e inguinal lymph
nodes prove histologicall) positive.
VAGINA
Radiotherapy is often chosen in place of 1-adical surgery,
especially in children. If the tumour is locatecl in tl1e upper
500 SHAW'S TEXTBOOK OF GYNAECOLOGY
one-third of vagina, radiotherapy is similar to that of the
cervix. Lf it is locaLed in the middle one-third, interstitial
needles (iridium-192) are placed in the vaginal tissue.
CHORIOCARCINOMA
Choriocarcinoma responds exu·emely well to chemotherapy
which has replaced surge•) and radiotherapy in yow1g
women. Radiotherapy is applicable in the distal metastasis
in a few cases.
CANCER CHEMOTHERAPY FOR
GYNAECOLOGICAL CANCERS
The use of drugs to u·eatdisseminated cancer has developed
imo a speciali:ted discipline. The first successful effort LO con-
trol cancer wi th the help of d rugs is atuibuted tO Mm Chiu Li
et al. ( 1956), who demonstra ted pe rma ne nt remission in
trop hoblasti c disease. T he understa nd ing of the mode of ac-
tion of th e drugs at DNA level has brought out newer effec-
tive drugs witl1 less LOxic it)' and has imp roved and p rolonged
tl1e survival of women with gen ita l cancers.
TUMOUR CELL KINETICS
A fundamental characteristic of malignant tumo urs is the
rapid proliferation of malignant cells. These rapidly prolif-
erating cells keep repeaLing a cycle of biochemical eventS
continuous!) which culminate in cell division (Fig. 39.5).
Each proliferative cell gives rise to two daughter cells that
continue the proliferative process, so the cell population
increases geomeu·icall).
A tumour is described as consisting of four t) pes of cells
(Figs 39.5 and :l9.6).
Dividing tumour ctliJ: This is the only compartment that
adds to me cell population. Cells in this compan.ment are
most sensitive to cytotoxic agentS.
Rellingcells: These are nondividing cells resting tempor:uily
(cells in Go phase). They are •-efractOI)' to chemotherapeutic
agents.
Differeutiated celiJ: T hese cells have lost tl1eir dividing po-
temial and are awaiting natural deatJ1. T hey do not h ave
malignant potential, so they are of little co ncern to the
chemo tl1erapist.
Dying T hese arc tc m1ina l cells.
Sma ll rap id ly growing w mours have many mo re rapid!)'
dividi ng and grow ing cells; he nce, th e do ub ling time is
short. However, these arc the same LU mo urs which have a
Postsynthetlc gap
DNA synthetic
period
Go
(Resting cells or
out of cell cycle)
Presynthetic gap
Figure 39.5 Scheme representing cell cycle: G1 ..... S ..... G2 ..... M phase.
Chemotherapy response
r
Sensitive to cycle- Insensitive to Of no concern
dependent agents cycle-dependent to chemotherapy
agents
->
I Resting
(G0 phase)
D
Figure 39.6 Cell types constituting tumour mass.
high number of cells sensitive LO cell cycle-specific cyto-
toxic drugs. As tl1e w mour mass enlarges, the growth rate
progressive ly s lows down, do ub ling tim e beco mes lo nge r
a nd the cell inp ut may eq ual loss; hence, a statio na ry size
may be reac hed, and tJ1e se ns itiv ity LO cell-specific drugs
dimi n ishes.
Another factor to be considered d uring cance r chemo-
therap)' is me wmo ur load present at tJ1e commencement
of therapy. Reduction in tJ1e b urden of tumour cell load
wi ll bring an apparent remission, but d uring the interva l
between successive courses of cancer chemotherapy, the
tLUUOLU' growth recurs. This results in stepwise decrease in
tLUUOLLr cell mass.
To attain maximlUn tumour cell kill, tl1e following principles
must be considered:
• The chemotl1erapist must be well aware of the 'total
tumour cell kill concept'.
• Tumour cell kill by C)lOtoxic drugs follows tl1e paLLern
demonstrated by Skipper and Perry S (1970) tl1at the
killing of tumour cells by cytotoxic agents occurs in an
exponential fashion, so mat a given close kills a constam
fraction oftl1e population, i•Tespective of its initial size.
• There is a clear close-1-esponse relationship.
• Prolonged u·eaU11ent may be necessary to reduce the ma-
lignant cell population to a low numbe•· which will tl1en
be dealt with by tl1e host immune mec hanism.
• Che motherapy is most effective whe n it is Sta rted ea rly
beca use tl1e number of wm our cell pop ulati o n is low and
the rap idly growing and d ivid ing cells are se nsitive to
ca ncer che motherap)'·
• Chemotherap)' must a im at d ifferen t cell kill. T he close
must be so aclj usted tJ1at max imum desu·uction of tumo ur
cell is achieved with minima l damage to norma l cells.
• Many cytotoxic dmgs in present use show some degree of
tissue selectivity.
• Combination drug regimens and/ or sequemial drug
regimens achieve superior tumour cell conU'ol with low-
ered side effects. Drugs with different actions yield better
response and reduce drug resistance.
• The problem of drug resistance must be constantly bome
in mind. This often happens with a single-drug therapy.
Drug resistance ma> be temporal)' because of poor vascu-
larity not allowing ch-ugs to •·each me tumour cells caused
by fibrosis or bulky tumour, or pennanem when it is
eimer spontaneous or drug-induced mutation.
 CHAPTER 39- RADIATION THERAPY, CHEMOTHERAPY AND PALLIATIVE CARE FOR GYNAECOLOGICAL CANCERS 501

Chemotherapy has advanced tremendously in recent

years, and is being increasingly used in the management of
CONTRAINDICATIONS
gynaecological malignancies. The drugs by virtue of prolon- • Hb % less Ulan 10 g%, WBC less u1an 3000/ mm 3 and
gation of life and prolonged remission period allow a platelet co Lull less t11an 100,000/ mm3
woman to li'e a near!) normal life. • Liver and renal d)Sfunction

CHEMORADIATION
It is now recogniJ.ed that some chemotherapy chugs act
also as mdiosensitiJ.enl and lead to superadded cell kiU prior
to or preferably along with radiotherapy and p•·ior LO surgery.
They are thus used as 'neoadju,oanLS' in a bulky tumow· and
locally achoanced cancer in the pelvis. The most common
drug used for this purpose is cisplatin either singly or as
in combination. Cisplatin 40 mg2 weekly is given 1 h our
before radiothempy. The renal functions should be normal
before instituting this regi me. Other chemoradiation drugs
in use are 5-FU, gemcitabine and cisplatin combined with
gemcitabine 40 mff in 200 mL saline 2 hours before radia-
tion- it takes 1 hour to admin ister. Postrtuiif!litm clumwtherapy is
1Wt e.ffoctive rmd fJoor resfxmse o<:mrs on ttttmmt ofp<xlr tissue oxygen-
ation mul poor va.:.cularity not ollorvi.ng t1111 drugs to reach and pene-
trate the tu11wur. In add ition, myelosuppression of racliotherapy
and high dmg toxicity because of decreased renal function
and w·ete tic obsu·uction (md iation caused by rad io-
tllempy limit tl1e use of chemotherapy drugs as posu·adiation
drugs.
Chemotherapy is also used for recurrem and advanced
diseases that are not amenable to surgery or radiother-
apy. to reduce tl1e tumour volume and provide short-term
palliation.
Combined lllJI'IltJ art' JujH'rior to tt therapy; they
mlumce tumour cell mluct- dose wxicit)' mul Tl!Sistance, ami
yiel.tl a bdter tlurajH'utic TI'!./XJII!.f with longer Tl'mission. They also
yiel.tl better TI'!>/XJI!Sf tlum drllg:l tt<ting similarly. Chemotherapy,
lwweuer, does not prnH'Ilf OCCIITTI'I!CI' of di.strd metastasis. It must
also be remembered that chemot11erapy yields better re-
sponse in distal metastasis as compared to in postradiated
recurrence, as its vascularity is not compromised.
Role of chemotherapy:
• Total response a nd cure is seen in 10%-20% of cases.
• Remission witl1 partial response is see n in 40%-50% of
cases.
Some drugs are no nspecific age nts, i.e. alkyla ting agents,
cisp latin, carboplatin and paclitaxel. T hese drugs damage
tl1e cells at any phase of cycle, altl10ugh d ivid ing cells are
most vu lnerab le. The specific agents are methotrexate and
Adriamyc in in gesta tional trop hoblastic d isease, 5-FU in
vu lval cancer, and hydroxyu rea, b leomycin and etoposide in
cancer cervix.
Route. Drugs can be given orally (alkylating agents), in-
travenously or inu·aperitoneally at the end of surgery (but
are not very effective).
required prior to chemot11erapy:
• H b%. WBC and platelet coum
• Serum eleCLrOI)tes
• KidnC)' function tests
• Ca•·diac function with doxon•bicin
• Pulmonary function test with Bleom)cin
• Liver function test with Methotrexate
COMPUCATIONS OF CHEMOTHERAPY
• Anaemia, tlHomboC)topenia and leucopenia
• Alopecia (reversible)
• Renal damage
• Liver damage
• Cardiac (doxorubicin)
• Pulmonary (bleom)cin)
CLASSIFICATION OF DRUGS
• include cyclophosphamide, ifosfamide,
chlorambucil, melphalan, thiotepa (nonspecific c!Jugs pre-
vent DNA S)11 Ulesis or its division) and 6-mercapwp wine
• Antimet.obolites: Me tllou·cxate and !>-fluorourac il in terfere
witl1 enzymes required for DNA sy nt11 esis.
• Antibiotics: Ac tin om>•cin-D, b leo m>•cin, Adriamyc in, mito-
myc in (nonspec ific) and doxorubicin. T hese inhibit RNA
and DNA S)•nthesis and hence a rrest mitosis.
• Plant alkaloid:.: These inc lude vino·istine, vinb lastine, Taxol,
docetaxel and etoposide (cell specific) -antimitotic.
• include high close preparations in endo-
metrial cancer and Tamoxifene in treated cases of carci-
noma breast.
• These include cisplatin, carboplatin, hy-
droxyurea and topotecan.
• Biologiatl: IF improves host immune defence and main-
tains remission.
NEWER ANTICANCER DRUGS
The development of new chemotherapy drugs has improved
the disease-free ime1"\oal and prolongs sunri,oal.
They are as follows:
l. Vascular targeting agentS (VII\)
a. Angiogenesis inhibito•-s
b. VEGF ligand bevacizumab (Avasti n , GeneTech)
c. Receptor ta1·geting Vl!:GF
Recep tor tyrosine kinase inhi bitor, cedirani b, ninte-
danib and anti -Vl!:GF a ntibody
T he form er primaril )' prevent deve lopment of new ves-
sels in tl1e uun ou1: The latter damage the established
vessels in tl1e tumo ur with cediran ib 30 mg daily
orall)'; 30% benefit is repon ed in recurrem epithelial
ovarian wmo w·s and fallopian tube cance.:
Complication includes hypertension.
Bowe l perforation is seen in intraperitoneal tumours
involving tl1e bowel.
Vascular disrupting agents (VDA) fosbretabulin,
olaparib (oral I00-600 mg daily).
2. Farletuzumab- a monoclonal antibody against ovarian
cancer.
3. ovel C) totoxic agents
(a) Trabectedin
(b) Epotl1ilone analogues
(c) Topoisomerase I inhibitors
(d) Pemetrexed
(e) Aurora kinase inhibito•-s
502 SHAW'S TEXTBOOK OF GYNAECOLOGY
VULVA
5-FU is effective in cancer involving the anus. It shrinks the
tt.tmour which may even disappear.
Local excision of the residual tumour is then successful.
VAGINA
The metastasis of choriocarcinoma responds to methotrex-
ate and aCLinOm)Cin-0.
CERVIX
The use of cisplatin concomitant with radiotherapy and
prior to surgery in endocervical growth is mentioned in
Chapter 33. It also •·educes the incidence of lymph node
metastasis in bulky cervical tumour in Stages IB and llB and
improves the smgical outcome, ahJ1ough the survival rate
has not shown improvement.
The drugs most effective are as follows:
• Doxon.tb icin 120 mg/m2 + cispla tin 50 mg/m2 i.v. over
24 ho urs weekl y for six C)•Cies (th ree cycles as radiosensi-
ti zers)
• PVB:
• Cisplati n 100 mg/m 2 i.v. o n day I
• Vinblas ti ne 6-12 mg/ m2 bolus on da)' I
• Bleomycin 15-30 mg i.m. on days I, 8 and 15 given
3-weekly for not more than eight cycles
Cisplatin requires adequate hydration.
Response rate of 50%-70% is seen.
Chemoradiation also improves survival in distal metastasis.
ENOOMETRIAL CANCER
Chemotherap) drugs are less commonly LLSed becaLLSe of
poor response in endometrial cancer and surgety and
radiotherapy being the comerswne in itS managemenL
Metastatic wmours respond better to progeswgens.
Medrox)p•·ogesterone acetate (MDPA) I g i.m. weekly or
400 mg orally dail)\ I g norethisterone i.m. weekly or 17-alpha-
h)droxyprogesterone i.m. are effective in well-<lifferemiated
tumours containing oestrogen and progesterone receptors.
Anaplastic tumour· does not contain these recepwr·s and fails
to respond. Tamoxifen 10 mg b.d. by iLS amioesu·ogen action
is also effective in advanced cases. T hi rty per cent response is
seen in hmg metastasis with progestogens.
Sarcoma of the uterus is trea ted with cisplatin and ifos-
famide. Doxorub icin is used as single-agent the rapy follow-
ing surgety. Recen t! )', d rugs such as doxorub ici n, platimm1,
taxa ne, carboplati n and pacli taxe l have been tried.
OVARIAN CANCER
Chemotl1erap)' p lays a m1ljor role after st.u·ge•y in the man-
agement of ovarian cancer. Nowadays, new drugs with less
toxicity has improved the survival as we ll as remission pe-
riod. Multiple-drug therapy yields better survival.
Indications are as follows:
• Prop h) lactic postoperative chemotherapy in Stage IC to
prevent recurrence. Carboplatin alone is adequate pro-
ph) lacticall).
• ln advanced stage, chemotherap)' as palliative t11erapy
keeps tl1e woman comfortable.
• In unresectable tumout; chemotl1erapy for 3-6 monms
followed by debu lking surge•y is recommended.
Chemotl1erap) for 3-6 momhs followed by debulking
SLLrgery and monitoring witl1 tissue markers for regression
and deciding on duration of the rap) is t11e routine prac-
tice in residual wmour, and in recurrent and advanced
cancer.
Cisplatin and Taxol the main dll.lgs useful in ov:u·ian
cancer. Carboplatin is supetior to cisplatin witllless nephrotox-
icity and less emetic potential. M)elosuppression is reduced
if used witll granulocyte colonr·stimulating factor (G-CSF,
175-200 mg/ m2). Corticosteroid and antihistamine prevent
hypersensitivity r-eaction to paclitaxel. Carboplatin requires
less hydration tl1an cisplatin. Six cycles are usuall y given.
Second-line drugs when woman fails to respond to cispla-
tin are cyclophosphamide, topoteca n , ifosfamide and doxo-
rubicin.
T he woman sho ul d be mo ni tored no t only fo r the re-
gressio n of the d isease h ut also for myelosuppressio n, vom-
iting, dia rrh oea, nep hro toxicit)', ne uro toxicity and fungal
infec ti o n.
T he d rugs used a re as follows:
• Doxorub icin (Adriamycin 120 mg/ m2 wee kly for 6 cycles
is cardioLOxic)
• Cisplatin 50 mg/ m2 i.v. over 24 ho urs with good hydra-
tion 3-weekly for six cycles (30% response)
• Ifosfamide 1.2 g i.v. over 30 minutes
• Metl1otrexate 50 mg/ m2 i.v. boiLLS weekly for 6 weeks
• Topotecan 1-2 mg/ m 2da)S 1-5, 3-weekly
• Paditaxel 135-200 mg/ m2 over 3-hour has infLLSion, fol-
lowed b) cisplatin 75 mg2 over I hour 3-weekly; cisplatin
causes nausea, renal faillll·e, pet·ipheral neuropatl1y and
m)elosuppression, but no alopecia
• BEP
• Bleom)cin 15 mg i.v. on day I, 2
• Etoposide 100 mg/ m2 on day 1-5
• Cisplatin 20 mg/ m2 i.v. on day 1-5
• Carboplatin 300-400 mg/ m2 4-weekly; response rate 30%
• VAC
• Vincristine 1.5 mg/ m2 i.v. day I
• Acti nomycin-D 0.5 mg i.v. 1-5 days
• Cyclop hosp hamide 150 mg/ m2 i.v. o n days 1-5 weekly
• PVB
• Cisp latin 100 mg/ m2 i. v. da)' I
• Vin blastine 6-12 mg/ m2 bolus i.v. day I
• Bleomyc in 15-30 mg i.v. days I, 8 and 15, maximum of
e ight doses 3-weekl y
• C)•clophosp harnide 500 mg/ m2, doxorub icin 50 mg/m 2
bo h.LS i.v. and cisplatin 50 mg/ m2 in fused over 30 minu tes
3-weekly for six cycles
• Taxol derived from the b.1rk of Pacific yew tree is expen-
sive and available in semis)'llthetic form; it promotes as-
sembly and stability of microtubules and inhibitS mitosis;
a dose of 175-250 mg/ m2 i.v. is infused over 3 hours is
LLSeft.d in cisplatin-resistant cases; side effectS are neutro-
penia, paraesthesia. scotoma, myalgia, bradycardia, alo-
pecia, vomiting and diarrhoea
• Alpha-interferon three times a week subcutaneously,
m:tint:tins emission period and improves sut·vival
 CHAPTER 39 - RADIATION THERAPY, CHEMOTHERAPY AND PALLIATIVE CARE FOR GYNAECOLOGICAL CANCERS
• Gemcitabine 100 mg/ m2 + carboplatin on first and
eighth days 3-weekly for six cycles
Extravasation should be avoided by using angiocatheter
when giving doxorubicin, actinomycin-D and vincristine.
Topotecan is another new drug which inhibi ts nuclear
erupne DNA topoisomerase and is well tolerated.
Genn cell tumour responds well to Bleom)cin, ewposide
(85%) and Cisplatin (BEP regimem).
CHORIOCARCINOMA
See Chapter 38.
SARCOMA
Cisplatin, ifosfamide and doxorubicin are used as single or
combination th erapy.
BREAST CANCER
Altl1ough tamoxifen im proves the survival period, it causes
endo metria l hyperp lasia a nd and req uires regular
monitoring witJ1 ultrasound swdy of e ndome u·ium and en-
dometrial biopsy.
The bf mvrtre of the limitations of che-
11wtherttjJ)' m well effel"tivenns. Tu mo ur markers s ho uld
be employed d uri ng chemotherapy to wa tch the effective-
ness and decide the duratio n of c hemotherap y in an
individua l case.
IMMUNOTHERAPY
Realizing that immunosuppressed women are more likely w
develop cancer, this t11erap) is recei\;ngconsideration. HPV
vaccine is now available for cancer cen;x prevention.
The best results are obtained if the nun our size is inilially
reduced b) surgeq, chemotherap) or radiation.
LmmunotJ1erapy includes:
• Vaccine against human papillomavirus for cancer cervix
(prophylactic)
• Chemical immunostimulants- levamisole and cimetidine
• Cywkines, LFN, imerleukin ( IL)-2 and tumour necrosis
factor (TNF)
• Chemother-apeutic drugs- cisplati n and doxorubicin
• Passive immuni:t.ation -immunological aCLive substances
direc tl y tmnsferrecl to the host:
• Cytoner, LF N and TNF
• Monoclonal antibodies
• Activated mac rop hages
• Drug immune modifie rs:
• Ami-CA-125 amibody (oregovomab) is given as a drug
imm une modifier.
• Bevaci:wmab-24 MAB arnibody is not tox ic, but
bowel perforation and proteinu ria are reported and
tl1 e drug is very expensive. Also helpfu l are bevaci-
zumab-15 recombinant humanized monoclonal anti-
body directed towards VEGF-A and a ntiangiogenesis
15 mg/ kg bod) weight every weekly for 6-21 cycles.
GENE THERAPY
Familial cancer of ovar1 and endometrium has been ob-
served in 5%-10% of cases. The genes BRCA-1 and BRCA-2
are responsible for O\<arian malignancy. Gene study and
503
gene therapy are LU1der research. Stem cell therapy may
play a major role in tl1e future.
Taxane. Apan from being antimitotic, it is also a radio-
sensit.U.er. It caLLSes neutropenia, paraesthesia, myalgia, car-
diac arrh) tl11nia and alopecia.
1l1e dosage is 135 mg/ m2 over 3 hours followed by 75 mg
cisplatin.
Cisplatin sensitivit) is t11e ke) predicLOr of response and
IL is now replaced by carboplatin, because of its
lesser toxicity. Cisplatin/ carboplatin with pacliraxel is t11e
first line of chemotherapy u·eaunent in advanced cancer.
ln ovarian cancer, chemotherapy is used as:
• Neoacljll\<an t therapy
• Concomiram therapy
• Ac!juvanL therapy
Neoadjuvant ther-apy is emplo)•ed befo re surgery.
T he dn.rg shrinks tJ1e tumour and reduces micromerastasis.
Disadvantage of neoacljuvant t11 erapy is Lhat it delays tl1 e
specific tJ1e rapy.
Dn.tgs used are cisplati n, carboplatin, bleomycin and
ifosfamide- with 50%-70% respo nse.
T he dose is 100 mg cisplatin + 1.2 g/ m2 ifosfamide.
Concomitant therapy (d uring trealment) acLS as radio-
sensitizer, and en hances radiotherapy effect, b ut increases
tOxicity (Table :39. 1).
Adjuvant therapy (drugs menlionecl earlier) is employed
following surgery or radiotJ1erapy but response tO local re-
sidual/ recurrence is low, because of poor vascularit:y of t11e
LLunoLu·. The distal metastasis however responds beLLer lO
adjuvam chemotherap), because of its intacL \'l\SCulariLy.
\\'itlt so 11t(ITI)' 11eru dnt!,ll bfcomi11g (IV(Iiktblt!, tissue stmsitivity
test w various dntgl ITUI)' imjJruur our dl!cisum regrmling the best
line of cltemotherttfJ)' in thl' fttlttrt'.
PALLIATIVE CARE
It is not enough to treat cancer disease per se. Apart from
palliative radiotherapy and chemotherapy in t11e advanced
stage of the disease, other adjuvantS are necessary in t11e
management of cancer'S. These are as follows:
• Nutrition
• Relief of pain
• Relief of sympto ms
• Psychological suppon
Table 39.4 Toxicity of Drugs
Drugs Toxi city
Cisplatin Vomiting, myelosuppression, renal toxicity,
peripheral neuropathy, ototoxicity; no alopecia,
hydration required
Carboplatin Myelosuppression
Taxane Hypersensitivity. myelosuppression, cardiac
arrhythmia, alopecia
504 SHAW'S TEXTBOOK OF GYNAECOLOGY
NUTRITION
It is necessary to maintain the woman's nutrition before,
during and after surge!), radiotherapy and chemotherapy
to obtain a good response and successful cure, longer remis-
sion and survival as well as a feeling of well-being. TI1e nu-
uitional problem arises in the advanced stage when ca-
chexia sets in. or following radiou1erapy and chemoilierapy.
The optimal n uu·itional stalliS is a prerequisite tO cancer
treaunenL
Assessment of Nutritional Status
• Weight of U1e woman: \\'eight loss more Ulan IO% of
previow weight is considered malnuuition.
• Haemoglobin should be more than IO g%, ideally
12 g%. Low haemoglobin before surge1)' can cause sep-
sis, Uuomboembolism and poor wound heal ing. Nonre-
sponse to radiotherapy a nd ch emoth erapy is seen in
anoxic tissues.
• Protein: Normal serum albumin is 4.0-5.0 mg/ L and
hypoproteinaemi a is a sign of ma lnuu·ition.
Management
The woman rece ive adeq uate calories, i.e. 2000-2400
kcal, dail)' along wiUl adeq uate protein and micronutrients.
Anaemia is u·eated wiU1 blood u·ansfusion p1ior to any treat-
menL Daily Auid imake should be at least 1500-2000 mL If
U1e woman cannot tolerate oral diet, intravenous am ino acids,
glucose and vitamins should be provided. Tube feeding is not
always tolerable and is uncomfortable. Initially 50 1nL/ hour, it
is increased graduall) to Ule required amounL Hydration is
especiall) important in chemoU1erapy wiUl cisplatin.
Apan from U10se mentioned earlier, neutropenia result-
ing from radioU1erap) and certain chemotherapy dmgs
requires blood u-ansftiSion.
RELIEF OF PAIN
It is impo1·tant to detect the cause and pailiology of pain to
deliver appropriate painkillers. Even when cw·e is not possi-
ble, painless da)S reduce me suffering of the woman and al-
low her to reach her end in peace and serenity. This pallia-
tive treatment should be instituted along wiU1 the definitive
or other palliative the1-apy including nuu·ition memioned
earlier, and not resorted to only in the term inal stage.
Pain may be because of local infilu·ation, nerve or bone
involvement, or psoas muscle spasm. Muscle spasm is relieved
wi U1 di azepa m. Mild pain ca n be re lieved with paracetamol
I g q. i.d. It provides mild seda ti on and may cause constipa-
tion in long-term U1erapy.
Opiates. Morphia onc-fourt11 gra in or diamo1phine (heroin)
I mg orally is effective when given 4-hourl)'· Diamorphine is
su·onger U1an morphine; I mg of diamo1phine is equi,-alent to
3 mg oral mo1phine. SubcutaneotL5 iqjection of heroin (2 mg)
can also be given and repeaLed as required in severe pain. Spinal
injection of opiates has also been employed.
SynUJetic opiate syrup (meU1adone) is tiSeful for cough
in pulmona11 metastasis. The side effects of opiates are
vomiting. sedation and constipation whid1 should be man-
aged b) haloperidol (3-5 mg) for vomiting at night or meLO-
clopramide. o,erdose of opiates leads to hallucina-
tions, Ill) oclon ic jerks, •·espil"atOI')' distress, pinpoim pupils
and addiction which is not a problem in the tenninal ill
women. Laxathes will reliC\e constipation.
Bony Pain
Morphine is not effective against bone metastasis. It re-
qttires a nonsteroidal anti-inAammatory drug (NSALD ) such
as naproxen 500 mg b.d. and diclofenac 50 mg Li.d. orally
or rectal!) if gastritis occurs. Subcutaneous injection can
also be given.
Bisphosphonate. 4-hourl) infusion eve!]• 3-4 weeks, pro-
teclS against osteoporosis. H>pocalcaem ia should be watched
for dUiing iliis therap)'·
When SAIDs fail to reliC\•e pain, steroicls are recom-
mended. Ste1·oids promote Ule feeling of well-being and
improve appetite. Prednisone 20 mg daily in divided doses
should be administered not too late in u1e evening, as it
can disturb U1e sleep pauern. High-<lose dexameU1asone
I 6-24 mg daily is weful in liver and b1-ain metastasis - it
relieves U1e pressure of the metastasis in these orga ns. IL is
also effective in bladder and bowel pain. A single morning
dose is adequate because of ilS long half-life. Diabetes,
hypertension, obesity and osteoporosis are its side effects.
Bowel and Bladder Pain
Anticho linergic drugs s uch as Buscopa n 20 mg q. i.d., oxybu-
tynin 5 mg b.i.d. chl orpro ma:t.ine 25-50 mg are effective
against b ladder and rectal pain.
Nerve Pain
Sodium valproate 200-300 mg t.i.cl. and carbamazepine
I00-200 mg t.i.d. cure ne1ve pain. AntidepressanlS such as
antiuiptyline 10 mg at night are effective too, but renal
fLL11ction needs obse1vation. In nonresponders, epidural,
sacral or pudendal blocks are required. SpnpathectOmy
may be the last resort. Ketamine is effective as an analgesic.
REUEF OF SYMPTOMS
Vomiting
Vomiting is because of drugs, chemothempy or J-adioUJer-
apy, or may be because of cachexia in the tenninal stage.
Haloperidol 3-5 mg at night or metOclopramide 10 mg
t.i.d. controls vomiting. Cereb1-al vomiting is treated wiU1
cyclizine 50 mg t.i.d. 01· domperidone 20 mg t.i.d. Ocu·eo-
tide reduces intestinal secretion and promotes absorption
with the effect that gastric volume is reduced and vom iting
stops. IL is also effective in diarrl1oea. Subcutaneously 300-
I200 mg b.d. is given but tJ1e drug is very expe nsive. Thrush
infection is not unco mmo n and ca n be u·ea ted \\1th flucon-
azole. Ondanse u·on 4 mg t.i.d. is effective aga inst radiation
vomiting.
PSYCHOLOGICAL SUPPORT
PS)'Chological impact may be considerable. More time
involvement, sharing emotions a nd compa.55ion form the
holistic care in the management of a woman suffering from
terminal cancer.
Other problems are as follows:
• Decreased sex libido can occur becatiSe of vaginal dis-
charge, bleeding and fear of cancer dissemination.
• Dyspareunia follows surge11 and 1-adiotherapy (short
vagina and vaginal stenosis).
• Ovarian removal with menopausal S) mptOms requires
hormone replacementthe1-apy.
 CHAPTER 39 - RADIATION THERAPY, CHEMOTHERAPY AND PALLIATIVE CARE FOR GYNAECOLOGICAL CANC ERS
• Men tal depression may occur because of oestrogen defi-
ciency or fear of a painful death.
• Ascites requires tapping.
Honnone therapy in tlUnours possessing oesu·ogen and
progesterone receptors does well with progestogens and
tamoxifen. Welklifferentiated tumours possess oesu·ogen
and progesterone r·eceptors than poorly differentiated tu-
mours, so response is good.
Role Hospitals. Temporary hospitalization gives
resprte to relauves and provides d1ange of e nviro runem for
the patjent. There are munber of special hospitals and care
centres whid1 look after these terminally sick cancer patients.
The ultimate goal of palliative treaunent is to allow the
woman to meet he r end gracefully and with serenity. Special
hospitals and nurs ing care for terminall)' sick cancer pa-
are of imme nse help.
KEY POINTS
• Radio th erap)' and che mo therapy p lay an important
role in th e ma nagement of genital tract malignancies.
• Prima ry rad iotherapy can be applied in cancer of the
cervix as an alternative to Wertheim's hysterectomy in
earl)' stages, with equa ll y good results, and is the treat-
ment in advanced inoperable cases. Surgery is how-
ever preferred in )Oungwomen, because radiotherapy
causes vaginal sten osis, p)omeu-a, destruction of ova-
r·ies and menopause.
• Preoperati'e radiotherap)' with cisplatin is recom-
mended in endocenical cancer of more than 2 an
and this shrinks the tumour.
505
• Postoperative radiotherapy is useful if surgef)' has been
incomplete or I) mph nodes are involved in cancer of
the cervix and uteline cancer.
• O.oarian cancer is dealt "ith b)' primmy surgery. Chemo-
therapy is the choice in tJ1e postoperati' e treaunenL
Granulosa celltumolll· and dysgenninoma are highly ra-
diosensiti'e and chemosensitiYe. HowC\er, chemother-
ap) is the prefen·ed u-eaunent in )OtUlg women.
• 'Mo,ing-&rip' ted1nique ofradiotJ1 emp) is safe in dealing
mtJ1 abdom111al and para-aortic I) mph node metaStasis.
• Choriocarcinoma responds well to chemotherapy
which is co nsidered the primar) treaunent. About
90%-100% success is reported witJ1 chemotJ1erapy.
• Chemotherapy is now e mplo)ed as neoadjuvant, con-
comitlll1l and adj uvant themp)'·
• The li mitations and harmful effects of radio therap)'
and chemotherapy sho uld he understood.
• Chemomdialion is also used in residua l a nd rec urrent
wm ours as palliative measures.
SELF-ASSESSMENT
I. Discuss tJ1 e role of radiother·apy in cancer of the cervix.
2. Discuss tJ1 e side effects of r-adiotJ1erapy.
3. Discuss tJ1e role of chemotJ1er-ap)' in ovarian cancer.
SUGGESTED READING
AaldersJ. Textbook ofOnoolog)•. WB Saunders: Else,ier. 1991.
BonnarJ. Recent Ad\ance. in Ob>teuic> and Gynaecology Vol20 1998.
' J, et al. Gp1ecol Oncol Vol 68: 274-279. 1998. '
Studd J. Progres. in Ob>tetric> ,md Gmaecology Vol 16. 2005.
 IMAGING MODALITIES,
ENDOSCOPIC PROCEDURES
AND MAJOR AND MINOR
OPERATIONS IN GYNAECOLOGY

40 Imaging Modalities in Gynaecology 43 Obesity and its Significance

41 Endoscopy in Gynaecology in Gynaecology
42 Major and Minor Operations in 44 Instruments Used in Gynaecology
Gynaecology

506
 Imaging Modalities
in Gynaecology

Plain Radiography 507 Rodionuclide Imaging 517

Hysterosalpingography 507 Duoi-Photon Densitometry 517
Ultrasonography 511 Key Points 518
Computed Tomography Scan 515 Self-Assessment 518
Resonance Imaging 51 6

PLAIN RADIOGRAPHY • To assess the feasibili ty of tuboplasty by s tudying t11e loca-

ti on a nd extent of tubal block.
Advances in imaging modalities have revolutionized the • To study uterine anomalies such as septate and bicornuate
practice of gynaecology in recent times. Plain radiograph ut.erus.
was the first modality used in older times but has limited • To detect uterine synechiae.
place in current gynaecological practice. Advem of ultraso- • To detect uterine polyp.
nography, CT and MRJ has made virtual real time imaging • To swdy incompetence of internal os. HSG has also been
possible in ID naecolom•. Sonography especially, uansvaginal described in Chapt.er 16.
sonograph)' provides excellent ' 'iew of anatomy of pelvic
organs. In mnaecological practice 80..90% need for imaging TECHNIQUE
IS met by ulu-asonograph). More advanced teclmiques such as
Cr scan, MRJ imaging having added newer dimensions in the • It is done as an outpatien L procedure, without any anaes-
management of g)11aecological conditions specially malignan- thesia, in the Deparunent of Radio lam.
cies. The latest addition to imaging techniques is PET scan • Premedication with atropine and analgesia may be re-
which is of immense value in managing cancers. quired in an apprehensive woman to prevent tubal spasm.
An abdominal radiograph is not used in t11e diagnosis of
pelvic pathology. However, an incidental radiograph taken
for other med ical or surgical conditions may reveal unsus-
pect.ed pelvic pathology suc h as the presence of a tooth in a
dermoid cyst or a calcified fibro id (Fig.10.1).
A plain radiograp h of t11e pelvis in ameroposterior (AP) and
lateral views ta ken after placi ng a uterine sound in t11e uterine
cavity help to locate an inu·auterine contraceptive device
(lUC D; comm on!)' a CoppeP·T in present times) (J<ig. 40.2) .
A p lain rad iograp h of the chest is req ui red in suspected
wbercul osis, to dete rmine the presence of metastasis in
gynaecologic malignancies, and finall y, as a pan of th e work-
up before undertaking any major gynaecological surgery.
A plain x-ray of skull (Sella view) ma)' be of help in women
,,;tJl galactani1oea to rule out a pituitary macroadenoma.

HYSTEROSALPINGOGRAPHY
Hysterosalpingography ( 1-!SG) where a radio opaque dye is
inject.ed in ut.erine ca,·it) is emplo)ed for the
• To Sllld) the paten C) of the fullopian tubes in infertility
cases and following tuboplast) (Fig. 10.3A-E). Figure 40.1 X-ray of pelvis sho\Ning teeth in an ovarian dermoid cyst.

507
508 SHAW'S TEXTBOOK OF GYNAECOLOGY

Rgur e 40.2 (A) showing presence of foreign body, and (B) shows a migrated Copper-T outside uterus. An anteroposterior (AP) and lateral
view of t he pelv is with a uterine sound In sit u confirm t he extrauterine location of the IUCD.

Rgure 40.3 (A) HSG showing patent fallopian ttbes with free peritoneal spill and intravasation of dye. (B) HSG showing bilateral hydrosalpinx.
(C) HSG showing genital tuberculosis- typically beaded blocked tubes seen. (D) HSG showing septate uterus with normal corresponding fallopian
tubes and free peritoneal spill.
 CHAPTER 40 - IMAGING MODALITIES IN GYNAECOLOGY
Rgure 40.3, cont'd (E) HSG showing unlcornuate uterus. (F) HSG showing bi oornuate uterus. Both fallopian tubes are normal and show free
peritoneal spill. (Courtesy (D) and (F): Dr K.K. Saxena, New Delhi.)
• The woman is asked to empty her bladdet:
• She is placed in the li t.hoLOmy position, perineal area
cleaned witJ1 Betadine and draped.
• Bimanual examination is done to note tJ1e size and
position of the uterus.
• The cervLx is exposed and held with an Allis forceps.
• Rubin ·s cannula, Leech Wilkinson cannula or Foley caili-
eter o. 14 is in u·oduced gen tJy into tJ1e uterine cavity
be)OilCithe internal OS (bulb of ilie catJleter distended lO
prevent leakage). The cone of Rubin's cannula snugly fiLS
in to ilie external os.
• The radiopaque d)e (usually water soluble, rarely oil
based) , 10-15 mL, is gemly injected by auaching the
loaded S)•ringe to the cannula or Foley catJ1eter.
• The ULerine cavity and fallopian tubes are visualized as
tJ1e eire passes tJwough them dut·ing fluoroscopy.
• At a specific time desired, X-t'S)'S are taken for a penna-
nent record.
• The insu·um enLS arc withdrawn, and tJ1e woman is
observed for half an hour.
CONTRAINDICATIONS
• The presence of gc niLa l trac t infection and bleeding.
• Pre mensu·ual phase. Avoid doing test in premenstrual
phase as tJ1ere are chances that pregnancy may have oc-
curred. Thick endometrium may prevent smooth flow of
tJ1e dye at the cornua I end. The risk of endomeu·iosis also
precludes doing HSC in the premenstrual phase.
• Suspected genital tuberculosi.5 because of risk of spread
of infection following the procedure.
• Allerro to tJ1e d)e.
COMPUCATIONS
HSC is usually a safe pt·ocedure, however, following compli-
cations can occur at times.
509
• Ascending infection, spread of tuberc ular infec tion.
• Pelvic in·itation and pain due to dye (c hemical peritOnitis).
• Allergic reaction to tJ1e dye.
• Pelvic endometriosis, if done premenstrually or while tJ1e
woman is mensu·uating.
ADVANTAGES
• Pro,·ides a pennanent record.
• Shows the ULerine patholOg)' and exact site of tubal
blockage.
• D)e may dislodge the mucus plug in tube, thus clearing
the tubal block.
SONOSALPINGOGRAPHY
Sonosalpingography is desctibcd in chapter 16 on lnfen.ili ty-
Male and Female. It is of particular use in tJ1e diagnosis of
uterine polyp.
INTRAVENOUS UROGRAPHY
Urograp hy ou tlines tJ1e urin ary tract fo llowing tJ1 e adm inis-
tration of an intravenous iodinated co nu·ast medium.
INDICATIONS
lnu·avenous urograp hy (IVU) is useful in the following
indications:
• Crnaecologic malignanC) to determine tJ1e normality of
the urinal") tract. In the advanced cancer cervix, tJ1e
Lu·eters ma) get invol,ed leading to partial or complete
obsu·uction. The advanced cancer of tJ1e
the parametrium consuicLS the ureter in iLS passage
through the ureteric wnnel causing obstmction, and
back pressure initially leading to h)drow·eter and
h)dronepht·osis and finally renal au·ophy.
51 0 SHAW'S TEXTBOOK OF GYNAECOLOGY
Rgure 40.4 Composite X-ray showing ectopic pelvic left kidney
demonstrated by retrograde pyelography (clinically diagnosed as left
ovarian tumour).
• ln ovarian cancers and in the presence of other pelvic
masses such as broad ligament fibroids, the t.u·eters
ma) get displaced and are prone to i•1iury du•·ing pelvic
surge•")·
• Rarely, an tmidemified peh·ic mass tums out to be a
solita•")' peh·ic kidney. Instances of removal of such kid-
ne)'S by the unsuspecting surgeon leading to disastrous
consequences ha\e been reported.
• ln ureteric injUI")' dtuing difficult pelvic surge•")', a de-
scending p)elography may help to con finn and locate the
site of i•1iury (Fig. 10. 1).
• Renal tract anomalies often coexist with Mullerian duct
anomalies; hence, in every case of congenital malforma-
tion of th e genital u·act, it is wise tO perform fVU tO
exclude urinary u·act abnormali ties.
• Urinary incontinence in )'Oung girls may be due to a n
ectopic meter: this ca n be demonsu"!ned on urograp hy.
• ln gen itominary Fistulae, the relati onship of the ureteric
olifice to tl1 e site of Fiswla is important in p la nning an y
surgical repail:
• To swdy tl1 e anatomy of the ureter in a difficult pelvic
surgeq•.
PRECAUTIONS AND CONTRAINDICATIONS
• fVU is contraindicated in women with iodine sensitivity.
• lt should be unde1taken witJ1 cautio n in women with im-
paired renal functions. Renal function sho uld be assessed
before tmdertaking IVU.
• Exercise caution before the test in women with allergic
diatl1esis. astl1matics and diabetics on metfonnin. It is
mandatory to perfonn a sensitivit)' test before the investi-
gation.
• Suspicion of pregnancy. Radiation is harmful to the
fetus.
Figure 40.5 Cystography showi ng altered shape of the full bladder
in case of a large cystocele. Note t he descent of t he bladder neck and
proximal urethra which predisposes to stress Incontinence.
CYSTOGRAPHY AND URETHROGRAPHY
Cysto urethrograph)' is useful in t11e investigation of t.uinat")'
incontinence (Fig. '10.5). MostoftJ1e info nnation is obtained
b)' combining video studies and pressure studies (simultane-
o us video cystomeu·ography). This investigation penn its the
evalt.tation of the anatomical disorders of bladder neck and
proximal t.t.retl1ral displacement and inappropriate detmsor
contraction in a patient witl1 incontinence of urine.
GASTROINTESTINAL IMAGING STUDIES
BARIUM MEAL AND FOLLOW THROUGH
This examination and gasu·oscop) are useful in suspeCLed
ovarian metastatic disease. Carcinoma of stomach is often the
primary site of malignancy in patientS with bilateral ova.tian
masses. Visualiation of the ileocaecal region may help tO dif-
ferentiate a pelvic mass due to ileocaecal tuberculosis from
an adnexal mass. Advances in endoscopy have resulted in
g•·eater reliance on upper Gl and lower Gl endoscopy in
comparison to barium meal studies.
BARIUM ENEMA
T his examination allows the visuali Lation of tl1e colo n. Many
gynaecological condi ti ons such as ovarian malignancy, pelvic
e ndomeu·iosis, pelvic inflammatory disease (PID), genital
and abdominal wbercul osis and previous rad iotl1 erapy may
all be assoc iated ,,1111 small and large bowel d iswrbances.
Large bowel in flammation, Crohn disease, chronic amoeb ia-
sis, wom1s and diverticulitis can all co nfuse tl1e clinical pic-
ture and complicate g)•naecological proced ures.
ARTERIOGRAPHY AND ARTERIAL EMBOLIZATION
The arterial supply of tlle uterus and appe ndages can be
demonstrated by aortogmph) or internal iliac arteriogra-
phy. ln modern-cia) practice, t11e use of ultraSonography,
computed tomograph) (Cr) scan, magnetic resonance
imaging (MRL) and Doppler blood flow swdies have mini-
mi£ed the need for arte•iograph). However,
can establish tl1e catLSe of heavy abnonna l uterine bleeding
not responding to tl1e conventional therapy, such as due
to an arteriovenous aneurysm, or \'3ricose veins. Selective
embolit.ation of tl1e same can result in cure.
 CHAPTER 40 - IMAGING MODALITI ES IN GYNAECOLOGY 51 1

Emboliation of th e antetior division of imemal iliac

anery has been successfully used in the u·eaunem of uncon-
trolled bleeding from the advanced cervical cancer, second-
ary haemorrhage after a hysterec tomy, cervical ectopic preg-
nru1C) ru1d for emboliatio n of uterine anery in menorrl1agia
ru1d in fi broids.

ULTRASONOGRAPHY {Figs 40.6-40.16)

This imaging moda lity was first pioneered by 1ru1 Donald
( 1974) in gynaecologyand obsteu·ics. Sonography is gener-
ally the first and often the only imaging modality used to
demonstrate pelvic anatomy and to document physiological
(ovulation monitoting) and patJ1ological changes. Ultra-
sound examination may be perfot·med by the u·ansalxlomi-
nal/transvaginal/tra nsrcctal o r u·ansperineal approach. T!te
vagiu11l fmJbe il comidere<L a natuml exteusion of bimamwl
examinat.ion with bPII.er tmd fJwcise fJel:uitjindinf:,l$.
AdvMtages of ultraso und are as follows:

• Noninvasive tec hnique.

• Soft tiss ue imaging possib le unlike X-rays.
• No ionizing rad iation, so it ca n be repeated.

Figure 40.8 (A) USG showing dermoid cyst of the ov;ry with hyper-
echoic area suggestive of cartilage. (B) USG showing a dermoid cyst
of the ovary with tuft of hair.

Rgure 40.6 USG showing a septate ovarian serous cystadenoma.

(Courtesy: Diwan Chand Satyapal Aggawal Imaging Researdi Center,
New Delli.)

Rgure 40.9 USG showing ovarian carcinoma. (Courtesy: !X. St.nesh

Figure 40.7 USG showing a multiloculated ovarian cyst. Kunar, AIIMS.)
512 SHAW'S TEXTBOOK OF GYNAECOLOGY

Figure 40.10 USG showing a bi cornuate uterus. (Courtesy: Dr Ashok

Khurana, New Deihl.)

Rgure 40.12 (A) Fibroid with endometrioma. (B) Left ovarian simple
cyst.

Figure 40.11 Ova-ian hyperstimuiation.

Standard exa minatio n of the female pelvis is performed

by transabdominal app roach er AS) and by th e transvagi·
na l route (TVS). TAS is perfo rmed with 3.5 MHz convex
u·ansd ucer with a full urinary wh ich provides an
aco ustic window as we ll as d isp laces the bowel loops away
from th e patJ1 of the ul trason ic beam. T he s u·uctures deep
and awa)' fi·om th e vag ina are better assessed by TAH
approach.
Transvaginal sonogram (TVS) performed with a high Figure 40.13 Uterine fibromyoma
frequency probe of 7.5 MHz which demonsu·ates beuer ana-
tomic details of tlle pelvic organs compared LO TAS. The
proximity witJ1 which the high-freque ncy TVS probe can be performed in virgins, or when TVS is refused by me woman.
placed on the pelvic contents produces vastly superior reso- l t is also difficult in a menopausal woman a nd in stenosed
lution. ln addition, demonsu-at.ion of local tendemess and vagina.
organ mobilit) ) ielcls information equiva lem to a gplaeco- LMti)) perineal ami mwl ultra.sou1uls are being employed in
logical examination (pain mapping). jaea1l inamtiuern:e amltuiU!II TVS i.s 1101 possible. They are also
The ulu-asonic scan should be initiated witll TAS and useful in stud) ing the peh·ic Ooor muscles and plan surgery
t11en followed up witJ1 ·rvs afler the woman empties her in genital p1·olapse. The ulu-asound ma)' reveal breaks in the
bladder. This also ghes the information of residual urine in Ooor muscles, and helps to detennine appropriate
investigation of urinary dysfunction. TVS should not be surgical approach in women witll prolapse.
 CHAPTER 40 - IMAGING M ODALITI ES IN GYNAECOLOGY 513

AdvrmllifJf'S ofTVS over TAS are as follows:

• Full bladder is not requi•·ed.

• Beuer resolution and imaging of pelvic organs.
• In obese women, sound wa\es are attenuated by subcuta-
neous fat, and TAS ghes a poor image.
• Sonog..aphy is the diagnostic modality of choice in pelvic
imaging to detennine and confirm the presence or
absence of pelvic pathoiOg), detennine the si£e, texwre
and comour of the lesion and to establish the oligin and
anatomic relationship of the lesion with other pelvic
structures. It also helps to determine t.he presence of ab-
sence of abnormalities associat.ed wit.h malignam diseases
such as ascit.es or metastasis. ILalso provides guidance to
the gynaecologist. in performing aspiration and biopsy
under sonograp hic control, and selec tive t.herape utic
p roced ures. Transvaginal sonograp h)' in infen.ilit)' prac-
Figure 40.14 Adenomyosis of the uterus Lice he lps in mo ni t.oring follicul ar mat.u rat.io n, oocyte
re u·ieval and emb ryo u·ansfe1:
Colo ur fl ow Dopple r s tudi es with spec t.rum are added to
the examin ati o n depe nd ing on the clinical sit.uatio n and
pat.hology de mo ns u·atccl o n a grey scale.

• 3D ul traso und accurately measures t he uterine and

ovarian volume and blood supply.

NORMAL ULTRASONIC FINDINGS

The mean dimensions of the lltentS of reproductive age are
7 on in length and 4 em in width in a nulliparous woman. It is
8.5 on in length and 5.5 on in width in a multiparous woman.
After menopause, reduction in the uterus occurs proportion-
ate to the duration of menopause. The location of the uten.JS
is LJSed as a road map in locating adnexal su·uctures.
Ovaries are oval shaped measuring 3.0 X 2.0 x l.O em
located laterally in the pelvis. Visualiation of the ovary
improves t.he det.ection of follicles wit.hin.
Figure 40.15 Ectopic pelvic kidney. Ovaries have a marked valiaLion in sue and shape,
so ovarian vo lu me is considered a more reprod ucible
parameter (S Campbell et al. 1982). Mean ovarian volume
in reprod uctive age is 9.5 :!: 5.0 mL
Mean ovarian vo lu me in peri menopausal age is 6.8-9 mL.
In posun enopallsal wo man, it d iminishes from 8 mL 1.0 2 mL
wit.h adva ncing age.
A do mina nt follicle t11at ovulates is 18-20 mm or mo re.
Co rpus lu teum is recogni:t.ed in the posLOvulawry phase
and a small hemo n·hagic cyst may be recogni zed . Corpus
lut.e um cyst. is occasionall y see n in wome n with ameno r-
rhoea but is abse nt in the postovulatory cycles.
Endomeu·ial cha nges: T hese vary according 1.0 m e differ-
em ph ases of t11e mensu·ual cycle.
ProlifnatitJ(' It is thin and st.arts growing up 1.0
6 mm before ovulation.
Secri10Y)' phase: The endomeuium thickness further grows
and may reach 10 mm in the late secr-etory endomeu·ium.
The glands ha,·e a cork-screw appearance and me vascular-
ity increases. In endometrial h) pe•·plasia, the endometrium
grows be)Ond 10 mm, shows irregular margins folds
Rgure 40.16 Downward displacement of Copper-T.
projecting in 1.0 the uterine cadt) as a sessile single or mul-
tiple polypi of same echogen iciL).
After menopause, the endometrium au·ophies and
shlinks 1.0 less t11an 4 mm. The endomeuial thickness of
514 SHAW'S TEXTBOOK OF GYNAECOLOGY
more than 4 mm, irrespective of poSUllenopausal bleeding,
is considered abnormal, and requires investigations. How-
ever. in a woman taking tamoxifene, this cut off value is
taken as 8 mm.
Subendometrial halo is demonstrat.ed in late prolifera-
tive phase and its infiltration b) endometrial tissue suggesLS
adenom)osis or cancer of the uterus.
DIAGNOSTIC INDICATIONS
• Suspected congenital anomalies ofthe ute1us.
• To diagnose haematocolpos, haemawmeu-a.
• To diagnose ectopic pregnancy. Absence ofinuaut.e1ine sac,
presence of adnexal mass with increased vascularity goes in
favour of ectopic pregnancy. Occasionall)\ free fluid may be
noted in Pouch of Douglas. On the other hand, in an intra-
uteriue pregumU.)'- the gestation sac is generally eccentric in
location. It grows at the ra te of 1.0 mm /day. In an ectopic
pregnancy, the pseudosac is ce nu-ally loca ted.
• To diagnose adnexa l mass.
• To diagnose uterine pathology - fibro ids, ade no myosis,
uterine S)' nec h iae.
• To monitor ovul ation.
• In abnorma l uterine bleeding- to SLUd)' the endometrial
pattel"l1.
• To study endome u·ial li n in g in posunenopausal bleeding
and its vascu lar pattern.
• To study ovarian pathology, i.e. polycystic ovarian disease
(PCOD ), ovarian cyst, ovarian wmour.
• Location of misplaced IUCD.
• lnfertilit) -to detect submucous polyp, fibroid.
• En dome trios is.
• Fine-needle aspi1-ation C) tology (F AC) in suspected
g) naecological malign an().
• Falloposcopy to study the medial end ofthe fallopian wbe.
• ln a male with low spenn coum to detect varicocele by
Doppler.
Details h a,•e been described in chapters II , 13, 14, 16
and 17 respectively.
INTERVENTIONAL ULTRASOUND
IN GYNAECOLOGY
• Oocyte re u·ieval in in vitro fertili zatio n ( IVF) programme.
• Drainage of chocolate C)'St/ sim ple benign cyst of th e ovary.
Laparoscopic sm gery is s uperio r to guided pro-
cedw·e, tho ugh more invasive.
• Dra in age of pe Ivic abscess.
• To break uterine synec hiae in Asherman S)•ndrome.
• Evac uation of mo lar pregnancy, and MT P under ultra-
SO tUl d guidance. This avo ids uterine perforation.
• Transcervical cann ulation and sperm injection into the
fallopian tube in infertility.
• Retrieval of embeclclecl IUC D
• Injection of methotrexate in to 1J1e ectopic gestational sac
in unruptured ectopic pregnancy. ow, i.m. u1.1ection is
preferred as it is noninvasive and equally effective.
Colour Doppler ultrasound is useful in suspected malig-
nant O\<arian tumour and endomeuial carcinoma. NeO\<aS-
cula•itation and decreased resistance index (<0.4) suggest
malignancy. Doppler ulu-asound is useful to diagnose a rare
case of arteriovenous malfonnation causing menorrhagia.
Reel colour indicates blood flow towards IJ1e u-ansducer, and
blue colotLr awa) from iL
INDICATION OF 30 / 40 ULTRASOUNDS: They pro-
vide multiple images used main I) to detect fetal anomalies.
In gynaecolog). these ulu-asounds are tLSed for effective
therapeutic procedures.
Some descriptions are mentioned below:
I. Congenital Miillerian anomalies (American Fen.ility Society
Classification S)Stem)
• Class I (agenesis, h)'poplasia). Uterus is absent in
total agenesis. Partial agenesis is identified as unico•·-
nuate uterus. In h ypoplasia, the endomeu·ial cavity
is small with reduced intercomual distance of less
than 2 em.
• Class ll (unicornuate uterus) appears banana-shaped
witl1o ut the rounded fund us a nd triangular-shaped
uterine cavity. If prese nt, rudime ntary ho rn presentS as
a soft tissue mass with simi lar myome u·ial ec hoge nicity.
Obsu·uction in tl1 e rud iment4t ry ho rn is recognized as
haematome u·a on one side.
• C lass Ill (uterus d ide lphys). The two ho rns a re widely
separated, with no vaginal sep utm.
• Class IV (bicornuate uLerus) shows two uterine cavi-
ties, wil11 concave fundus, with fundal cleft greater
IJ1an 1 em, and this differenliates between IJ1e bicornu-
ate and the septate uterus. The in tercornual distance
is more tlmn 4 em.
• Class V (septate utenLS) shows a convex or flatt.ened
fLmdus. The imercorn ual distance is nonnal ( <4 em)
and each caviL) is small.
• Class Vl (a rcuate uterLLS) with no fundal indemation is
of no clinical importance.
2. Uterine polyp. Endomeu·ial pol)p is sessile, single or
multiple, less than I em in si.te and homogenous with tl1e
surrounding endomeuium, as it is fonned by folding in
of endom etrial hyperplasia. Submucous fibroid on the
otl1er hand is larger than I em, sessile or oft.en peduncu-
lated, mobi le. It has a different texture compared to the
endometrium. Sonosalpingog•-aphy reveals a polyp, but
cannot differenti ate between submucous and endome-
trial polyp. TVS yields be tter image than TAS.
3. Endometrial cancer. Apart from endome u·ial thi ckness,
e ndo me ui al irregula tit)', in creased b lood fl ow b)' Dop-
p ler and di srupti o n o r abse nce of sube ndo me u·ial halo
suggests myometri al in vasion best seen o n TVS.
4. Uterine fibroids. It is not only importam to confirm
clinical diagnosis of uterine fibroid b ut also necessary to
assess the number, size a nd localio n to plan the manage-
ment and decide on tl1 e type of surgery req ui red. A rap id
increase in the size of the fibroid in a perimenopat.LSa l
woman suggests sarcomatous change in a fibroid
5. Ovaries. In ovaries with heteroge no tLS morphology,
several pal11o logical changes can be idemified by
ulu-aso u nd.
• FLmctional C)Sl. It is the most common finding
in the reproducti' e age group. A follicular C)SL may be
persistent at times, but never grows more than 5 em
and spontaneously •·esolves within a montl1
or so. A Graafian follicle startS growing soon after
 CHAPTER 40 - IMAGING MODALITIES IN GYNAECOLOGY 515

me nsu·ua tion , and grows by 1- 2 mm near ovulation,

reac hing about 20 mm in site o r little larger. Ovulation Ta ble 4 0.1 Role of Ultrasound In Gynaecology
is recogn ited b) iLS disappearance at ovulatio n and Diagnostic Therapeutic
the prese nce o f free fluid in the po uch of Douglas.
T his is followed b) growth o f co rpus lu te um. The cor- study - IVF - ova
pus lu teum qst has a thick, hypoecho ic, sometimes, thickness Drainage of pelvic
irregularity, polyp, haema- abscess
in·egular wall and has echoge nic co nte nt. Haemor-
toc:olpos, haematometra During falloposcopy
rhage in th e cyst reveals as low-level ime mal echoes. Uterus - f1broid, adenomy- Retrieval of IUCD
• Ovarian byperstimulation (OHSS) has been osis, misplaced IUCD, Injection of
desuibed in chapter 16. Asherman syndrome, ate, KCI in ectopic
• PCOD is charactet·ited by more than 12 small follicles, intermenstrual bleeding, pregnancy
2-9 mm in site placed periph erally giving a necklace postmenopausal bleeding, MTP under ultrasound
like appearan ce menorrhagia, uterine guidance
• Endomeu·iosis. UltraSound shows \-at·ied appearance abnormality, absent Evacuation of a molar
ranging from an aned1oic cyst, with low echoes ''1th or uterus pregnancy
witho ut solid componentS tO a solid-appearing mass, • Falloposcopy • Drainage of a simple
• Tubal ectopic pregnancy ovarian cyst
resembling dermoid cyst, beni gn neoplasm or a fibroid.
• Tuba-ovarian mass
6. Fallopian tubes (PID). Ultrasound shows o ne or more of • PID, ovary: PCOD, ovarian
the following fea tures: cyst, differentiate between
• Th icke ning of the wbe wa ll of more than 5 mm. benign and malignant
• 'Cogwheel' sign, de fined as cogwheel-shaped struc- ovarian tumour
tw·e vis ib le in cross-secti o n of th e wbe with thick ,,-ails • Ovarian follicle monitoring
in acute salpingitis. • Pelvic endometriosis
• Inco mp le te se pta witJl a d ilated tube, wh ich is sonolu- • Chronic pelvic pain
cen t o r co ntains low-leve l ec hoes. • Infertility
• Beaded a ppea rances measuri ng 2-3 mm seen in a fluid • Varicocele in male
distended su·ucture. Cukle-6<\c may show the presence
of free fluid in the pouch o f Douglas in acute infectio n.
• H)drosalpinx appears as a re to rt-shaped o r mbular
strucwre showing inco mplete septa and the ovary is
seen in the vicin it) of the lesion .
7. Infertility. Ultrasoun d has a role in the infertility
wo rk-up. lt is used for:
• Sonosalpingography whi ch d elineates L11e uterine
cavity and swdi es the patency o f the fallopian tube.
• Detecting unsuspected endomeu·iosis.
• LVF - To monitor ovul ati on, to reu·ieve O\-a and e m-
bf)O transfer under ul traSound guidance.
• ln a male, to detect varicocele.

To decrease the cost and invasiven ess of gamete inu-afal-

lopian ua nsfer technique (GirT), some employ transvagi-
nal ulu·aso und to rc u·ieve O\-a and transfer oocytes and
sperms into the fu llo pian tube by ulu·asound-guided cathe-
tetization u·anscervi call )'·
Some tim es, the abnormal findings on ultraso und are
inciden tal a nd have no bearing on a wo ma n's symptoms
and cli nical fealltres. It is im portant th erefo re, to correlate
these findings wi tJ1 cli nical features. T he ro le of ultrasound
is discussed in Table '10. 1.
Figure 40.17 CT scan showing dermoid cyst.

COMPUTED TOMOGRAPHY SCAN

ln gyn aeco logy. cr scan supple mentS info nnation obtained
on ul trasound examinatio n. The ach-an tage of cr is itS easy
avai lab ili t) and tJ1 e abili t) to survey tlle whole abdome n and
pelvis accumtel) a nd rapid I) in o ne sitting. CT is accuta te in
assessing local w mo ur im-asion and enables acctua te loca l-
i.tati on for biopS). C r ca n also d emonSU'ate Other masses
(Figs 10.17 a nd 10.18) and abnonna lities o f e xuagenitaJ
origin. Howe, er, both C r a nd ilie MRJ cann ot d etect small
pe ritoneal metastatic implan ts and lymph nodes in ma lig-
na ncies that are less tJ1 an I em in site.
Recentl) . .spiml CT has been in troduced into clinical
p ractice. Th is e nables con ti nuo us volume tric data acquisi-
tio n in a single breath-hold. This po te ntially o ffers
improved lesio n d etecti on, optimi tation of conuast media
enha ncement a nd mul tiplanar or 3D image infonnation.
516 SHAW'S TEXTBOOK OF GYNAECOLOGY
Rgure 40.18 CT scan showing right ovarian cyst filling the Pouch
of Douglas.
TECHNIQUE
&fore undertaking a CT PxcludP the possibility of
f>regnartC)'· The patient is requ ired to have a full bladder.
The patient is given 600--800 mL of a dilute oral contrast
medium about I hour before th e commencement of the
procedure. Just before starting, a vaginal tampon is
inserted to he lp delineate the position of the vaginal
vault and cen ix. a nd a rectal co ntraSt medium given. The
oral and rectal co ntrast media he lp to differentiate bowel
loops from other pehic o rgans. The patient is scanned in
a supine position. In g)llaecologic malignancies, inu·ave-
nous injection of iodinated conu·ast medium is recom-
mended to improve wmour delineation, characteriza-
tion, assess vascula.-ity and lymph node identification.
Advantages of Cr are as follows:
• It is useful in th e diagnosis ofintraabdominal abscess.
• It is useful to diagnose pelvic vein thromboph lebitis.
Rgure 40.19 (A) Mirror image of fibroid seen on MRI. (B) MRI showing fibroid uterus.
Disadvantages of CT are as follows:
• It is expensive.
• Radiation up to 2-10 cC> does not penn it iLS use in obstetrics.
• CT scan does not pick up I) mph nodes less than l.O em
in sue.
INDICATIONS
• Cancer of the cen·ix - to detect local spread, parameu·ial
infilteration and l)lnph nodes metastasis.
• Endometrial ca ncer- to detect m>omeu·ial im'asion and
lymph nodes metastasis.
• Ovarian cancer- to detect intrahepa ti c, omental involve-
ment and para-aor·ti c lymph node metastasis.
• Choriocarcinoma- to detect brain metastasis and metas-
tasis to oth er or·gans.
• In infertility- to detect hypcrprolactinaemia and amenor-
rhoea.
• To diagnose inu·aabclom inal abscess, pelvic vein thrombosis
MAGNETIC RESONANCE IMAGING
MRI is well-established cross-seCLional imaging modality.
It prov1des multiplanar imaging capability with high soft
tissue conu·ast resolution witho ut inte rference from air or
bone. There is no need for administration of oral contraSt
or for injection of intravenous dye for vascular contraSt.
MRI, LLnlike CT. has no adverse effecLS on pregnancy, em-
bryo, fetLLS or fuwre reproductive potential of the ovary as it
has no radiation effect. The major limitations are availability,
ume taken for procedure and cost It cannot be done in
women with prosthetic vahe and other prosthetic u-ansplant
INDICATIONS
• To assess pelvic anatomy in women with endomeu·iosis
and adenom)osis.
• To evaluate Mullerian anomalies.
• Localize the position and of the fibroids (Fig. 40.19A
and B) and sarcomatous change.
 CHAPTER 40 - IMAGING MODALITIES IN GYNAECOLOGY 517

Table 40.2 Indications of CT and MRI in Gynaecology

CT MRI
Diagnostic Endometrial cancer -
Endometrial cancer stag- myometrial invasion and
ing, lymph node assess- endocervical extension
ment, recurrence MOIIerian anomalies
Cancer cervix extension, Endometriosis
lymph node Involvement Fi broid , sarcoma
recurrence Cancer of the cervix -
Ovarian cancer staging , involvement of pa-ametria
lymph node involvement, and lymph nodes
recurrence Ovarian cancer
tumour In obstetrics - to detect
Hyperprolactlnaem ia fetal anomali es
Amenorrhoea THERAPEUTIC
Cerebral metastasis
• Abdominal abscess MRI-gulded procedures
• Pelv ic vein thrombosis In uterine fibrolds and
Contraindicated In pregnancy adenomyosis
due to radiation Figure 40.20 PET scan showing Increased FOG uptake in uterus,
bilateral kidneys and brain.

• Staging and assessment of pelvic neoplastic diseases such as
cancer cervix, e ndo me trial carcinoma and o ther cancers.
• Assess adnexal pathology, endomeu·iosis and chocolate cyst
• To assess depth o f myo meltial invasion and endocervical
extens io n in a case o f e ndome u·ial carcinoma.
• Staging o f cervical ca ncer and detec tio n of recurrence.
• Assess rec urre nt pelvic d isease and metastasis.
• ln o bsteu·ics, it can pick up fe tal anomalies.
• Detection of l)ln ph nodes metastasis.
• MRI-guided therapeutic procedures used in leio myomas
and ade nOm)OSis.
CONTRAINDICATIONS
• Pati ents with a pacema ker o r cochl ea r implant.
• Metallic foreign body in th e e) e.
• Paramagneti c anetu)sm clips.
• Overan xious patients need pri or sedation.
• Those who suffer from clausu·ophobia may not tOler·ate
the procedure well. However, newer open machines ru·e
now available whi ch overcome this disadvantage.
• Epileptic and wo me n with atria l fibrillation, because
electroco nvu lsio ns ca n occ ur.
indica ti ons of C l' and MRI are listed in Table 40.2
RADIONUCUDE IMAGING
This fo rm o f imaging in gynaeco logy is used for specific
clinical situations . Bone scans us ing tPc/mPtiwn-99 m diph os-
phonate are used to detect bone metastasis in patie nts witl1
maligna ncies. Ventilation fJeifusion swns are used fo r de tect-
ing pulmo nal') emboli. Radhrktbelled wltite cell scan s can be
used for locating abscesses.
DUAL-PHOTON DENSITOMETRY
suffer from earl)' me no pause or who undergo oophorec-
tom)'· The lu mba r spines and hip are scanned with a d ual-
pho to n de nsitomete r; which produces co mp ute rized graphs
and measureme nts of bo ne de nsity and rela tes the m to age-
re lated normal values.
Positron emission tomography (PEl) is a functional
diagnostic imagi ng tec hnique, ta kin g advan tage of t11e fact
t11 at mal ignant cells have a greate r glycolysis co mpared to
no nnal tissue. It helps in initial staging, management and
fo iiO\N rp of cancer growths (Fig. 10.20). PET-Cr combines
me meta bolic stattlS with the anatomical details o f the pa-
tie nt, respecti,·el).
[F-18)-fluoro-2 d eoxr-0-glucose (FOG) is used as a .-adio-
pha nnacological agen t whi ch is an analogue o f glucose.
Glucose uptake by ma lignant cells is higher than tl1at of
normal cells. PET maps the tissue spread. It also helps to
distinguish cell death following radi oilierapy from tumour
r·ecurrence, and helps in posur-eaunent management.
PET scru1 is a nuclear biological modality and functional
diagnostic image techn ology using ra dioactive material
given orall y, injected into the body or inhaled. It is now used
in t11e di agnosis of ca ncer in its ea rly s tage, detect its extent
and severity a nd a lso assess the pa ti ent's response to thera-
peutic ime rve nti o ns by Stttd)'ing the mo lecul ar ac ti vity in
the tissues . It is no ninvasive. scan measures the blood
flow to t.he organ, oxyge n consump ti on and glucose
metabolism, wh ich is high in the ca nce r cells.
Combining with CT, which provides anatOmical details
and PET showin g metabolic sta tus, it improves the acc uracy
of the tes ts.
' Ho t-spo ts ' ru·e de tected wh ere large amo unts of radio-
tracer have acc wnulated, and these spots are mapped in
planning tl1e rapy.
Preparation:
The womru1 should not eat food for a few hours iliis
caLLSes misinterpretation of th e test, but take plenty of oral flu·
icls. PET takes 30 minutes to perform, and Cf about 2 minutes.
PET is contraindicated in the following:

The use of this new imagi ng techni que is becoming increas- • Pregnancy and lactati on , because o f the use of radi ou acer.
ingly popular in d etermining the r·isk of osteoporosis in • Diabetes- one sh ould be careful , as tissue blood sugru· is
postmenopausal women. It is recommended in women who usually high .
518 SHAW'S TEXTBOOK Of GYNAECOLOGY
• An obese woman as she ma> not fit imo Lhe nan·ow
machine.
• All metals, i.e. hait·pi ns, jewellery and metal implanLS
should be removed.
Sensitivity of PET is 80%-90%. Currently PET scan is
used to detect rec urrences in wome n treated for cancer
cervix, endome u·ial cancer and ova ri an ca ncers. Some peo·
p ie are exploring useful ness of PET sca n in pre-opera tive
worku p of cases of carcino ma cervix, endometrial cancer
and other gen ital tract cancers.
KEY POINTS
• Se'eral newer imaging m<XIalities have come imo
'ogue for accurate assessment of the clinical prob-
lems, however, ultrasound remains the most com-
mo nl y used techni que.
• A plain radiograph in gynaecological prac ti ce involves
a posterio r anterior (PA) view of the chest as pan of tl1e
preoperative work up of patie nts undergoing surge ry.
X-my of the chest is requi red in suspected lun g metas-
tasis in cho riocarcit1o ma and other malignancies.
• A h)Sterosalp ingogram is perfo rmed to test tubal
paten C) in infertility, imraca' itat) uterine lesio n and
to demonstrate Mi:tllerian anomalies of the uterus.
• Ulu-asonography has now become Ll1e first line of imag-
ing imestigation in the management of ID naecological
problems because of iLS wide availability and low cosL It
is an excellem first-line investigation to determine Lhe
location and nature of th e pelvic pathoiOID'· Ulu-asouncl
is noninvasive and Ll1e report is available o n the spot.
• CT sca n and MRI are used as additi o nal wols to de-
fi ne L11e exte m of neop lasia and to dete nn ine spread
to adj acent su·uctures and '>'mp h nodes. These have a
great ro le to p lay in staging of genital cancers.
• A Doppler examination helps to determine the
pattem of blood flow in the organ, ide mil) an ectopic
pregnancy and detect suspicious malignant tumours.
• Sonosalpingography is indicated in suspected cases
of endomeu·ial polyp an d submucous fibroid.
• PET is the la test technology whi ch swdies the
metabo lic sta tus of the tumo w·, a nd whe n co mb ined
witl1 CT wh ich gives ana to mical details also.
SElf ·ASSESSMENT
I. What is the ro le of hysterosalpingography in Ll1e practice
of ID naecology?
2. Discuss Lhe impon.ance of ulu-asonography as an
imaging modali ty in obsteuic practice.
3. What is L11e role ofTAS and TVS in g)11aecological practi ce?
1. Wri te short notes o n (a) colo ur Doppler and (b) role of
CT and MRI sca ns in ID'naecology.
5. What is the ro le of dual-pho to n bone dcnsito me ll)' in
ID'naecological prac tice?
SUGGESTED READINGS
Guiddino for diagnostic Imaging during American
College of Ob>tetricians and Gp1ecologiscs Commiuee. Opinion
:Xo. 299, Sept 2004.
Kamel li S. Dan\'ish et al. Comparison of ultr.;sound
and :.onohp.terO),...-;tphy in the detection of endometrial polyp$. Acta
Obsttl Cynrrol Srand, 2000, 79 (I): 60.
Rosen CJ. Postmenopausal osteoporosis. N E11g j Mtd, 200!5; 363(6) :
59!>-GOG.
Repon on Ullm"ound Screening - Supplemcnc to Ullrasoun d
Screening for Fetal Abnorm alicies London. 1l1c Royal College of
Obscetricians and GynaecologistS Working Parc y. RCOG, !WOO.
E. Prevention and of O>tt'<>porosis. OB/ G\'N
6th Edition. 2006: 3 1.
 Endoscopy in Gynaecology
Laporoscopy 51 9 Key Points 531
Solpingoscopy and Folloscopy 530 Self-Assessment 531
Endoscopes are telescopes designed to view the interior of
body spaces or viscera. AlLho ugh attemptS at e ndoscopy
ela te back to over 100 )'CCII'S, th e po te ntial of this method as
a diagnosti c and therape uti c too l was apprec iated and came
to the forefront on ly in the past t11ree decades. When used
appropriate I)'• endoscopic surgery offers t11e advantages of a
more acc urate diagnosis, less invasiveness, red uced pain,
faster recovery and shortened hospital stay or a clay care.
Advances in instrumentation and techniques now enable
t11e endoscopist to accomplish several operative procedttres
hit11erto performed on I) b) open surgery, including cancer
surgery. Some of t11e advances are harmonic scalpel, suture
mate rials and laser.
Minimal invasive surge•) (MIS) implies avoiding an ab-
dominal scar, minimal handling of and abdominal
organs, less pain and thereby fast recove•)'·
Advantages of laparoscopy: (i) lesser pain, (ii) few anal-
gesics, (iii) sho•·t hospital stay, (iv) quick return to daily
work, (v) no scar- no scar site hernia, (vi) good cosmetic
and (vii) less pelvic adhesions.
Disadvantages of laparoscopy: (i) longer procedure lime,
(ii) more anaest11esia, (iii) expensi\e and (iv) expen.ise required
LAPAROSCOPY
Laparoscopy was deve loped in late 1970s, and operative
laparoscopy has started gaining ground in t11 e past two de-
cades. Advances in tec hno logy led LO the development of
high-resolution cameras, video laparoscopy, the develop-
ment of safe instrumentS permitting t11 e use of electrical
and laser energy and harmonic scalpel for cutting and cau-
te•izing tissues or ach ieving haemostasis.
LLS role in the management of infertili ty stands twdis-
puted, so also the benefi LS of laparoscopy over laparotomy
of being minimall) invasive and having a lower incidence of
adhesion fom1ation. Low incidence of infection render en-
doscop) to be an attractive alternative procedure in many
gynaecological diseases.
Despite t11ese advantages, t11ere are potential limitations.
For example, tlle exposw·e to tlle operative field may be re-
ducecl, manipulation of the pelvic ,-iscera often 1-esu·icted and
tissue apposition during suwring is as accw-ate. Moreover,
t11 e feel of tissues experienced b)' the surgeon durin g open
surgery lacks during endoscopic surgery.
The endoscopic sw·geon in t11e making has to go t11rough
supervised u-aining and acq uires the skills over a period of
Lime. There is a longer learning curve d Uiing wh ich t11e endos-
copist in u·aining tmderstancls t11e li mitations of t11e procedure
and knows when to stop. Thereafter, t11e incidence of compli-
cations dLUing endoscopy begins to decline and prog•-essively
more complex procedw·es can be successfully tmdertaken.
Laparoscope (Fig. 11.1 ). Laparoscope is a rigid telescope
varying in diameter between 4 and LO mm and it is 30 em
long, incorporating an optical S)'Stem as a means ofillwnina-
tion. The light is transmiued from an external source to
the distal lens b) means of fi breglass cables. L.iglu source of
300 W is usee) for illumination of abdominal ca,•ity. Photog-
raphy requires light source of 1000 W. Other insuumenLS
include Ve•·ess neeclle, u·ocar- cannula and accesso•·ies to
perform tllerapeutic procedUI-eS (Fig. 11.1 ). A long Veress
needle is a\'<lilable for obese women and for poste•ior colpo-
pneumoperitoneum. C0 2 pneumoperitoneum machine to
create pneumoperitoneum is specially designed for laparos-
copy. About 0.5-1 L/ minute is instilled into the pe•-iLOneal
cavity, maintaining intrape•itoneal pressure below 15 mm
Hg. About 1000 mL is required for adeq uate pneumope•ito-
neum (Fig. 11.2).
INDICATIONS FOR LAPAROSCOPY
T he laparoscope has eme rged as an in va luab le wo l in t11 e
armamentalium of tl1 e gynaecologist, both for diagnostic
and for therapeuti c uses (' Ill hie tJ I. I).
DIAGNOSTIC LAPAROSCOPY
The common indications for diagnostic laparoscopy are
described below (Figs IJ. :l 0- 11.7).
Infertility and Tubal Disease
Laparoscop) is indicated if h)Sterosalpingography reveals
abnormal or ambiguous findings. It can reveals block tubes
or ambiguous findings, salpingog•-aphy and presence of
endomeu·iosis. Chromopenubation using meth) lene blue
d)e is a pan of diagnostic laparoscop)' for infertility evalua-
tion to determine tubal patency.
519
520 SHAW'S TEXTBOOK OF GYNAECOLOGY

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Rgure 41.1 Laparoscope and oommonly used acoompanying inst ruments . (A) Laparoscope with angled eyepiece. (B) Laparoscope
- I

with paral lel eyepiece. (C) Biopsy forceps. (D) Semm forceps. (E) Scissors. (F) Large grasping forceps . (G) Suction manipulator and syring e.
(H) Palmer biopsy (unipolar) forceps. (I) Bipolar forceps.

Table 41.1 Indications of Laparoscopy

Diagnostic Therapeutic

Infertility - tubal patency ad · Pelvic adhesiolysis

hesions, pathology uterine Ablation of endometriosis
disease ovulation, PCOD PCOD - drilling
Ovary - PCOD, size, Ovarian cystectomy
volume, adhesions ovariotomy, surgery
PeMc endonletriosis Lymphadenectomy in
Chronic pelvic pain cancer cervix uterus, ovary
Ovarian malignancy, Myomectomy
nature of the tumour - Myelinolysis
benign, malignant, extent, GIFT in
staging of carcinoma, • Septate uterus
second-look surgery • Ectopic pregnancy
• Uterus - malformations, • Tuboplasty
Rgure 41.2 View of the pelvis with uterus anteverted from laparos-
absent uterus, septate, • LAVH
oopy. Right ovary t umed over with probe to expose right pelvic sidewall.
fibroid, adenomyosis, • Hysterectomy
FT, fallopian tube; POD, pouch of Douglas; US, uterosacral ligament. perforation during surgery • Removal of h ydrosalpinx
From Figure 1· 1, Robert W Slaw. David Luesley and Ash Monga: • Tubal - patency, PID, and pyosalpinx
Gynaeoology, Fourth Edition, ElseVIer, 2011 .)
ectopic pregnancy • Vault prolapse
• Pelvic tuberculosis • Stress urinary Incontinence
• Prior to tuboplasty to • LUNA (laparoscope
Occasionall)' a Fibro us band is recognized extending from
study the feasibility uterosacral nerve ablation
the right tube to the unde rsurface of the liver in pelvic inflam-
In dysmenorrhoea)
matOt")' disease (PLD ) caused by go nococcal and Otlam)'dil:t
infection. This goes by the name Fitz-Hugh-Curtis syndrome.
The relatio nship between the ovary and the ovarian fimbria
can be studied in infett.ility. The laparoscopy helps to choose Chronic Pelvic Pain
treatment between tuboplasty and in vitrO fertilization (fVF) . l n patients complaining o f chro nic pe lvic pain, no t re-
Salpingoscop) th ro ugh laparosco pe studies the ampullary sponding to usua l them peuLic measures, laparoscopy is in-
portion of the tube and exte nt of wbal damage. dicated. Ofte n unsuspected paLho logy is brought LO light
such as adhesio ns. C)Sts, chro nic PID, 1ubal h)drosalpin.x,
Endometriosis e ndo meuiosis. pelvic congesLion , window tears in. 1he broad
ln a bout 20% of pati entS wi th infet·tility, e ndomeu·iosis is ligaments a nd \'ad cosil) of th e pampinifo nn plexus of veins.
present without a ny S) mptoms. It remains wldetected until Even a negati,·e finding is ,·aluable to reassure a pati emthat
demonsu-a ted a tlaparoscopy. there is no peh·ic pathology.
 CHAPTER 4 1 - ENDOSCOPY IN GYNAECOLOGY 521

Gross appearance Gross appearance Laparoscopic view

Laparoscoplc view Laparoscopic view Laparoscopic view

Rgure 41.3 Gross and laparoscoplc appearance of genital tract abnormalities. (A) Septate vagina. (B) Two cervices with two vaginas.
(C) Bicornuate uterus. (D) Bicornuate uterus with rudimentary horn. (E) Rudimentary uterus (RKH syndrome). (F) Streak ovary.
0 Scan to play Diagnostic Laparoscopy

Figure 41 .4 (A-F) Laparoscopy in ovarian and parovarian pathology. (A) Dermoid cyst.
(B) Intact endometrioma (C) Draining of chocolate cyst. (D) PCOD - multiple follicles.
(E) Polycystic ovaries. bilateral enlargement in size - multiple follicles and thickened
tunica albuginea seen. (F) Fimbrlal cyst with fallopian tube stretched on its surface.
(G) Laparoscopic view of spillage of aye through fimbria! end . (Courtesy (G): Dr \Iivek
Marwah, New Delli.)
522 SHAW'S TEXTBOOK OF GYNAECOLOGY

Agile 41.5 Laparosoopy In uterine and tubal pathoklgy. (A) Diffusely enlarged uterus because of adenomyosis. (B) Anterior wall subserous
pedunculated fibromyoma of the uterus. (C) Multiple fibroids - uterus subserous and intramural. (D) Posterior lsthmical fibromyoma. (E) Tubal
pyosalpinx. (F) Bilateral tubal hydrosalpinx. (G) Tubo-ovarian mass. (H) Genital tuberculosis - tuberculous pyosalpinx. (I) Unruptured tubal
ectopic pregnancy.

Agile 41.6 Laparoscopy: miscellaneous. (A) Endometriosis: peritoneal implant. (B) Chronic PID: perihepatic adhesions. (C) Chronic PID:
pelvic adhesions. (D) Abdominal Koch's disease: peritoneal adhesions. (E) Genital Koch's disease: tubercles on the uterine serosa. (F) Genital
Koch's disease: beaded tuberculous fallopian tube.
 CHAPTER 4 1 - ENDOSCOPY IN GYNAECOLOGY 523

R gure 41.6, cont'd (G) Family planning: tube occlusion w ith bipolar cautery and cutting. (H) Family planning : tube occlusion with silastic band.
(I) Cystoscopy: ureteric orifice seen - probe in vesicovag inal fistula.

R gure 41.7 Laparoscoplc appearance of endometriosis - manifestations. (A) Superficial peritoneal flame -like patch. (B) Nodular uterosacral
endometriosis with adhesions. (C) Endometrlotlc patch on an terior surface of the uterus . (D) Endometri otlc nodule and powder burn marks in
ovarian fossa. (E) Superficial endometriosis on ovari an surface and ovarian fossa. (F) Endometrlotlc adhesions binding down the ovaries into
the pouch of Doug las, 'kissing ovaries'. (G) Chocolate material drained from smal l chocolate cyst. (H) Endometrlotlc adhesions on posterior
uterine surface and the ovaries. (I) Large chocolate cyst of the ovary (endometrioma), chocolate material drained.

'Co nscious pain mapping' he lps to ide nti fY the organ
whid1 causes pain.
Ovarian Disorders
Most reproducth e e ndocrine d isorders of the ova lies do no t
need a diagnoslic lapa•·oscop)'• ova•·ian surge ry or biopsy.
Ulu-asonography a nd blood hormo nal assays usually suffice
in a•·riving at a d iagnosis. However, in case of polycysti c
ovarian disease (PCOD), laparoscopy is useful to co nfirm
the diagn osis. and to funhe r investigate t11e patie m for
o ther causes of infert ili t). The operation of ovaria n drilling
is perfo rmed to impro' e the resul tS of ovulation inductio n
me .-ap)'· Ova lian C)Sl, exten t and spread of malignant
tumour can be assessed by laparoscop)'· Second-look surgery
is now re placed mostly by ulu-asound, MRJ and tissue
marke rs.
524 SHAW'S TEXTBOOK OF GYNAECOLOGY
Suspected Adnexal Masses
Ultrasonography, CTscan or MRI he lps in detecting adnexal
masses and establishing th eir site of origin. However, often it
is not possible to differemiate a pedunculated fibroid from
a solid oval'ian tumour, and laparoscopy may be necessary.
L.aparoscop) he Ips LO dis tin gu ish a pehic mass of uterine in
origin. common!) a fibrOm)oma from an ovarian mass. An
as)'InpLomatic fibroid rna) require observation, whereas an
ovarian solid mass needs prompt surgical removal.
Suspected Ectopic Pregnancy
ln a patiem with abdominal pain, irregular mensu·uation
and a positive pregnancy Lest, a laparoscope can detect an
ectopic p•·egnancy even before it has ruptured and enable
conse•vative su•-gery, thereby preserving her future repro-
ductive potential.
Pelvic Inflammatory Disease
ln PID, the diagnosis ca n be co nfirm ed on laparoscopy.
Peritoneal fluid or pus ca n be obta ined for culture, and
other causes such as acute appendi citis and pelvic tubercu-
losis considered in LJ1e d ifferentia l d iagnosis can be n1 led
out with ce1taiIlL)'·
Ovarian Malignancy
Ln advanced ovarian malignancy, a laparoscopy may be
useful in staging the disease and in obtaining a biopsy from
t11e affected tissue, wh id1 co nfirms the type of tumour and
helps the oncologist to select chemot11erapy or radiot11er-
apy as the alLemative t11 erap) in an inoperable case.
Ascites
ln ascites. laparoscop) helps to o btain ascitic fluid for cytOl-
ogy and biochemi cal analysis. It also helps to detennine the
cause of ascites as attributable to wmour, wberculosis or
hepatic cin-hosis. A biopsy from ilie wmour establishes t.he
diagnosis. Ultrasonic-guided aspirat.ion of fluid and biopsy
is however a simpler procedure as compared tO laparoscopy.
Tuberculosis
Genit.al wberculosis accounL.S for 5-10% of patiems witl1
unexplained infertility in our counu-y. The fallopian tube is
t11e most commonly affected site. Prese nce of tubercles on
t11e serosa, multiple constrictions, t11i ck rigid tubes, pres-
ence of violi n-string ad hesio ns and tobacco-pouch appear-
ance of the termina l parL.S of th e tubes should aro use s uspi-
cion. Presence of tubercles on the bowel se rosa or peritoneal
surface can be biopsied to arrive at the d iagnosis.
Uterine Abnormalities
L.aparoscop)' reveals uterine abnormalities:
• These include t11e Mt"llle rian anomalies such as absent
uterus as in cases of Rokitansky-KC•ster-Hauser (RKH )
syndrome, bicomuate uterus, septate or presence of a
rudimental") horn, testicular feminizing syndrome.
• L.aparoscop) can distinguish between a septate uterus
and a bicomuaLe uterus.
• An enlarged ute rus because of fibromyomas or adeno-
m)osis can be diagnosed.
• Adhesions to the uLeniS and iLS ret.rovened fixity can also
be diagnosed.
Uterine perforation during MTP/ D&C can be confirmed
or refuted laparoscopicall)', and decision made regarding
t11e need for laparoLOmy.
Inspection of the Pouch of Douglas
This can be inspected; often e ndomeuiosis is presem at iliis
site, so also adhesions Lo t11 e rectum present. This can be a
site of peh1c abscess and metastasis.
OPERATIVE LAPAROSCOPY
Minimally imoasi'e surgery is replacing comentional surge•)' as
ilie procedure of choice in selecth·e gynaecological surgeries.
General Indications
Pelvic Adhesions
These adhesions are often postinflammatery, posL.Surgical
or endometriotic in nature. Laparoscopic adhesiolysis re-
stores the ana tomy of pelvic organs a nd their mobili ty, and
relieves pain and discomfort arising o ut of b ind ing of the
organs by adh esio ns. Pe lvic endo metriosis ma y affect many
pelvic su·uctures such as t11 e ovaries, LUbes, uterosacral liga-
mentS, serosal surface of tJ1 e ute rus, pelvic peritOneum and
the pouch of Do uglas, as also tJ1 e rec tum , b ladder and ure-
ters. Adhesio l)'Sis is done by ablation with cautery, laser or
sw·gical excision of t11e lesions within tJ1 e li miL.S of safety and
relieves symptoms.
A.dhesiolysis is especially required in tubal infertili ty to
restore t11e patency and mobilit)' of the fallopian tubes and
iL.S fimbria.
Ovaries
The vru;ous MLS procedures o n ovaries are:
• PCOD: The medical hormonal therap) cures PCOO in
most women. Ln t11ose who fail to respo nd and in infertile
women, laparoscopic puncture of C)SL.S by caute•')' or laser
improves ilie response to hormonal ovulation stimula-
t.ion, avoids hyperstimulation syndrome and improves t.he
fertility rate to 60%-70%. However, because of possible
subsequent adhesion formation and t11ereb)' impaired
tubal fertility, women are advised tO try conception in t11e
first year of ovar-ian puncture. It is su·ongly recommended
that no more t11an four cystS sho uld be punctured in each
ovary. More puncwres may increase t11e ovarian adhe-
s ions and ovarian desu·uctio n leadin g to premature
menopause later.
• Ovalian cyst: A simple C)'St less tJ1an 5 em is usuall)' a func-
tional cyst. and it disappears in 3 mont11s' Lime and needs
only observation. A large benign cyst ca n be aspirated laparo-
scopicall)' and fluid sent for cytology. The cyst wal l is then
peeled off b)' aqua suction and tissuesem for histopathology.
• Chocolate cyst: The chocolate cyst is incised, the content
aspirated ru1d the cyst wa ll cauterized or peeled off
(Chapter 14). Pelvic endometriosis is also ablated.
• Gamete inuafaJiopian transfer (GIFT) technique in as-
sisted reproduction is perfonned laparoscopically b)' plac-
ing 2 ova ru1d 50.000 sperms at each ampullary portion in
an infertile woman "; th patent LUbes.
• Second-look surge•") laparoscopicall) is undermken follow-
ing p1ima•1' sw-ge•1 and a complete course of chemot.her-
apy for ova1ian cancer, befo•-e deciding wheilier furt11er
chemoilierap)' or excision of residual tumour is required.

Lately, however, LUmour marke rs are relied upon and this
procedure is avoided.
• Pelvic lpnphadenecto m> is now performed laparoscopi·
cally in earl> cancer cervix and followed by vaginal hys-
te rectom> or trachelectOm). This inflictS less surgical
morbidit) and allows quicker recovery, especially in an
obese woman.
Expen o ncologists a•·e now performing \\'en.heim's hys-
terectomy laparoscopically safel)• with equally good resultS.
Uterus
Operative procedu•·es on the uterus include myomectom)•,
laparoscopy-assisted vaginal hysterectom>' ( LAVH ), total lap-
aroscopic h ysterectomy (TLH), excision of a rudimentary
horn and We•·theim's radical abdominal hysterecwmy for
cancer ce•·vix.
• Myomec to my is indica ted planned for young women. Ide-
ally it is rewarding in cases with not more than four fi.
broids, p refe rab l)' s ubse rous, and of moderate size not
exceeding abo ut 5.0 em in size. After en uclea ting the
m>•omas from tJ1eir beds, tJ1e caviL)' is obli terated with in-
te •n•pted apposing e ndosutures to achieve haemostaSis
and preve nt ad hesion formation. Large fibro ids may be
removed by morcellation or tJ1ro ugh a small suprap ubic
incision. Small myomas can be removed piecemeal after
shredding ( myelolysis) or by tJ1e vaginal route through
tJ1e posterior colpotom> incision (Chapter 29) .
• LAVH and TLH are performed in women in need of a
h)'Sterectom> for benign conditions (myomas, adenomyo-
sis. menorrhagia and abnorma l ute rine bleeding) in
women with in situ cancer of tJ1e in whom there is
no d escem of tJ1 e uterus tO facilitate vaginal surge•)', and in
women o lder tJ1an 15 >ea•-s in whom concomitant removal
of the O\oaries is desirable. The purpose of LAVH is LO con-
venan abdominal h)'SterecLOmy to vaginal hysterectOmy or
a difficult ' oagi nal h)Sterectomy to an easy surgery. Realiz-
ing that LAVH ca•·ries a higher morbidity in terms of pro-
longed anaestJ1 esia and resui cted view, many lapru·osco-
pists now pe•·fonn vaginal hysterectOmy even on
undescended uterus and are able to remove botJ1 the ova-
ries from below as well. In T LH the entire procedure is
carried out laparoscopicall)' and at tJ1e end of procedure
uterus is delive red vaginally. T he vaginal vault is closed
laparoscopica ll y.
Other uterine surge ries done unde r laparoscopic guid-
ance are excision of ute rine septum and S)•nechiae in Asher-
man S)'ndrome . A rud ime ntary no ncomm unicating horn
may be the site of a haematome u·a, ec topic pregnancy or
to •sion. Laparoscopic re mova l is feasib le in s uch cases.
Laparoscopic Radical Hysteredomy
Oncologists now perform We rtJ1 eim's hysterectomy lapru·o-
scopicall) (radical abdo minal hyste rectomy and bilateral
extrape•·itoneal dissection a nd excisio n of tJ1e iliac atld pel-
vic I) mph nodes for ca ncer of the ce rvix).
Fallopian Tube
The most comm on ope ration perfonned on the tube is ster-
ililatio n for family planning. The tubal occlusion is achieved
through occlttsion "itJ1 ' Falope rings' or ' Filshie clips'.
CHAPTER 4 I - ENDOSCOPY IN GYNAECOLOGY 525
Edopic Pregnancy
An early unruptured ec topic pregna ncy can be treated ef-
fectively laparoscopically. The surgeo n may attempt milking
out the gestationa l sac, particularly so if it is close to tJ1e
fimbria! end. An ampullar> ectopic pregnancy can be
treated b) linear salpingostOm) and enucleating the tubal
gestational sac. An earl> unrupwred ectopic pregnancy catl
be treated b) local injection of metJ1otrexate into tJ1e gesta-
tional sac. All these procedLU·es are conse rvative measures
aimed at preserving tJ1e woman ·s reproductive potential.
H) drosalpinx of the tube can be treated by lateral salpin-
gostomy and fimbli oplasty with eversion of the inverted
fimbl'iae by fashioning a cuff. In blocked LUbes, segmental
resection and anastomosis h as been successfully performed
lapa•·oscopicall y. Hyd•·osalpinx is also removed prior to fVF
to improve th e pregnancy l'l\te (Ch apter 16).
OTHER INDICATIONS
Amongst the othe r opera tive proced ures accomplis hed lap-
aroscopicall y, tJ1ose given in tJ1 e s ubseq ue nt text deserve to
be noted.
Genital Prolapse
Conservative procedures for seco nd-degree uterine pro-
lapse such as abdo m inoce rvicopex>' and uterine sling ope ra-
Lion have been successfully performed laparoscop ically.
Vaginal vault prolapse is correc ted by sao·opexy.
Stress Urinary Incontinence
The operation of colposuspe nsio n has been successfully
performed laparoscopicall). Both the Marshall-Marchetti-
Kranu procedure a nd the Burd1 operation can be under-
taken laparoscopicall).
Pelvic Floor Repair
This has been perfonned laparoscopically to restore tJ1e
at1atomy of the peh•ic floor (lapa roscopic colposacropexy).
Dysmenorrhoea
Laparoscopic ULerosacral nerve ablati on ( LUNA) aims at
cautel')' and cutting of botJ1 tJ1 c uterosacral ligaments close LO
their uteline auachme nt. The uterine pain-carrying nerve fi.
bres travel along tJ1e uterosacral ligaments to reach tJ1e pelvic
auto nomi c ganglia. Di visio n of tJ1ese liga mentS interrupts the
pain pathway and provides relief. However, tJ1e re is risk of
damaging tJ1e ure ters, and in d ue course of time, tJ1 e nerves
regenerate, so tJ1at dysm eno n·hoea ofte n re turns. T he presa-
cral nerve lies in front of tJ1e sac ral promomory. Exposing the
nerve b uncU es laparoscopicall y and d ivid ing the same is pos-
sible. Howeve•; witJ1 tJ1e availab ilit)' of efficie nt analgesic
drugs, tJ1e 1-e is seldom an)' need to have •-ecotu se to such
drastic surgical proced u1-es except in endome u·iosis.
Others
Procedures such as repair of he rniae, a ppendicectomy and
pelvic lpnph node biopsies are being performed laparo-
scopically.
TECHNIQUE OF LAPAROSCOPY
Lapat'Oscopy has become a safe MIS; tJ1erefore, it is employed
more liberally than before, both for diagnoStic and for cen.ain
therapeutic procedures. Howe,er, bearing in mind tJ1at a l'al'e
526 SHAW'S TEXTBOOK OF GYNAECOLOGY
but a serious complication may develop d t.u·ing therapeutic
procedures such as myomectomy, hysterectomy and ablation
of endometriosis, certain preoperative preparations are re-
qt.Lired These are:
• It is desirable to sh 1ink a huge fibroid to reduce
bleeding and make it easier to perform m)omectomy. This
is done b) gonadou·opin-releasing honnone (GnRH) in-
jection administered monthly for 3 months (Chapter I3).
• Bowel preparation and intestinal antibiotics (metrogyl)
are safe precautions in case bowel injury occurs.
• Bladder should remain empty throughout the procedure
using a catheter.
• Systemic antibiotics should be staned a day before surge•y
• Signawre for open should be obtained in the
case of complication or inabili ty to complete the proce-
d ure laparoscopicall y.
PROCEDURE
• Whereas d iagnosti c proced ure may be ca n·ied o ut under
sedati on and local anaesthesia, the therape utic procedure
always requi res general anaesthesia because of prolonged
ti me taken and intra-abdom ina l ma ni pulatio ns required.
• Position: The patient is placed in sem ilithoto my and
slight Trendelenburg position.
• Pneumoperitoneum is created with a Veress need le using
carbon dioxide (CO!) gas through a small infrawnb ilical
incision. Air and niu·ous oxide (N 20) should not be em-
ployed, because oftJte risk of air embolism in tJte former and
combustion witJ1 lO if electrocautery is used. llte proper
pneumopetitoneLUn is confirmed by noting the t.mifonn
distension of tJ1e abdomen and Palmer test, which consistS of
i11iecting 5 rnL of saline tJwough Veress neeclle. Failure to
aspirate saline indicates proper placememoftJte nee<Ue.
Continuous Aow of C02 is maimaine<l at the rate of
100 m L/ minuteand pressure at15-25 mm Hg. Trocar and
laparoscope inse•·tion follow, through the same skin inci-
sion. Under fibre optic illumination, the pelvic organs are
inspected, and feasibility of the procedure under consider-
ation confirmed.
• Bipolar cautery is safer tJtan mo nopolar cautery as it does
not spread the burn to tJtc surround ing suuctu res. Laser is
even safer and does not form postOperati ve ad hesions, but
is expensive. La te!)', hannon ic scalpel is available and,
tJto ugh ve ry expensive, is very safe and cuts tJ1e tissues well.
Add itional portals and instrumen ts are used in tllerape u-
tic procedures. Suction and irrigation are also p rovided to
n
clear tJte b lood and uid from tJte abdom ina l cavity.
At tJ1e end of tJ1e proced ure, after making sure haemo-
stasis is secured and no gut injury has occurred, gas is ex-
pelled from tJ1e pe1itoneal cavity and t.he skin cutS sutured.
During the procedure, tJte ut.erus is manipulated in dif-
ferem directions b) tLSing uterine manipulatOr inserted
transcervicall) before tJ1e start of the surgery.
COMPUCATIONS
Complications (0.5%-1 %) are observed in minor proce-
dures, bUL the incidence as high as 5%-15% is repon.ed witJ1
major procedures. Death is reported in 0.08/ 10,000 of cases.
Major complications are as follows:
• Cardiopulmonary an·est and gas embolism
• Acidosis. arrh)tltmia and cardiac arrest caused becat.LSe
of C02
• Haemon·hage
• Caute•') burns to \'al'iotLS viscera
• Sepsis
• Injury to tJ1e bowel, small intestine, blood vessels, bladder
and ureter with the sharp instrumentS and bum i•'\iuries
• Failure to complete the procedure
Cardiopulmonary arrest is an anaesthetic complication.
Embolism occurs witJ1 the use of air, but excess C02 and ac-
cidental insei'Lion of Veress needle imo a blood vessel can
also cause embolism. T his mishap is avoidable if pneumo-
peritoneum is checked by Palmer test.
Haemorrhage
Inju ry 10 tJte epigastric vesse l occ urs cl u1in g inse rtio n of the
Veress needle and u·oc<u: to the aorta, inferior ve na
cava, iliac vesse ls and mese nteric vesse ls mainl y occ urs witJ1
a s harp insu·um enL such as a t.rocar. Prolonged s urge ry du r-
ing m)•omec tom)' can also cause loss of b lood.
Careful insertion of the t.rocar can avo id tJte i•'\i ury. Un-
comrolled haemo11·hage req uires laparoLOmy.
Cautery Burns
Accidemal burn tO the surrounding struc LUres occurs with
unipolar caULef) and sometimes with laser. The injury may
go t.mnoticed during surge!') and may not manifest clini-
cally as peritonitis for 24 hours or even more. The ab-
dominal distension and vomiting are then the first indica-
tions of gut inju11 and peritonitis. The bowel i•'\iury
requires laparotomy, resection of the bowel and end-to-
end anastomosis.
Sepsis is avoided by preoperative antibiotics and aseptic
precaution.
Traumatic uyury to the viscera and ureter occurs with
sharp insu·umenrs (bladder, ureter and intestines) or burn.
OTHER COMPLICATIONS
T he other complications include surgical emph ysema and
haemaLO ma.
• Postoperati ve peritoneal ad hesio ns occ ur less co mmo nly
with laparoscopy t11an with lapa ro to my, because t.he vis-
cera are not handl ed and a re not exposed LO air d•)•ness
as in open surgery.
• Hernia at tJ1e site of portals witJ1 omental p rot.rusion
rare!)' occ urs. The uterine perforation witJ1 tJte uterine
manip ulator does not normally req ui re laparotomy. Met-
astatic cancer has been reported at. the port site.
• Emergency therapeutic procedures which are done
laparoscopically for torsion and haemorrhage of ovar-
ian cyst or rupture of endomet.rioma carry greater l'isk
than planned surgeq since preoperative preparation
may not be adequate.
• Failed procedure: Because of adhesions, extensive pelvic
lesions or unconu·olle<l haemonitage, laparoscopic proce-
dure needs to be abandoned and convened to laparot-
omy. The prior consent to this effect a'oids medicolegal
problems.

CONTRAINDICATIONS TO lAPAROSCOPY
• Extreme obesity makes laparoscopic procedure and pneu-
moperitoneum difficult if not impossible. Alternatively,
pneumoperitoneum can be created through posterior
culdoce me sis.
• Cardiac and respirat0 11 diseases contraindicate Trende-
lenburg position and C02 pneumoperiwnewn.
• Diaphragmatic h emia precludes Trendelenburg position.
• Umbilical hemia. The trocar can i•1iure the bowel if the
latter is adherent to the hernial sac.
• Previous abdominal scar also exposes the bowel to injury
during trocar inse rti on.
• Acute pelvic infection can spread during laparoscopy.
• A large uterus (puerpe•-al) and an abdom inal tumour can
be injured by the sha•·p instrument.
ADVANTAGES OF LAPAROSCOPY OVER
LAPAROTOMY
• Avoiclance of abdo mina l sca r, wo und sepsis and scar hernia
• Reduced pain and q ui ck. recove ry
• Short hospital stay
• Less peritoneal ad hesions postoperative!)'
LATELY, robotic surgery is gaining pop ularity.
HYSTEROSCOPY (Fig. 41.8}
Hysteroscopy, which started first in 1869 with Pamaleoni as
a means of inspecting the ute rine cavity, is tOday function-
ing as an exte nded g)naecological annamemarium in vari-
ous therapeutic procedures. Despite the initial poor light
sotu·ce and nonavailabilit) of distending media, hysteros-
cop)' was not abandoned, and itS improvemem developed
into an important MIS and has led to a resurgence of inter-
est worldwide in recent )ears.
Figure 41.8 Hysterosooplc view of the patent corrual end. (Cotrlesy:
IJ Viwk Mawah, New Delhi.)
CHAPTER 41 - ENDOSCOPY IN GYNAECOLOGY 527
Hysteroscope
Hysteroscope comprises a rigid 4-mm telescope with Hopkins
rod lens optical system having a wide viewing angle and
fibre optic illumination cable. C1mera and television system
enables video stud) and therapeutic procedures. The sheath
is of 5 mrn diameter, in tJ1 e centre of which the telescope is
fitted. The uterin e caviL) is distended with C02 at the rate of
70 mL/ minute and pressure less tJ1an 100 mm Hg, or wiili
saline, dexu·ose, Hysk.on o•· gl)cine 1.5%. The scope is cov-
ered by inner sheatJt for inflow of distending mediwn, and
outer sheaili for itS outflow.
Types of Hysteroscopes
• Microhysteroscope provides magnification of30-150 times.
• Contact hyste•·oscope is a diagnostic tool witJ10ut distend-
ing medium.
Flexible hysteroscopy can be directed to all partS of me
uterine cavity and ex tensive inspection is possible.
TECHNIQUE
Hys teroscop)' s ho u ld be performed in the f>rlltrrl'ulatory
phase when the endometrium thin and bleeding is less likely
to occur. ln transce rvica l resection of endometriu m
(TCR£), shrinkage of endometrium is ac hi eved with pro-
gestOgen , danazo l or Gn RH given contin uo usly for
6-8 weeks prior to surge ry. Diagnostic hysteroscopy can
be performed und e r local (paracervical) anaestJtesia
and sedation, but the therapeutic procedures mandate
general anaesthesia (Fig. 11 .9 0 ). The ce rvical dilation is
not alwa)S required.
ln a postmenopattSal woman, ce rvical or misoproswl
vaginal tablet (prostaglandin E1) will soften the and
dilatati on '' ith the meta l dilator made atraumatic as
and when required.
The woman is placed in lithotom y position, and bi-
manual examination confirms the position and size of
the uterus and also rules out adn exal mass. The ce•·vix is
dilated up to 4-5 mm. The h ysteroscope is connected to
the source of distending media. tJ1e distension me-
dium distends th e cervi cal ca na l and uterine cavity, the
telescope is progressively advanced into the uterine cav-
ity under direct vision. This preca uti o n avoids perfora-
tion. T he endocervical and uterine lining are studied,
and bo th uterine os ti a identified. Gas inflating machine
used in laparoscopy s ho uld not be e mp loyed in hysteros-
copy, s ince hi gh p ressure of the former can cause gas
embolism.
The h)•Steroscope is provided with a cervical adaptor
which fits sn ugl)' on to tJ1e cen•ix and preventS back.flow of
the uterine-distended medium.
Distending Media
C02 obscures tJ1e vision in the presence of blood and can-
not be employed in the presence of bleeding. Its use is
therefore limited o n I) to diagnostic hysteroscopy.
Five per cent glucose is cheap, and is miscible with
blood.
Hysk.on and gl)ci ne a re used moSLI)' nowadays. Hysk.on
(32% dextrose) coalesces with blood into globules while tJ1e
medium remains clear.
528 SHAW'S TEXTBOOK OF GYNAECOLOGY

Rgure 41.9 Diagnostic hysteroscopy. (A) Panoramic view of uterine cavity. (B) Normal view of left tlbal ostium. (C) Appea-ance of uterine wall in
adenomyosis. (D) Endometrial polyp. (E) Submucous libromyomatous polyp in uterine cavity. (F) IUCD-Cu-Tin uterine cavity. (G) MUllerian anomaly,
intrauterine septum. (H) Polyp protruding into the endocervical canal. (I) Polyp restricted to endocervix.
0 Scan to play Diagnostic Hysteroscopy

NORMAL APPEARANCE OF ENDOMETRIUM is septate or bicomuate, enables the assessment of the

The appearance of endometrium cha nges with the phase of
t11e menstrual cycle. During follicular phase, tl1e endome-
trium looks tl1in and pale with a smooth surface and mini-
mal vascularization; tJ1 c glands are not easil y seen. At ov ula-
ti on, the e ndom etrium appears oedemawus, and the glands
are seen. In tJ1e luteal phase, the increased vascularity
causes oedema, and endometrium looks p ink with glands
seen. Posunenopausal endome trium is tJ1in, pale in colo ur.
The glands are hard ly seen even with higher magn ification.
DIAGNOSTIC INDICATIONS
1. The study of endocervical mucosal lining: Panoramic or
contact hysteroscope allows inspeCLion of endocervical
epitl1elium in dysplasia and carcinoma in situ ofthe cer-
vix. to trace t11e neoplastic process into endocervix and
map tl1e extent of neoplasm. A biopsy can be taken from
tlle suspicious areas. Endocervical polyp can also be
idenl.ified and removed. Staging of cance•· of tlle cervix
and endomeu·ium is done by endocen·ical biopsy.
2. Congenital malfor mation of tlle uterus: Hysteroscopy
combined witl1 laparoscop)' confirms whetller t11e uterus
capacity of each horn and also studies tl1e depth and
thickness of tl1e septum in planning corrective surgery.
The presence of t11e fundus seen laparoscopically indi-
cates that it is a septate uterus. In a bicornuate uterus,
the fundus is absenL
3. Endometrial tuberculosis: The presence of caseo us areas,
ul cers or w bercles on the e ndomeu·ial li ning suggests
tuberc ulosis. Selec tive biopsies are required LO confirm
the diagnosis or cure uage done.
4. Asherman syndrome: HysterosCOP)' confirms uterine
S)•nechiae, and type (ni rTIS)' o r fibro us) and extent of
adhesions.
5. Misplaced IUCD: Although ultraso und can locate a mis-
placed IUCD, hysteroscope determines whether it is
embedded in tl1e endometrium and allows itS safe re-
trieval under direct view.
6. Endometrial lesions and AUB: Endometrial and placen-
tal pol) p. submucous fibroid pol) p, endometrial hyper-
plasia and carcinoma can be idenl.ified by h)Steroscopy.
Selective biopS)' and downward extension of endome-
trial cancer can be assessed and staging done. In a sus-
pected case of cancer, it may be prudent tO perform

contact hysteroscopy which avo ids the risk of peritonea l
spillage of cancer cells when distended medi um is used.
Negative findings for cancer can be very assuring to the
woman.
7. Polyp: Endometrial pol)p ma) be single or multiple, less
than I em in siLe, and its appearance is identical tO the
stm·ounding endomeu·ium. It is tt.sually sessile and im-
mobile, and is caused b) folcls of endometrium in hyper-
plasia. Therefore, the pol) p disappears during follicular
phase. On the contrary, a mucus pol)p is often bigger
than I em, sessile or pedunculated, mobile and penna-
nent. A fibroid polyp is a finn, pennanent and of various
sues, paler than a mucus polyp.
8. Cornual tubal blockage: 'vVhen hysterosalpingography
shows blockage of the come at end of the tube, hystero-
scope enables the falloscope to be insened into th e cor-
n ual end and study its patency a nd mucosa. T he decision
regarding the feasibili ty of tubal surge ry ca n then be
taken. Cann ul ati o n and ad hesiolysis are also possible.
THERAPEUTIC INDICATIONS
In th erape utic procedures, cervical dilatio n up to no. 10 may
be requi red to insert iJ1e opem tin g cha nnel, and because of
prolonged surge r)', general anaesiJ1esia is necessary.
INDICATIONS
• Uterin e septum (Fig. I I. I0) is cut with scissors, ca uter)',
laser or resectoscope. It is not necessary tO excise the
entire septum, as the fibrous tissue retracts and shrinks
after cutting. Bleeding is minimal. Done under laparo-
scopic guidance, uterine perforation can be avoided.
Sevent) per cent pregnane) rate is observed following
operation.
• Asherman syndrome: The adhesiolysis under laparoscopic
view pr-e,•ents uter·ine perforation. lnsen.ion of I!JCD for
3 months and oestrogen iJ1erapy prevent reformation of
adhesions and helps to build up the endomeu·ium. Lately,
many omit the insertion of IUCD. ResectoSCope, scissor,
laser or cautery is used to break up adhesions.
• Embedded IUCD can be retrieved hysteroscopically.
• Pol)pectomy: The polyp can be grasped and twisted off
with the grasping forceps. If the pedicle is broad, it can
be abla ted by cautery and polyp rem oved.
• Submucous fibroid: T)•pe 0 fib roid (ped unculated) and
type I fibroid with 50% in tramural locatio n ca n be mo r-cel-
lated or desu·o>•ecl b)' coagulati o n . T he leftover myome-
u·ia l po rti o n of the fibro id ca n be re moved in the second
stage when it protrudes further into the uterin e cavity.
Infec tion and b leeding are iJ1e risks of iJ1 is operatio n.
Flgure 41 .10 Hysterosex>pic excision of uterine septum.
CHAPTER 4 1 - ENDOSCOPY IN GYN AECOLOGY 529
• AUB is now u·eated by TCRE in premenopausal women
and hysterectomy is avoided. Prior to TC RE, malignancy
and hyperplasia should be excluded. The endometriLUn
is resected or ablated with cautery, laser or roller-ball co-
agulation. SLXt) per cent of women become amenor-
rhoeic and 20% develop oligomenorrhoea at the end of
I year. Recurrence of menorrhagia by the end of 3 years
in 25% of women requires eiiJ1er repeat TCRE or hyster-
ectomy. The details of TCRE and other ablative proce-
dures are gi,•en in the chapter on AUB. Par·tial TCRE is
done to procure oligornenorrhoea. Lately, because of
availability of t-Il RENA, T CRE has become less popular.
• New techniq ue o f tubal sterilization using sclerosing
agents, caULerr or intratubal plugs is not universally ac-
cepted and not legaliLed in India, because of high fail ure
rate, irreversibi lity of the procedures and compli catio ns.
• T ubal blockage: Tubal cannulatio n and breaking up of
fl imsy ad hesions of the cornual e nd, removal of polyp
and balloonoplasty are possible thro ugh hysteroscope.
• In IVF progra mme, it is now ro utin e to perfo rm d iagnos-
tic hyste roscope to stud)' the e ndo metriu m prio r to fVF.
• lntrafall opian inse rni na Li o n in infe rti lity is prac ticed b)'
a few.
• Indica tions of h)'Steroscopy are explained in Tab le 4 1.2.
CONTRAINDICATIONS
Conu·aindications to therapeutic hysteroscopy are as fo llows:
• Genital tract infection present.
• Pregnane)
• Dming menstnaation, as view is obscured and infection
rate increases.
• Scan·ed uterus and enlarged utent.s more than 12 weeks'
siLe fonn relati'e conu-ainclications.
• Cenical stenosis can calt.se cen·ical tear and uter·ine per-
foration.
• Cardiopulmonary disorders: These include anaesthesia
risks, fluid over blood and pulmonary oedema.
DISTENSION MEDIA IN HYSTEROSCOPY
Several distension media arc in current usage for hysteros-
copy. T he choice of medium depends o n iLS ava ilabil ity,
safety, effec ti veness and cost as well as whethe r cautery and
laser are to be used . T he media in comm o n usage include
Table 41.2 lndlcati ons of Hysteroscopy
Diagnostic Therapeutic
• En docervical study In • Endometrial polypectomy
suspected endocervical Submuoous fibroid
malignancy, preinvasive Septate uterus
cancer and biopsy Asherman syndrome
uterus - malformations, Removal of IUCD
endometrial TB, Asherman Tubal sterilization
syndrome, misplaced Balloonoplasty
IUCO, menorrhagia, IVF intrafallopian insemi·
intermenstrual bleeding, nat ion
submucous fibroid, polyp
Falloposcopy
530 SHAW'S TEXTBOOK OF GYNAECOLOGY
carbon dioxide gas de livered through the Hysteroflator at a
maximum rate of 70 mL/ minute and pressure less than
100 mm Hg. This gives a clear panoramic view of the
imerior of the uterine caviL), but flattens soft pedunculated
poi>'P against the uterine lining as against those seen as
floating objects when liquid media are used
The popular liquid media used in practice indude
no•mal saline, 5% dextrose and Ringer's laCLate solutions.
To provide adequate uterine distension, the inu-auterine
pressure needs to be 10-50 mm Hg. More sophisticated
pressure S)'Stems are a'<ailable for use dlll·ing prolonged
hysteroscopic ope1-ative procedures such as myomeCLomy,
septum cuuing or endometrial ablation where continuous
flow of fluid is essential. In the above-mentioned proce-
dures, the use of electrocautery is necessary. In such cases,
l11e distension medium must be n onionic (not normal
saline) to prevent the of elecuical e nergy; also, the medium
sho uld not get admixed with blood as lltis wo ul d in terfere
with proper visuali:tati on of llte o ngoing opera ti ve p roce-
du re. T he distending media in commo n use are Hyskon and
glycine. Hyskon 1.5% is ve r)' thi ck and sticky; he nce, imme-
dia te ly after the operation, the hyste roscope and itS sheath
mus t be thorough!)' cleaned and llte sheath scrup ulo usly
brushed of all u·aces of the med iu m. Dela)' may lead to j am-
ming of th e instrument. Hysko n is a concentrated dextt·an
solu tion (32% dexu·ose). not miscib le with b lood and with
good optical qualities. It can cause anaphylactic reaction
and infection. Glycine is absorbed from the uterine cavity
and peritoneum. Excess gi)Cine can lead to problems of
fluid overload and eleCLrOI) te disturbances. Hence, it can-
not be overemphasiLed that strict monitOring of the amoum
of gl) cine used, its input and output must be acclll'ately
docLtmented. Also, a record of l11e elecu·olyte readings
before commencement of surger)' and at the end of the
same must be documented as safet)' precautions.
CONTACT HYSTEROSCOPY
This 4-mm contact h)Steroscope (Hamou t)'Pe) can be in-
serted into l11e utel'ine cavity "1thout prior dilatation. On
light contact wil11 l11e endometrial surface, and S)'Stematic
examination of all llte uterine walls and l11e fun dus, it en-
ables assessment of llte normali ty of l11e endomeuial tissue
li ning, and helps to diagnose any early neoplasti c cha nge.
COMPUCATIONS OF HYSTEROSCOPY
T he fo llowing complicati o ns are repo n ed d u1in g hystero-
scopic surgery:
• Anaesthesia complication, more wiLh C02 used as a d is-
tending medium. Cas embolism can occ uc
• Uterine perforation occurs in I %- 10% of cases, mostly
during insertion of the hysteroscope thro ugh tlte cervix
and du1ing operative procedures. This can be avoided b)'
introducing the telescope under direct vision and per-
fonning surger) under laparoscopic guidance. Perfora-
tion is SLLSpected when the distending medium escapes
into the peritoneal caviL) and uterine walls collapse with
poor ,;sion and fall in the inu-aute•·ine pressure. The
perforation is managed by obser,<ation, laparoscopic co-
agulation of llte bleeder or laparotomy.
• Organ injury to the bowel and intesline is rare.
• Themtal injury to the bowel occurs with ca utery and
laser. The injury is not diagnosed at the time of surgery
Llllless perforation also occurs. Delayed diagnosis in-
creases the morbidit). Bipolar cautery is safe from this
point of view.
• Bleeding occurs in I o/o-2% of cases. Bleeding can be
minimiLed b) perfonning the surger) in the preovulatOI)'
phase and l11inning the endomeu·ium by honnones prior
to TCRE. The bleeding nonnall)' occurs as the medium is
released and inu-autel"ine pressure drops. It can be con-
trolled b)' inse•·ting the Foley catheter, distending its bal-
loon with 30 mL saline and leaving it in the uterine cavity
for 24 hours for haemostasis.
• Sepsis occurs tLSuall y following mromecLOmy.
• Embolism with C02 can be avoided by using l11e proper
instrument. not increasing the flow LO more than 70 m L/
mi nute and pressure less than I 00 mm Hg. Avoiding
head-low position also red uces the morbid ity whe n embo-
lism occ urs.
• Distending medi a ca use complica tio ns in 4% of cases.
While allowing p roper view and surgical procedures, the
vario us d istending med ia ca n inc rease the p rocedu re
morbid it)'·
• Allergic reaction is noted with dextran and glycine.
• Fluid overload occurs in 4% of cases, and leads to pul mo-
nat-y oedema if deficit of nuid is more l11an 1000 mL and
electrolyte imbalance occurs. DiureLics are required. Sa-
line and dextrose cause h)ponatraemia, hypokalaemia,
haemolysis and encephalopath). Hyskon causes anaphy-
lactic reaction. pulmonal') oedema and encephalopathy,
bmin he•·niation andtempo•<ll) blindness. fluid overload
occw·s when the inu-auterine pressure exceeds 100 mm
Hg. Cereb1-al oedema and cardiac failure ma)' occw·.
• There may be failure to perfonn the•-apeutic procedure.
LATE COMPLICATIONS
• Haematomeu-a following ce•vical stenosis may occur.
• Unwanted pregnancy may be present following TCRE.
• Cancer endomeu·ium may go unnoticed for a long time.
Delayed diagnosis WOI'Sens the prognosis.
• Infection may lead to PI D.
• Dysmenorrhoea following TC RE req ui res hyste rec tomy.
• Ame no rrhoea following TCRE may not be desirable in
some wo men.
• Treatm e nt failure ma)' occur.
• Repeat surge•')' for u·eaunent. fa ilure is seen in 12% of
cases at the end of 1 )'Ca r and in 25% of cases following
TCRE a t the end of 3 )'Ca rs. Eithe r repeat TC RE or hyster-
ec tom)' is ind icated.
• Uterine rupture during pregnancy and lat.e d iagnosis of
endomeuial pathology are other complications.
SALPINGOSCOPY AND FALLOSCOPY
In salpingoscop). a fine salpingoscope I mm in diameter is
inu·oduced through llte fimbria! end of the fallopian tube
via the laparoscope, and ampulla•)' portion studied after
distending its lumen wil11 saline. Flattening of mucosa, ad-
hesions and mucus pol)p can be recogniLCd, and feasibility

of tuboplasty consider·ed. Hysteroscopic fal loposcopy re-
veals the tuba l pathology of the cornual and interstitial en d
of the fallopian tube. The risks of these endoscopes are
perforation, damage to the wbal mucosa, infection a nd d if-
ficulty in inserting the catheters.
KEY POINTS
• endoscopic te lescopes ha,e bee n designed to
e nab le t11e ' isuali£ation of bod) cavities. O f particular
use in t11e practice of ID naeco loro are the laparoscope
an d h)Steroscope.
• T he laparoscope has bee n very useful in the diagnosis
o f uterine, tul)<'\ ), ovarian and ge neralized diseases
affec ting the pelvic organs such as endo metriosis,
chro nic PIO and genital wberc ulosis, and in staging
of genital ca nce rs and chro ni c pelvic pain.
• The role of t11e laparoscope in tl1e evaluation ofinferti lity
is undispmed. It is now a comm on practice to combine
laparosCOP)' witl1 hysteroscopy in its evaluation.
• Opera ti ve laparoscopy has made great inroads into
cli ni cal prac ti ce, making minimall y in vasive surgery a
valid and safe t11erapeuti c optio n in man y situati ons .
• Diagn ostic h ysteroscopy helps in the evaluati on of a
patient presenti n g with th e menstrual disturbances,
endomeu·ial polyps, submucous fibromyomawus
CHAPTER 41 - ENDOSCOPY IN GYNAECOLOGY 531
polyps, a misplaced I UCO and endometrial malig-
nant growth. Th e indications h ave expa nded in
th erapeutic procedures.
• Operati' e hrsteroscop)' is also performed effectively
to cor-rect se-eral mensu·ual problems, mainly abnor-
mal ute rine bleeding.
SElf-ASSESSMENT
I. Disc uss the diagnostic indications of laparoscopy in gyn-
aecology.
2. Disc uss t11e therapeutic procedures done laparoscopically.
3. Oisc us.s t11e contra ind ications and complications of lapa-
roscopy surge ry.
4. What a re the d iagnostic ind ications of h)'Steroscop)'?
5. t11 e therapeutic ro le of h)'Steroscopy.
6. Me ntio n the complica ti ons and co ntraindicatio ns of
hyste rosco py.
SUGGESTED READING
and minimal inv.t&he surgel)t
Tulandi T (ed). Adv-dnCCS in
ObsiCI Gyna<X:ol Clin ' Am Vol 31,2011: 38.
S1uddj (ed). Progress in Obs1c11ic G)11accologyVol7, Edinburgh: Else,ier,
1988.
S1udd J (ed). Progress in Obs1c1ric GynaL>Colol.'Y Vol. 16, London:
EISC\ier, 2005.
 Maior and Minor Operations
in Gynaecology

Minor Procedures 532 Preoperative Workup 538

Dilatation of the Cervix and Endometrial Steps of Abdominal Hysterectomy 539
Curettage (Dilatation and Curettage) 533 Vaginal Hysterectomy 539
Cone Biopsy of Cervix (Conisotion) 537 Postoperative Care 540
Major Procedures in Gynoecology 537 Key Points 541
Preoperative Investigations 538 Self-Assessment 541

Surgical proced ures have become very safe nowadays, be-
cause of improved anaesthesia, ava ilab ility of blood uansfu·
sion, antibiotics as we ll as good preoperative and postOpera-
tive care of the woman. The advanced surgical technologies
have also contributed to reduced surgical morbidities and
operation-related complications.
A munber of major and minor procedures are commonly
done in th e specialt) of ID naeco log). Although moSt of the
minor procedw·es are done to establish a diagnosis, majority of
major operations such as alxlominal and vaginal hysterectomy
or laparoscopic hysterectomy are done to u·eat underl)ing
disorders such as fibroid uterus, endomeuiosis, adenomyosis,
m•naecological cancers or prolapse ofthe uterus.
Following section describes commonly done minor a nd
major operations in gynaecology.
MINOR PROCEDURES
Pap Smear: It remains most commonly done procedure, and
it is done to screen a sex uall)' acti ve wo man to detect preinva·
sive lesio ns of ca ncer ce rvix. It is part of gynaecological exami-
nation in most of tJ1e coun tries; lac k of faci li ty and
trained manpower li m it its ava ilab ility for opportunistic screen-
ing in developing counLries. A detail description of procedure
has been described in chapter I o n G)11aecological Diagnosis.
Cervical biopsy: Obtaining a small tissue from cervix in a sus-
pected case of cancer of tJ1e cervix and submitting for hiswpa·
t11ology is a commonly done procedure. Indications include,
a visible growth on cervix, abnonnal Pap smear report sug·
gesting an unde rl) ing carcino ma or an abnonnal colposcopy
suggestive of Cl 11/ III (HSIL) o r frank carcinoma.
Steps: This procedure is usuall) done on an out-patiem
depanmem OPD basis, with vaginal speculum in place
showing cervix biopsy is taken with the help of a
punch biopsy forceps. Any undue bleeding can be con-
Lrolled by pressure at a biopsy site with a gauge piece.
532
Loop electrosurgical excision procedures (LEEP): It is a pro-
cedLu·e done to obtain cervical tissues for biopsy. A wire loop
attached to a diat11enn y is used to excise en tire transforma-
tion zone (sq uama columnar funClion) on t11e surface of
cervix for biops) purpose. It avoids crushing of tissues which
may happen with t11e use of cervical punch biopsy. Indica-
Lions include Pap smear showing HSIL, carcinoma in situ or
when t11er-e is a disparit) between clinical findings, Pap smear
report and colposcopic findings. This procedu r-e can be done
on an OPD basis in a minor opemtio n theau·e (OT), but
requires an elecLraSLLrgical diather·my and fine-wi r-e loops.
Complications: Mostly a simple and short procedur-e of few
minutes, any bleeding from the surface of cervix after LEEP
can be controlled by pressw·e, application of Mansel's paste or
cautel')' of bleeding points. Patients are advised to avoid sexual
relations for next2-3 weeks to avoid any r·isk of bleeding.
Conization of cervix: Conization of cervix is r-eq uired when Pap
smear and colposcopy reveal CIN II or CIN Ill. It is clone under
general anaestJ1esia, using cold knife or laser to cut in to
t11e ti ssue. 1l1e vaginal wall is incised all ro und I em above the
ex ternal os or above tJ1e visible lesion and dissected off the
cervix. T he cone is cUssec tecl ex tending up to or short of
t11e internal os. 1-laemostasis is secured and tJ1e a1-ea is left to
gmn ulate and not covered "1 tJ1 tJ1e vaginal flap, as this gives a
wrong reading on t11e follow-up P-,1p smear (Figs <12.1 and <12.2) .
Conization causes bleed ing, so it is now mostly replaced by
colposcopic dir-ected or large loop excision of the trans-
foimation zone (LLETZ) and LEEP (see Chapter 38 on Can·
cer of t11e Cervix). Coniation is used as a t11empeutic proce-
dLu-e in Cl N lll in young women desiro iL5 of future pregnancy.
COMPLICATIONS
Apart from bleeding and infectio n, coni.tation can cause
cervical stenosis and incompetent os. This can lead to hae-
mawmeLra, habitual abor·tions and ce rvi cal dystOcia during
labour.
 CHAPTER 42 - MAJOR AND MINOR OPERATIONS IN GYNAECOLOGY 533

Rgure 42.1 (A) Immediate postoperative chest and upper abdominal X-ray showin g gas under the diaph ragm. (B) X-ray erect abdomen
show ing dilated bowel loops on postoperative day 2.

t=-
-

...._ -
Rgure 42.2 Hegar's double-ended dilator used to dilate the cervix.

With the achen t of LEEP, coni.au.ion of cervix has become

less popular as LE.EP is associated \\ith fewer complications,
is an oULdoor procedure and pro,·ides equally good speci-
men for histopathology.
Endometrial Tissue Sampling: Obtaining endomeuial tissue
for biopsy is indicated for cases of abnonnal uterine bleeding
(AUB), cases of infertility, cases of posunenopausal bleeding
and before a woman is to a ml!jor procedure sud1 as
abdominal or \'<lginal hysterectomy. T here are number of pro-
cedures by which endomeuial tissue ca n be obtained for histol-
ogy. Following is the description of such procedures: Figure 42.3 Karman's cannula.
Endometrial Biopsy (Endometrial Aspirate): After initial
steps (making woman void urin e, placing he r in li thotomy Rarely, there may be difficul t)' in nego ti at.ing interval cervical
position on an ope ration tab le, clea nin g th e vulva and va- os, while introd ucing ute rin e so und o r Ka rm an 's ca nnula .
gina with ant.isept.ic solu tion and pelvic exam ination) a Sims Suspected perforat.i o n of the uterus sho uld be managed by
speculum is inu·octuccd LO retract pos te rio r vaginal wall, immediate!)' s topping th e procedure, ca refu l obse rva tion of
anterior lip of ce rvix is he ld with a vu lsellu m or tenaculu m patients for possible intraabdom ina l bleeding and by giving
or a long Al lis forceps. Uterine sound is inu·od uced to ac- antibiot.ics to prevent infections.
curately measure ute rine length as well as confirmation of
position of the uterus. A 4 mm plastic cann ula (Karman's
type, Fig. 12.:l) is imroduced in the uterine cavit)' and at- DilATATION Of THE CERVIX AND
tached to a 20 disposable plastic syringe. By sucking ENDOMETRIAL CURETTAGE (DilATATION
with S)'l"inge, endometrial tissue so obtained is sem for his- AND CURffiAGE)
topatholog> and if indicated for bacteriological examina-
t.ion. Previous!), a r-igid metal cannula was used for the same Dilatation and Curettage (O&C) remains one of the most
purpose. Procedure is a short OP[).based test and can be often can·ied OUt procedure in g)naecology.
done without an> anaesthesia. Howeve r; for an apprehen- O&...C is a minor ID naecological procedure of dilating the
sive patient, local anaesthesia with mild sedation given by cervix and cur·ett.ing (scraping) the endomeu·ial tissue from
intramuscular or intra,enous route suffices. Complicatio11s: the uter·ine ca,•ity.
534 SHAW'S TEXTBOOK OF GYNAECOLOGY

It is mainly a diagnostic proced ure; can be

t11erapeutic in cettain obsteu·ic co nditions. Dilatation of the
cervix alone is required in the following conditions:

• Before curettage (commonest).

• For cervical stenosis.
• To prevent cet'l ical stenosis following Manchestet· opera-
tion for prolapse of the uterus.
• To prevent postoperative cen·ical stenosis in cauterization Figure 42.4 Hawkln's single-ended dilator.
of cet'l•ical erosion and conir.ation.
• To drain haematometra.
• To drain p)Omeua.
• Befot·e insertion of radium into tlle utet·ine cavity in can-
cer oftl1e cervix and endometrial cancer. N

• Before removal of embedded inu-autet·ine conu-aceptive

device (IUCD).
Figure 42.5 Fenton's dilator.
• Before breaking ute tine adhesions in Asherman syndrome.
• Before endoce t'l•ical cureuage (ECC) for endocervical
cance t:
• Before hysterosco p)'· c=
• To di agnose inco mpe te nt os. If No. 8 d il atO r goes in
easily, tl1e inte rnal os of t11e ce n•ix is co nsidered as an
incompe te nt os witl1 the risk of hab itual abortion and
preterm !abo ut:
Figure 42.6 Metal Curette.
Obstetric indicaLions a re as follows:

• Before evacuation in missed abortio n, inco mplete abor-

tion. evacuation of a h)datidifonn mole. It is also necessary
for medical termination of pregnancy.

Curettage of endomeu·ium is mainl)' diagnostic. This is

indicated for following: Rgure 42.7 Blunt and sharp curettage.

• AUB to obtain endomeuium to stud)• tlle honnonal pauem

causing abnormal bleeding.
• S«inulary tWU?IIOrriiO«I to detect tubercular endomeu·itis.
• Postmf!lwJxmMII bleeding to rule out endomeu·ial cancer.
• amcerto study t11e endocervical tissue and the
extent of spread. This helps in staging and deciding on
treaunent.
• lufertilit:y. Now a days, ulu-asound is used for monitoting ovu-
lation. if geni tal wbercul osis suspected tllen tl1is
procedw·e is incUca ted. The endomeu·ial tissue is preserved
in saline for culture. The tissue is also to poly-
merase chain reactio n. Co rpus luteal pha\ie defect is diag-
nosed when tl1e endometrial histo logy lags behind the
mensm tal date b)' 2 da)•S.
• H onnoue RepltJctmumt Themfl)' (HRT). If a woman o n HRT
complains of b leedin g per vaginal, s he should be sub-
jected to D&C to rule out e ndome u·ial hyperplasia or
carcinoma.
• A woman on Tamoxifen for breast D & C is indi-
cated if endomeu·oid thickn ess is more t11an 8 mm or if
she has irregular bleeding.
T herapeulic D&C is indicated for following:
• Missed abortion, incomplete abortio n and retains of
products of conception.
• To remo1e endometrial pol)p (pOI)pectomy).
• Obstetric indications mentioned for dilatation of cetvix.
The dilators used are as follows:
• Hegar's double-ended dilator (Fig. 12.2) .
• Hawkins' single-ended dilator ( Fig. 12. 1).
• Fenton's dilator (Fig. 12.5). They come in different sizes
(No. 3-10 dilatOI"S).
Slow cervical dilatati on ca n be performed witl1 prosta-
glandin £ 1 ( misopros tol) vaginal pessa ry (200-400 meg).
T he pessary is inse rted in t11e vagina 3 hours before D&C,
a nd tl1is s low di lata ti on avoids ce rvical traum a.
C ure ttage is perfo rm ed usuall )' with a sharp cure Lte. T he
b lu nt cw·e LLe is used in obstetric co nditio ns to avo id uterine
perforation (Figs 12.6 a nd 12.7).
Kam1an 's p lasti c cureue is mainly used for suction evac u-
a tion in medical te m1ina tion of first-u·imesLer pregnancy.
These come in sizes No. 3-10.
PROCEDURE OF D&C
The equipment required are as follows:
• Sims speculum (Fig. 12.8)
• Antel"ior vaginal wall reu-actor
• Vulsellum or Allis force ps to hold the ante tior lip of t11e
• Uterine sound
 CHAPTER 42 - MAJOR AND MINOR OPERATIONS IN GYNAECOLOGY
Rgure 42.8 Sims speculum.
• Cervical dilators
• Curette
• Sponge-holding forceps and sponges to clean the area
and 'oagina
• Savlon, Betadine
• 10% formalin lO preserve the endomeu·ial tissue
• Saline to preserve endometrial tissue for culture
D&C is performed under sedati on, paracervical block
or ge ne ra l anaesth esia. Local anaestJ1csia is adeq uate in a
mu ltiparo us woman, b ut a nu lliparous o r an apprehensive
woman may requi re general anaesthesia.
• The woman is put in the lithotom) position. The peri-
neal and inner migh area and vagina are cleaned witJ1
Savlon or Betadine. The area is draped with sterile
sheets.
• Bimanual examination is done to ascertain the size of the
utents and its direction and to rule out adnexal mass.
• \NitJ1 tJ1e help of Sims speculum and anteri or vaginal wall
retractO r, tJ1 e cervix is exposed and the anteri or li p held
with Vu lsellu m or Allis forceps.
• T he ute tin e so und confirms the si:t.e of the uterine cavity
and its direction (normallengtJ1 is 7-8 em).
• The cetvix is d ilated starting from No. 3 up to 8 mm.
• The curette is introduced into the uterine cavity and the
uterine lining scraped from above downwards.
• A griLL) sensation indicates the end of curettage.
• The tissue is preserved in 10% fonnalin. For culture and
polymerase chain reaction (PCR), tJ1e tissue is sem in
saline. Other memods of obtaining endomeuial tissue
for the histological study are as follows:
• Fractimwl cr.tmtwge
• biopsy
Frattimwl curettage is indicated in suspec ted endometria l
carcinoma. In this proced ure, ECC is done before cervical
dilatation. Following dilatation, tl1e isthmic portion is curet-
ted and the tissue kept in a separate bottle. Thereafter, the
uterine is curetted and sent separately.
ormal endometrium appears pink and healthy. Profuse,
pale looking and fiiable tissue suggests malignanC)( Fractional
cut-ettage detennines me extent of sp•-ead of malignancy
do",, tJ1e utet·ine ''>all, so tl1at staging can be done and ap-
propti ate u·eaunem planned. Involvement of endocervical
lining places tl1e malignancy in Stage II of the disease.
l!:ndomeui al biopsy is perfonned as an outpatient
proced ure without anaesthesia or under sedati on. T he cervix
is not d ilated and a biopsy curette is inscrted and a sui p or two
of endomeu·ial tissue is obtained for histo logical study.
535
CONTRAINDICATIONS
Conu-aindications to O&C are as follows:
• Suspected pt-egnancy
• Lower geni tal tract infection
T his surgical p roced ure is performed only afte r the
infec Lion clea rs up with antibio tics.
COMPLICATIONS ASSOCIATED WITH D & C
Dilatation of X can cause following:
• Ascending infection.
• Cervical tear and bleeding.
• Incompetent os.
• Utel"ine perforation occurs mainly in a soft utems,
i.e. pregnant, puerpeml uten.lS, and in au·ophic post-
menopausal or scarred uten.ts. It ca n also occ ur in a
mali gna nt ute rus.
Perforation is suspected when me dilator or Cur-e tte goes
further in witho ut resistance beyond tJ1e measured length
of tl1e uterine cavity. The first tl1ing to do is to remove tl1e
instrument and postpone SLLrger). Lf the bleeding is
slight, tJ1e woman is obsen·ed for internal bleeding. Hea\y
bleeding requires immediate laparoscopy and someLimes
laparotomy. LaparotOmy is required when intestinal it'\iut")'
occurs.
Curretage Can Cause Following Complications
• Infection of upper gen ital u·act.
• Ashe rman synd rome - In Asherman S)•nclrom e band of
adhesions develop between anterior and posterior uter-
ine wall. This condition is caused b)' vigorous curettage,
in tubercular endometritis and following packing of the
uterine cavity to control postparwm haemorrhage. It also
follows utetine sepsis.
Asherman S)ndrome is classified as mild, moderate or
se,•ere depending on the degree and extent of adhesion.
The woman presents with hypomenorrhoea, seconda.t)'
runenon·hoea, infet·ti li ty or habitual abortions.
• lnferti li t)' d ue lO ascending infection ca using tubal bloc k.
• Ectopic pregnancy d ue to PID.
• Rupwrc uterus d uring subseq uent pregnancy or labo ur.
• Adherent placenta in subseq uent pregnancy.
INSTRUMENTS USED
!>pentium is a double-ended specullUn which reu-acLS me
posterior 'oaginal wall, in dorsal and left lateral positions
(Fig. 12.8). It comes in differentsiLes.
Sim-1 <mlerior Vltginal wall retractor is a double-ended insu·u-
ment witJ1 a loop at eitl1e1· end (Fig. 12.9).
Vu.!Jellwn Jorteps is a long forceps with teeth at one end
whic h ensures a firm grip on tl1e cervix when the Vulsellum
is locked. It is app lied to the an tetior li p of tJ1e cerv ix dur-
ing D&C, Fothe rgi ll's opera tion and vagina l hyste rectOmy. It
can also be app lied to the posterior lip during culdocentesis
536 SHAW'S TEXTBOOK OF GYNAECOLOGY
Figure 42.9 Anterior vaginal wall retractor.
Rgure 42.10 Vulsellum forceps. It Is used to grasp the cervical lip
and steady the cervix during vaginal surgery.
Rgure 42.11 Allis forceps. also hold the cervix, edges of the
vagina during colpography and edges of the rectus sheath during
abdominal surgery.
for aspirating pus in pelvic abscess and blood in ectopic
pregnancy. ln a pregnant uterus and menopausal uterus, it
is safer to use Al lis forceps- this wi ll avo id cervical trauma
and b leeding (Figs '1 2.10 and '12. 11 ).
is used LO ho ld the soft cervix durin g
obsteuic D&C. Apart from its use LO clean the area with
sponge, th e spo nge forceps is also used LO ho ld the cut
edges of the lowe r uterine segmem in caesarean section and
tl1e cut edges of the cervical tear fo llowing vaginal delivery
and as a haemostatic as we ll.
Uterine is a 30 em long angulated instrument with a
handle at one end and a rounded blum tip at ll1e other. It
is marked in inches or centimetres. The angulation accom-
modates for Aexion of the uterus (Fig. 12.I2).
USES OF UTERINE SOUND
• It measures the ute1ine ca' ity and the cen·ical lengt11.
• It is used to diagnose cervical stenosis.
• It is used to sound a pol) p, I IJCD or ute•·ine septum.
Figure 42.12 uterine sound. It measures the uterine cavity, sounds
a polyp and IUCO.
Rgure 42.13 Cusco speeculum.
• It helps to break adhesions in Asherman syndrome.
• l t differentiates between chronic inversion and fibroid
polyp.
• ln a misplaced LUCD, the uterine sound can be inserted
and X-ray oflhe pelvis taken, and tl1e position of IUCD in
relation to tl1e uterine sound shows if IIJCD is perforated.
OTHER TYPES OF SPECULUM
• Cusco speculum (Chapter I, see a lso Fig. 12. 13).
• Auvard speculum (Fig. 12. 1 lA) is a heavy retractor pro-
vided witll a heavy metal ball and is self-retaining. It is
emplo)ed in vaginal hysterectomy to reu11ctthe poste•·ior
vaginal wall. A channel is provided in the handle to col-
lect the blood and d111in.
The ovum forceps is a noncnashing forceps which does
not have a catch or lock on its ha ndle and is meant to grasp
the products of co nceptio n. The fo rceps is introduced
closed into tl1e uterine caviL)'· It is th en opened, ll1e products
of conception grasped, tJ1 e instrum ent closed and rotated to
detac h th e products from the ute rine wa ll.
Fractional CuretttiJ.,rtl: It is a modification of D&C where
initially, curettings are ob ta ined from endocervical canal
before dilatation ofos fo llowed by d ilaLa tion of os and curet-
tage of endometri um . Specimen ob tained fi·om endocervi-
cal canal is separate ly sent for histopathology in add ition tO
endomeuial curettings. l n the past, it was a commonly done
procedure in a suspected case of endometrial cancer to
kn ow whether tl1e disease has spread downwards to involve
e ndocervix.
E1ui011U!Irial ilspiratioll + /\ll(WCI'rvical Curettt•ge (M+ECC):
This procedure. being less painful has replaced fi11clional
curettage. Dilatation of imernal os is avoided, so it makes
procedure pain-free and an OPD procedure. Tissue speci-
mens from endocen•ix and endomeuium are sem sepa-
rately for h islology.
 CHAPTER 42 - MAJOR AND MINOR OPERATIONS IN GYNAECOLOGY 537

Figure 42.15 Cone Biopsy of Cervix.

0 Play to scan Cervical Biopsy-Conisation

Rgure 42.14 (A) Auvard speculum (B) Instruments required for D&C.

CONE BIOPSY OF CERVIX (CONISATION)

Cone Biopsy is a procedure in which a co ne shape tissue

of cervix is ob tained un de r anaesthesia (Fig. 42.150).
T his procedure can be used both for d iagnostic and thera-
peutic purposes. A deta iled desc ripti on of the proced ure
has been given in Chapter 33.

CRYOTHERAPY OF CERVIX
This is a minor procedure clone in OPD to treat benign and
pre malignant lesion of cervix. In this procedure a cone Figure 42.16 Cryotherapy of Cervical Lesion .
shape probe is attached to a source of C02 gas and probe is
applied to surface of cervix for a duration of 3m in. Under
tJ1e effect of Cl) o probe, the underline tissue undergoes MAJOR PROCEDURES IN GYNAECOLOGY
free.ting subsequentJ), tJ1is tissue slowly heels replacing
tJ1e unhealth) tissue. This procedure is commonly used in Hysterectom) or removal of the uterus is a fairly common
tJ1e treaunem of cerYical erosion (Fig. 12.16). gynaecological operation done for a ,oa,·iety of conditions
• Preoperative workup such as fib•·oid ute•·us, AU13, adenom)OSis and ronaecologi-
• Pw·pose of preoperative workup cal malignancies.
538 SHAW'S TEXTBOOK OF GYNAECOLOGY
Removal of the body of the ULeniS with cervix is called
total h)'Merectom)', if only body of the u tertiS is removed and
cer. ix is retained it is called subtotal h)•:.terectonl)' {supracer-
vical hysterectomy). Removal of the uterus with cervix and
both tubes and ovaries is called total abdomirwl h)•Sterectorrry
with bilateral (TAl-l with B/ L SO). In
cases of malignancies where besides re moval of th e uterus,
ce rvix, wbes and ovaries, o ther strucwres such as upper
vagina, parametrial tissue and lymph nod es from pelvis
and para-aortic area are rem oved arc labelled as Radical.
1erec Iomy.
Routes of hysterectomy: Depending on the expertise of
sUI·geon, siLC of uterus, underl) ing pathology, removal of
the uterus can be carried by open abdominal surge•)' or by
laparoscopic approach or by vaginal route.
Preoperative workup and preparation for major g)'llaeco-
logical surgery.
PREOPERATIVE INVESTIGATIONS
Before th e submission of th e patient to any major g)•naeco-
logical surge•) ', it is necessary to evaluate h er fitness for iL
The pt·eoperative investigations include the following:
• Complde bkxxl count. This indudes haemoglobin assess-
ment and total and differentialleuCOC) te counL
• This includes routine and microscopy urinaly-
sis. CuiLUre examination is requisitioned. if microscopy
reveals significant number of pus cells (more than 5) or
histO t)' of urinary tract infectio n (UTI), especially in
women with C)'Stocele, urin at)' complaints and fistula.
• FasLing and postprandial b lood suga r es tim ati ons.
• Kid11ey function tests. Blood urea, sentm creatinin e and
uric ac id.
• Liverfuuclion tests. Pan.icula.-ly in women witl1 a history of
jaundice and in all women undergoing cancer surge•)'·
• 13/Qod ltsllfor VDRL, Ausu-alia antigen and HlV-l and ll.
• Serum electroi:J•t.es. Na, K, Cl and HCO,.
• R(u/iograph of the chest, preoperatively or in genital cancer
for metastasis.
• 1\CG and test whenever indicated.
• fJJelogmplry (IVP) in case of cancer cervix and
urin at)' fistulae.
• Blood group and Rh factor.
• BIPediug time arui clotting time.
PREOPERATIVE WORKUP
PURPOSE OF PREOPERATIVE WORKUP
It is the comers tone for successful surgical outcome.
• To make the correct diagnosis.
• To decide on the need for Stu-ge•)' and its correct selection.
• InvesLiga Lions to:
• con firm the diagnosis.
• fitness for anaesthesia and surgeq•.
ldentil)' the risk factors, any abnorma l condition and
rectify tl1is before undertaking sw·ge•)'.
CORRECT DIAGNOSIS
Detailed histOf) and clinical examination can lead to cor-
rect diagnosis in most cases. History includes the presenting
symptoms, drugs taken, any allergy and previous blood
transfusion and surgery.
CUNICAL EXAMINATION
Apan from abdom inal, speculu m and biman ual examination,
general exa mination rules o ut hitheno undetected anaemia,
tl1y•-oid enlargement, breast disease and cardiovascular exami-
nation besides blood pressure. Pap smear is taken as required.
INVESTIGATIONS
These include the following:
• Confirmation of clinical diagnosis b) ultrasound, CT
and MRI.
• To assess tl1e extent of the disease, any anatomical disto•tion
of b ladder; ure ter b)' the pelvic tumour and malignancy.
• St.aging a nd feasibility of s r11-ge•y In case of uterine fi-
broids, tJ1 e number, size and loca ti on of fibro ids decide
the t)•pe of surgery appropriate to tJ1 e case.
• Decide on tl1e type and route of surge•)'.
FITNESS FOR SURGERY
It is necessary to ens w-e that the woman is fit for surgery, by
perfonning the following investigations:
• BP check-up.
• Hb% white cell coLrnt, differential count, blood group-Rh.
• Ro utine urine examination for pus cells, sugar and p•-otein.
• Kidn ey function tests.
• Li ver function tests in cancer surgery and in previous
liver disease.
• Blood sugar. ln a known d iabetes patient, to check on
sugar control.
• X-ray of the chest, routine and for secondat)' malignancy.
• ECG.
• Th) roid function tests if required.
If an) abnormality is deteCLed, the woman is refen·ed w
the appropriate specialist for treaunent and t11e operation is
postponed until the woman is considered fh.
To protect the surgical staff regarding hepatitis B virus,
HI V in high-risk patients. Patient test such as HBsAg, H[V
s houl d be done.
In an e me rgency and life-saving condition, minimal es-
sential in vestigations are done, blood arranged and the risks
of ope•-ation explained.
In a planned surgery, some g)•naecologists prefer auto-
transfusion, and blood of tl1e woman is withdrawn 2 da)S
before su•-ge•·y and preserved. Altemately, a relative donor
is a•·ranged. This avoids t11e •·isk of HIV and other sexually
transmitted diseases, hepatitis B vint.S.
B) assessing the fitness in this way, sudden cancellation
and prolonged postoperative hospitalization due to compli-
cations are avoided.
DRUGS
Woman on a ny drug needs counsell ing, rega rding tempo-
rary stoppage or addition of alternative drugs or a new drug.
Any alle•·gy to a particular drug should be noted. HistOt) ' of
 CHAPTER 42 - MAJOR AND MINOR OPERATIONS IN GYNAECOLOGY
previous blood transfusion, t.h e reason for transfusion and
any adverse reaction is noted.
Oral comracepuve pills should be stopped 4 weeks before
surgery. These can cause thromboembolism. Warfarin should
be stopped and replaced b) heparin with good monitoring.
Aspir·in is also best a' oided as it can cause bleeding. Anaemia
should be treated and Hb% should be at least 10 g%. Any
infecuon should be cleared with anubiotics.
Smoking and alcohol should be stopped for a few days
befor·e surger)'· Lithium andUiC)clic anti-<lepressanLS should
also be stopped. The dr·ugs for h)penension a nd diabetes
should continue. Many prefer to switch LO insulin before
and after the surger)'. Thyroid chugs need to be continued.
lHROMBOPROPHYLAXIS
Prophylactic hepari n is n eeded in a high-risk woman for
thromboembolism and it sho uld be co ntinued for a variable
period postoperative!)'·
CONSENT
Proper co unselling and inform ed co nsent should be ob·
tained in wri tin g. A girl )'Oun ger than 18 years a nd a woman
wi th a ps)•chiaui c problem are considered unfiL to give con·
sent and the gua rdian'ssigna LUre is required.
PREOPERATIVE PREPARATION
• The woman should not take a ny food or liquid at least
12 hours before surge!").
• Bowel preparation. The patient is advised to take Dulco-
lax or other laxauves at night so that her bowels move
well. and it is empt) during surgeq•. It is importamso that
the bowels do not move and soil the operation table, and
also intesunes are not distended and obstruCLthe surgery.
Some recommend enema earl)' in the morning, but this
is cumbersome and some enema water may be retained.
Preoperative bowel preparation is required for laparo-
scopic surger1• and surgery for a malignant tumour. This is
necessary in case bowel ir"Uury occurs during surgery.
Nowada)'S, the vaginal wall is cleaned just before surgery
"1th Betadine after the bladder is cath eterized. The bladder
needs to remain empty throughout th e surgery. lf spinal or
epidu ral anaesth esia is e mployed, the woman may not be
able to miclltrate as such and bladde r ca the ter for 24 hours
postoperati ve ly becomes necessary.
In prolapse, if infec tion o r a decub itus ulce r is present,
vaginal packing witJ1 Betadine for a few days heals tJ1 e ulcer.
Menopausal woman may req uire oestrogen vagina l cream
for a few days.
Most women are now adm itted ea rly on the day of the
operation, and this saves the cost. On ly those at high risk or
"1 th a medica I disorder get adm it ted one day before surger)'.
Shaving tl1e part is essential. The area for surgery is
cleaned witJ1 Savlon and spirit in the operatio n theatre. The
vagina is cleaned witJ1 Savlon or Betadine lotion. The blad-
der catheter keeps the bladder empty tJHoughout the sur·
ge r). This a' oids ir"Uuq to tJ1e bladder.
ANAESTHESIA
It is left to the choice of the anaesthetist, and this parliy
depends on the condition of the woman.
539
ANTIBIOTICS
Today's practice is to start inu·avenous antibio tics intraop-
eratively. ln caesarean section, antibiotic is administered
after t11e deli vel") of the bab).
STEPS OF ABDOMINAL HYSTERECTOMY
0 Scan to Play Total Abdominal 1-l)Sterectom>•
For remo,<al of Uler·us per abdomen following are necessary
steps. However, a small '<ariation in steps may occur depend-
ing on the underlying disease, si£C of uterine and practice
of surgeon.
I. indwelling catJ1eter for dr-ainage of urine during procedw-e.
2. Antiseptic prepar-ation of area of operation.
3. Choice of anaesthesia: It is at tJ1e discretion ofanaestJ1etist.
4. Abdominal wa ll incision: llotJ1 a u·ansver'Se suprap ubic
incision and a vertical midline incision can be used
depending on the undc rl)•ing disease, size of the uterus
and previous lapa roLOm)' scar.
5. lnspecuon and palpation of pelvic orga ns and exploration
of remaining part of abdomen. fl uid/ peritoneal
washings ma)' be obtained in C.'l.Se of suspected malignancies.
6. Packing awa)' of intestines and re u·acting bladder with
the help of This provides adeq uate exposure
of pelvic organs fac ili taung surge ry
7. Decision regan:Ung of It will depend on
age of women. (Uagnosis and her desire to preserve uterus.
8. Clamping of round ligaments and dividing tl1em be-
tween two clamps and suturing t11e lateral ends with
absorbable suwre.
9. Clamping. division and suturing of infundibula pelvic
ligamentS in case O\'<lries are to be removed. In case 0\'<1·
ries ar-e to be preser,ed, clamp is placed close LO uterine
fundus and O\<arian ligament and the fallopian tubes are
divided close to later-al wall of the uterus and stitdled.
10. Opening of uter·o-vesical fold of peritoneum and dis-
placing bladder a\1'<1)' from anterior aspect of cervi.x.
11. T)ing ofutednevessels close to later-al border oft11e uterus.
12. Di vision, t)'ing of Mackcnrodt's and Uterovesical liga·
menLS close to later-al mar·gin of cervix.
13. Opening of '<agina at junction of cen•ix a nd vagina.
After h)s terectomy specimen is removed, edges of vaginal
cuff are sLi tched.
14. Obtaining haemostasis; co unting of spo nges and instru·
menLS an d need les.
15. Closure of abdomen in layers.
Surgical specimen shou ld be cut open to see inside of
endomeu·ial cavil)', endocervix and ret of the specimen
(ovaries & fallopian tubes).
VAGINAL HYSTERECTOMY
0 Scan to pia) Vaginal h)Sterectomy for prolapse uterus
Removal of the uterus b) \'<lginal route is called \<aginal hys-
terectom). This procedure is moSU) carried out for prolapse
of the uterus and is called \<aginal hysterectOm)' witJ1
floor repair·· as in the oper-ation simultaneously repair of an-
terior \<aginal prolapse (cystocele, urethrocele) and posterior
540 SHAW'S TEXTBOOK OF GYNAECOLOGY
vaginal wall prolapse (rectocele a nd enterocele) is carried
o ut However, so rne gynaecologist perform vaginal hysterec-
tomy in tlte absence of associated prolapse of tlte uterus, tl1is
procedure is labelled as 'non descent vaginal hysterectomy'.
STEPS OF VAGINAL HYSTERECTOMY
l. Anaesthesia
2. Litllotomy position
3. Antiseptic preparation of operative area
4. Emptying bladder
5. Exposure of vaginal walls by placing Sims speculwn,
labial retraction suwre and pulling cervix downwards
by h olding witJ1 a vulsellum
6. Placi ng a u-ansvet-se incision o n cervix at the lower limi t
of bladder
7. Separating vaginal mucosa from underlying bladder
8. Displacing bladder upwards ti ll o ne reaches uterosacral
fold of peritoneum and ope ning of peritoneum
9. Posterio rl y open ing of the pouch of Do uglas
10. 1b cla mp c ut and ligating a uac hm e m s of the uterus
from below upwarcls (Mac ke nrod t's ligame nt, uterine
vessels, fundal s trucllt res)
II. Mter removing tJ1 e m e rus, sec win g all tJt e pedicles and
cl1ecking haemos tasis
12. Closure of vault
13. Repair o f cystocele, repair of e nte rocele
14. Gentle packing of vagin a a nd leaving behind Foley's
catlteter for a conti nuo us drainage of urine
POSTOPERATIVE CARE
Postoperative care is impottam if surgical complications are
to be avoided.
IMMEDIATE CARE (24 HOURS)
Vital signs such as
• Pulse, te mpet-ature, BP a nd respit·ation chan tO be main-
tain ed.
• T he patient needs intrave no us fluid for first 24 h o urs.
Foll owing a minor s urget) ', o ral fluids a re all owed 4 hours
after the s urge ry, a nd a soft d ie t is given o n the day of
s urgery.
T he average patient needs 2 L of fl uid intrave no usly
for 24 ho urs. T h is comprises I L of 5% glucose, 1/ 2 L of
glucose saline and 1/ 2 L of Ringer's lac tate to maintain
elecu·o lyte balance. If the woman vomitS, extra fluid is
required to make up for tJt e loss.
• !make-output c hart sho uld be maintained to monitor
renal function as well as to decide o n tlte amount of
inu-avenous fluid required. CatJteter for hours
preventS ul'inat) retention.
• Anlibiotics are best administered in u-avenously in tlle
fit-st24 hours. The first dose is given dut·ing surge ry. Later,
oral antibiotics can be stat·ted. The choice of antibiotics
depencls on the surgeon, but it is prudent to administer
i.v. meu·ogy l for tJ1 e first 24 ho urs to combat anaerob ic
organisms in addition 1.0 other a ntibiotics.
• Analgesics are required for a day or two, and tJte choice
depends o n the need of the woman. Night sedatio n allows
tl1e woman to sleep well a nd wake up fresh. NSAlD sho uld
be avoided in a woman with astJtma a nd gastric ulcer.
• The palien t should be observed for respiratot·y complica-
tions and pain in the legs (thrombosis).
• The abdomen is wmched for distension and bowel
sounds. Once the bowel sound retums, o t-al soft diet is
started (Fig. 12.16).
• Urine culture should be obtained, if tJte indwelling cath-
eter is placed f-or 2 da)S or more.
• The patient sh ould be observed for vagina l bleeding. A
slight bleeding is noted during the first few days, and tltis
weat-s off gt<Jdua lly.
• Blood transfusion sho uld be avoided as far as possible. lf
postOperative haemoglo bin falls below 8 g%, iron tlt erapy
will restore it to normal. It s ho uld be no ted tha t o ne
unit of blood raises haemoglobin byjust I g, witJ1 its o ther
associa ted risks of b lood u·a nsfusio n.
• Early a mbul a tio n is prac ticed nowadays LO avo id thro m-
boembolism . T he patie nt is advised LO move o ut of bed
once tlle inu·avenous fl ui d is stopped.
• Bowels s ho uld be moved witJ1 Dulcolax s uppository or
enema on tlte 3 rd or 4 tJ1 day o nce she is on a solid diet.
• The abdominal dressing s ho uld be c hanged on the
third day and when tJ1e s utures are removed. Nowadays,
subculicular catgut sulU re for the skin does not require
removal.
• The woman is nonnall> discharged home o n tJte 4tll or
5tll day of operation. The patient is advised against inter-
COLLrse for I mon tJ1.
Fo llow-up is done a montJ1 after the surget)' to check all
is well. The woman needs counselling regarding lifesty le,
sexual activity and any special precaution. A woman oper-
ated for cancer needs pmlonged chemotllempy and •-adio-
therapy a nd sh ould be under observatio n for recurrence.
Immediate Postoperative Complications are as Follows
• H aemorrhage
• Infection such as wound infectio n, chest infecti o n, uti nary
infection
• Pamlyti c ileus
• Embo lism
• Burst abdomen. Burs t abdome n in gynaeco logical s urgery
is now rare with tJ1e use of Pfan ne ns tie l in cis io n.
• Bmvel perforation: A rare compli ca tio n which ca n occ ur in
patients with extensive bowe l ad hesions (Fig. 42. 1).
• Pe lvic vein thrombosis witJ1 fever and tac hycard ia is less
common wi tJ1 early amb ulatio n and prop hylactic antib iot-
ics. CT is useful in tJ1e diagnosis of pe lvic vein thrombosis.
Heparin and antibiotic are needed.
Late seque lae are as follows:
• Scar site hentia
• Dyspareunia in vaginal surget)
• Abdominal adhesions caLtSing chron ic pain
• Recurrence of fibroids and endomeu·iosis
• Recurrence of malignancy
 CHAPTER 42 - MAJOR AND MINOR OPERATIONS IN GYNAECOLOGY 54 1

KEY POINTS SELF-ASSESSMENT

• To make an> surger> safe, preoperative and postOpera- 1. Disc uss t11 e indicatio ns of D&C.
ti'e care are as important as the surgical technique. 2. What are the complicatio ns of D&C?
• Preoperati\e care includes co nfi rmalion of the clini- 3. Discuss m e role of con iLation.
cal diagnosis, assessment of the e xte nt of the surgery 4. Describe indications and steps of abdominal hystereCLomy.
required and mal..ing the patient fit for anaesthesia as
well as sw-ge•1·
• PostOperati'e care looks after her nuu·ition, preven- SUGGESTED READING
ti o n of infection with approp•·iate and adequate antibi- llacker and Moore"s E»cnli.lh ofOb>tetrics and C) necology 2010.
otics, pre\ents thromboembolism by early ambulation
and m akes t11is period as pain-free and comfon.able as
possible.
• D&....C is a minor di agnostic procedure.
• Dilatation of ce1vix is required in a few cases.
• Endomeu·ial study is required in AUB, secondary
amenorrhoea and posunenopausal women suspected
of endome u·ial ca nce r.
• Conization of t11 e ce•v ix is resu·icted lO t11erapeutic
procedure in young women witll C IN Ill. As a d iag-
nostic procedure, it has been rep laced by colposcopic
biopsy, and Lt::t::P.
 Obesity and its Significance
in Gynaecology

Prevalence 542 Complications and Sequelae 543

542 Management 544
Aetiology 542 Key Points 545
Pathophysiology 543 Self-Assessment 545
Clinicol Features 543

Obesit)' is on an increase the world ove t: In Ind ia, the

incidence is reported to be 10%- 15%. Obesicy affects men-
strual functions, reproductive functions and other organ
systems in tl1e bod)' with a profound effect on tl1e incidence
of PCOD, infertilit), pregnancy outcome, endometrial can-
cers (increased) and a variety of mensu·ual irregularities.
WitJ1 an ever-increasing incidence of obesity, it looks like a
major factor which will influence healtJ1 of the people in the
next few decades.
Obesit) until recentJy,,'as considered a cosmetic nuisance,
personal issue and social problem, blll now it is realized tl1at
it also poses a major health haard in later >ears, causing
morbid conditions and, at Limes, early death. Now consid-
ered a metabolic disorder, its prevalence has increased
globally and threatens the health of the individual. Once
acquired, it is difficult to get rid of, despite dietary comrol
and exercise. It is therefore important to d1eck the growtl1
and weight of adolescents and adults before it creates healtl1
problems.
PREVALENCE
Increased prevalence ove r Ll1 e previous )'ears is because of
several factors:
• Better social and economic environ·
mem has changed the li festyle of people; overeating
and overindulgence in wrong foods has led tO obesity
(fatty food)
• Lack of exercise because of heavy and prolonged
hours at work, ph)sical disability and sedentary life,
causing less utilit:ation of calories and accumulation
of bod) fat
o Genetic
o Increased birthweight and maintenance of increasing
weight Lllrough childhood and adolescence
542
DEFINITION
Obesity is defined in terms of bod)' weight over heighL Body
mass index (BMI) is expressed as follows:
BMI = weight(kg)
height(m: )
o onnal BMI is between 18 and 25.
o Below 18 is considered underweighL
o Between 25 and 29.9 is overweight.
o Between 30 and 35 is obese.
o BMl over 35 is considered morbidly obese.
o ·waist-to-hip ratio should not exceed 0.8.
AETIOLOGY
Apart from the above-mentioned fuctOt'S well known for
gain in weight, obesity is considered a metabolic disorder
originating in the fellts itse lf, part!)' conu·ibuted by mother's
environmen t dwin g p regnane>'· Materna l conditions dur-
ing pregnancy are ove rnuu·iuon, glucose intOlerance and
diabetes, leading to mac rosomi c fetus. The metabo lic
changes in tl1is fetus persist Ll1rough chi ldhood, ado les-
cence and adu ltl1ood leading to overweight and obesicy.
Other factors are as fo llows:
o Genetic Family history reveals obesity.
o Prepregrumc;• weight: Overweight mothers gain more weight
than nonnal women during pregnancy. They also retain
increased weight gain postpartum, and put on some extra
pounds or so following each delivery; multiparae there-
fore tend to be overweight compared to pt·imis and those
lesser pregnancies.
o Menopause: Low metabolic rate and inacti\·ity add tO tl1e
woman's weight after the menopause.
 CHAPTER 43 - OBESilY AND ITS SIGNIFICANCE IN GYNAECOLOGY 543

• Overeating and eati ng wrong food also lead to obesity.
• Lack of exercise and seclen Lary lifestyle lead tO an
increase in the woman's weight.
• Thyroid (h)'J)Oth)TOiclism) and oedema occur
because of hepatorenal disorders.
• Dru(Jl: Corticosteroids over a prolonged period, andro-
gens and oral hormonal conu-aceptives tend to increase
the woman's weight.
PATHOPHYSIOLOGY
Bones make up 12% of the total body weight, muscles 35%
and body fat 27%. The rest comes from other organs and
blood and body fluid.
Of the tota l fat, abdom inal and visceral fat (waist circum-
ference) is linked to diseases in the adult life. Women tend
to accumulate more fat over the abdomen than over the
hips, as compared to men, th ey te nd to suffer from
obesity more tl1anmen.
Lep tin ( 167-am ino ac id prote in ) is a ho rm one secreted
by adipocytes in the fat that influences hypo tha la mus
regard ing appe tite. Increased leptin increases fat acc umu la-
tion. Lep tin secretion is also regulated b)' insulin which
stim ulates lep tin secretion. In pregnancy, some wo men
develop insulin resistance, a nd hype rinsulinaemia may be
responsible for excessive weight gain thro ugh fat depos ition
and retention of weight gai n postpartum.
CLINICAL FEATURES
• Agrr. Pregnane> and menopause are linked to obesity in
women.
• Parit)' Multiparous women tend to be more overweight
than less parous women.
• Farllily history (genetic) also leads to obesity.
• Many obese women are born overweight.
COMPUCAnONS AND SEQUELAE (Fig. 43. l )
• O bese adolescents tend to have precocious puberty
which in turn reduces their height over-all (see
Chapter 6).
• There may be mensu·ual d)Sfunction because of
horm onal and metabolic cl)Sfunction.
• Pol yc)stic ovarian syndrome ( PCOS) is nowadays seen in
young women who are over·weight. They also demon-
strate insulin resistance.
• Anovulatory infertility may occur beca use of anovul ation
and PCOS.
• T he success of in vi tro ferti lizatio n (IVF) in infertile
obese women is repo rted to be low.
• Breast, uteri ne and colonic ca ncer are repo n ed to be
higher in obese women than in lean women.
• Stress incon tine nce of urin e is more prevalem amongst
overweight women.
• Fungal and uri nat")' infection are mo re common in obese
women.
• Obese women tend to suffer more from tl1e
following medical problems tJ1an lean women:
• Gall bladder stones
• Cardiovascular disease, especially myocardial infarct
• Su·oke and osteoanhritis
• Thromboembolism and pulmonary embolism
• Respiratoq problems such as asthma
• Sleeping disor'(lers

( Complications of obesity )

I
!
Adolescents
!
( Childbearing period )
• Precocious puberty
• PCOD

• Anovulatory infertility
• Poor IVF outcome 1 Pregnancy
• PIH insulin resistance
• Macrosomia
• i Caesarean delivery
• i Anaesthesia risk
• i Surgery difficulty
• i Postoperative sepsis
• Thromboembolism
• Scar site hernia
• Postpartum depression
Figure 43.1 Complications of obesity.
l
CVD
l •
l
Breast Cancer
• Myocardial infarct • Uterine Cancer
• Diabetes • Ovarian Cancer
• Hypertension • Colonic Cancer
• Stroke • Stress incontinence
• Arthritis
• Thromboembolism
• Hyperlipidaemia
544 SHAW'S TEXTBOOK OF GYNAECOLOGY
• Diabetes II
• 1-lyperlipidaemia
• S111gery•: lt is cUfficult to procure a vein for intravenous
drip during surgeq.
• Intubation during general anaesthesia and getting into
an epidural space for spinal anaesthesia could be a
problem.
• Laparoscopic surge•1 is technica lly difficult.
• Dlll·ing laparotomy, inadequate space and exposure of
organs may make surgery difficult. Trauma to organs
occurs more in obese women, so also bleeding during
surgery.
• Postoperati,·e per·iod may be complicated b)' infection,
poor wow1d healing, thromboembolism and scar hemia.
• Pregu an cy
• Pregnanc)'-inclucecl h ypertension
• Insulin resistance and gestatio nal diabetes
• Macrosomic baby
• Increased incidence of caesarea n sec ti o n li kely because
of abnorma l position ca used by macrosom ia, cephalo-
pelvic disproportion and feta l d istress
• PuJtjJartum complication$; Reten lio n of we ight gain, post-
partum depression, thromboembolism a nd poor lacta-
tion. Poor lactation is see n in obese women. T his, in turn,
causes overweight infants th rough boule feeding.
• Contraceptive$: Hormona l conu·aceptives are contraindi-
cated in obese women.
• Functional limitations because of overweight are well known.
MANAGEMENT
Management comprises:
• Prophylaxis (pre\'ention)
• Treatment
PROPHYLAXIS
DIET
Proper balanced diet is the essential step in maintammg
normal weight. A bala nced diet sh ould co ntain 60%
carbohydrate, 20% protein and 15%-20% fat. Intake of diet
with 1800-2000 cal cla il)' is adeq uate, but also depends on
body weight (body weight [kg) X 35).
A diet containing fibres delays abso rpti o n and lowers the
glucose level.
Carboh)•drates sho uld be main ly of low gl)•caemic index.
Animal proteins with amino ac ids a re preferred.
EXERCISES
Yoga, mecUtation and regular exercises help in red ucing
weight. Rapid weight loss is not recommended, but! lb/ week
is safe.
Walking for half an hour daily for 5 days is sufficient to
maintain weight.
PREGNANCY
• Prepregnancy "eightshould be nonnal. Overweight women
should be asked to reduce weight before conception.
• 'v\'eight gain should be monitored regularly.
• Postpartum weight should be carefully mon itored. Most
women reduce weight and return to prepregnancy
weight by tl1e end of 3 months postpartum; othenvise,
diet control and exercises are recommended.
Breastfeeding prevents obesit) in infants. Obese infants
tend to remain obese throughout life, exposing themselves tO
diabetes, h) pertension, h) perlipidaemia and certain cancers.
MANAGEMENT OF OBESITY
• Diet
• Exercises
• Drugs -lipase, inhibitors
• Orlistat
• Rimonabant
• Sibutramine
• Surgery- bariauic li pectomy
• Gene therapy
DRUGS
Li pase inhi bitors are p resc ribed for obese women. T hese
are as follows:
• Orlistat (Reshape) is an a ntiabso rbe nt of fat and 120 mg
dail)' red uces 30% of fat abso rption from imestinal tract.
It also prevents absorption offaL-solub le vi Lam ins which is
a rusadvantage. lt a lso causes fatigue a nd depression.
• Rimonank reduces food intake.
• Sibutramine en hances safet) and is thermogenic b)'
inhibiting serotonin and noradrenaline reuptake. lt acts
centrally.
FETAL OBESITY
Apart from changing lifest) le, diet and exercise, the impor-
tant cause of adult obesity and its sequelae is fetal obesity or
what is also known as macrosomia. It is now realiLed that
fetal macrosomia is because of a disorder in the matemal
environment causes fat deposition in the newbom and in-
fant. Metabolic disorder thus sets in and continues through
adolescence and adulthood. Pregna ncy adds LO this meta-
bolic disorder and incr·easing weight gain during pregnancy
worsens the situation. Once obesity sets in, it is extremely
difficult to shed it off. Valious seq uelae of diseases follow,
impairing life and eve n ca using early dea th (Table 43.1).
Prevention th e refo re lies in managing pregnancy,
co ntro ll ing weight ga in and blinging back th e o riginal
prepregnancy we ight in the postpartum peliod. Con u·olli ng
Table 43.1 Classification of Disorder s of Obesity
BMI Classification
< 18.5 Underweight
18.5-24.9 Normal weight
Overweight
30.Q-34.9 Class I obesity
Class II obesity
>40.0 Class 111 obesity
 CHAPTER 43 - OBESITY AND ITS SIGNIFICANCE IN GYNAECOLOGY
preconceptional weight and avoiding obesity before preg-
nane>• are also very important for optimal outcome for the
individual and long-ter·m health benefiL
TREATMENT
SURGERY
When medicines fai l, stu·get) is resonedto as follows:
• Sleeve gastrectOm) and gastric b)pass Sttrgery are two
common!) done procedures for morbid obesity.
• Gastric Bypass surge f) t."lkes 3 hours to perfonn, but is a
one-time procedure.
• Li pectOmy may be helpful.
• Lapa roscopic ac!justable gasu-ic band (Lap Band) takes
half an hour LO perform, but the band needs periodic
adjustments, so follow-up is necessat)'·
• Gas u·ointestin al im planLab le electrical s timula tion of
nerves is be ing tried.
• Gene the rapy tn tl)' prevent obesity.
KEY POINTS
• BMI is used to rate a pe1'So n as overweight or obese.
• Obesity poses many health h azards in adult life and
some can be life-threatening.
• Common causes of obesity are well known and can be
rectified.
545
• Gynaecological problems 1·elated to obesit)' are men-
strual d)Sfuncr.ion, anovulatOI)' infertility, PCOS and
certain malignancies. IVF also )ields poor resultS.
• Obsteu·ic problems to obesity are considerable. Apan
from maternal complications, fetal macrosomia is now
considered a ve11 impo 1tant cause of adult obesity.
• Surge!") increases morbidities in obese women in
the form of infection , respiratOI) problems and
thrombo em bolism.
• Medical problems in ad ults impair qualit) of life and
ma> even catLSe earl) death.
• Prevent u·eau11enl, treau11enr. of obesit) often fails and
can be fntstrating.
SELF-ASSESSMENT
I. Disc uss th e haza rds of obesit)' in reproductive fun ctions.
2. Disc uss th e seque lae of obesity.
SUGGESTED READING
Green BB, Weiss NS, Rhk in relation
I<) body weight F'enil 721-726, 1988.
Laros, Abrams BF, Laros RK.Jr. AmJ Ob!.tcl Gynttol154(3): 503-509,
1986.
MA, <'i al. J Am Med A;;,oc 300: 2286. 2008.
Rayburn WF'. Clinics of 1\onh Amcric; 36(2) . 2009.
WIIO. Obesil)'· Technical repon >eri<.'>, 894. 2000.
 Instruments Used
in Gynaecology
Instruments Used to Retrad Vaginal Wall
and Expose Cervix 546
Instruments Used to Catch Anterior lip of
Cervix 546
Instruments Used for Dilatation of Cervix 547
Other Commonly Used Instruments in Vaginal
Gynaecological Operations 547
Instruments Needed for All Gynaecological
Operations (Abdominal or Vaginal
Surgeries) 548
A variet) of instrumenlS are used in gynaecology during
clinical examination, minor and major operations. Follow-
ing section describes these instrumenlS.
INSTRUMENTS USED TO RETRACT VAGINAL
WAll AND EXPOSE CERVIX
SIMS SPECULUM WITH ANTERIOR VAGINAL WALL
RETRACTOR
This is tl1e most commonly used instrument in gynaecological
pt·actices (refer chapter 42, Fig. 42.9). ItS uses include:
• Exposure of cervix to obtain Pap smear or cervical biopsy
• Exposure of cervix tO ca tch itS anterio r li p before minor and
major operations on ce rvix, endocervix o r endometrium
Dis(l(lvrmt.llgtr. lle lp of an assistan t is needed if some pro-
ced ure is to be pe t-formed.
Method ofi11JimmnH: It is done by autoclaving/
boiling in water/ p lacing in gluLaraldehyde solution (Cidex)
for at leastl5 minutes.
CUSCO'S SELF-RETAINING SPECULUM
This bivalve speculum when introduced in vagina gives a
good exposure of cervix for the purpose of OPD exami-
nation. obtaining Pap smear, obtaining cen1cal biopsy
or removing a small cervical polyp (refer chapter 42,
Fig. 42.1 3).
IF To \iew the k-cturc note> :.can the >)lllbol or log in I() rour account on
546
Instruments Used in Specialized
Procedures 549
Endoscopy Instruments 549
Instruments Used in loporoscopy 549
Instruments Used in Hysteroscopy and
Hysteroscopic Operative Procedures 551
Sterilization of loporoscopic
and Hysteroscopic Equipment 552
Advtmtagtr. It does not require the help of an assistanL
DistulvtmUtge It covers anterior and posterior vaginal
walls; hence, conditions such as fistula in anterior or poste-
rior vaginal wall can be missed.
Metlwd of sterilizatio11: It is clone through autocla,1ng/ heat
boiling/ Cidex.
INSTRUMENTS USED TO CATCH ANTERIOR
UP OF CERVIX
Whi le performing any procedure on endocervi.x and endo-
meu·ium, one n eeds to hold the anteri or li p of cervi.x to sta-
bilize the uterus. Some of these procedures are endome-
trial biopsy, endomeu·ial aspiration for histology/cytOlogy,
endocervical biopsy, di latation and curettage, hysteroscopy,
HSG and those during laparoscopy.
Commonly used insu·ume nts for this purpose are tenac u-
lu m, vu lsellu m, long Al lis forceps or a sponge-hold ing forceps
in pregnancy.
TENACULUM
It has a single pair of teelh to grasp the anterior lip of
cervix (Fig. II. I ). It is useful to catch the amerior lip of
cervix for procedures where dilatation of cervix is not
needed such as EB, £A, ECC, Copper-T insertion and HSG.
DistulvtmUtge lfa force is used to pull on cen1x, it can cut
through substance of cen ix.
Metluxl It is done through auLOclaving/ heat
boiling/ Cidex.

Figure 44.1 Tenaculum.
VULSELWM
This instrument has three to four pairs of teeth at itS catchi ng
end, tllUs giving a good grip of cen1x. It is useful in procedures
"i1ere dilatation of intemal os needs 1.0 be carried out such as
in dilation and curettage (D&C), h)steroscopy, removal of sub-
mucous polyp or fibroid or suction evacuation of pregnancy
(refer chapter 42, 42. 10).
It may ca use a small amount of pain while
ca tchi ng cervix. It cannot be used to ca tch p regnant cervix
as it may cause local b leeding.
Metlwd It is clone through autoclaving/ heat
sterili zation/Cidex.
LONG ALUS FORCEPS
Long Allis forceps can also be used tO catch the anterior lip
of cervix but gives a poorer grip of cervix as compared tO
vulsellum. lt ma) be desirable to catch the anterior lip of
cervix in a pregnant state b) either sponge-holding forceps
or Allis forceps (refer chapter 42, Fig. 42.11 ).
Method of It is done by autoclaving/ heat
ste•·ili.t:ation/ Cidex.
SPONGE-HOLDING FORCEPS
The ante•ior lip of cervix can also be held with a sponge-
holding forceps especially in a pregnant State such as during
McDonald stitch application or in a case of traumatic post·
partum haemor·rhage to explore cervix for tear (Fig. H.2).
Method of lleriliwtion: It is done by auLOclaving/heat
sterilization / Cidex.
Figure 44.2 Sponge Holding Forceps.
INSTRUMENTS USED FOR DllATAnON
OF CERVIX
For a va.-iety of conditions in ID naecological practice, one
may have to dilate internal os of cen·ix to gain access to
endomeu·ial cavity. A number of metal dilatOrs are used to
CHAPTER 44 - INSTRUMENTS USED IN GYNAECOLOGY 547
dilate internal os such as Hegar dilatOr and Pratt d ilator b ut
slow dilatation of cervix can also be achieved by devices such
as lamina.ria tent/lsabgol tent or by use of prostaglandin
gels or tabletS.
HEGAR DILATORS
This is the most common!) used metal dilator used tO
achieve dilatation of cen·ix. Dilatation of cen·ix is needed
in a v;u·iety of ID naecological procedures such as D&C,
fractional Cl.ll'ettage, h)Steroscopyand hysteroscopic proce-
dures, for drainage of p)ometra and haemawmeu-a. Dilata-
tion of cervix is also needed for MTP and evacuation of
missed abortion. Dilatation is a part of conservative ope•-a-
tion for prolapse uterus (Manchester ope•-ation). ln tl1e
management of cancer ce•vix by placing intrautel"i n e
so urce of irradiation, di latation of os is needed.
Hegar di lator has two ends which are used for dilatati on of
os. Hegar dilators are ava ilable "1 111 va ri ous d iameters which
are num bered at tl1e end of d ilata tio n (refer chapter 42,
Fig. 12.2).
Ge nerally for gynaecological operati ons, dilatation up to
nu mber 7-8 is needed. for h)•Steroscopic proce-
d uressuch as pol)•pectomy, resection of sep tu m and myomec-
LOm)', a greater degree ofdilatat.ion up to n umber ll- 12 ma)'
be needed to be ab le to inu·od uce resectoscope.
with the we of dik1tors. It is a painful proce-
dLtre; hence, adequate anaesthesia should be given as either
general anaestltesia or local paracervical block anaestltesia.
Perfomtion of uterus: Introduction of Hegar dilatOr with
force without adequate anaestltesia can cause perforation of
uterus. Two common sites of perfo•-ation are just above in-
tenlal os or fundus of uterus. Management of uterus re-
quires immediate suspension of procedure, checking pulse
;md blood pressure, looking for signs of inu-ape•iwneal
bleeding and giving proph)lactic antibiotics. Lap;u·oscopy/
laparotomy may be needed for features of inu-ape•iwneal
bleeding or sepsis.
OTHER TYPES OF DILATORS
A valiety of cen•ical di lators are avai lable; these include
Hawkins (refe•· chapter 42, Fig. 42.4), Pratt, etc.
OTHER COMMONLY USED INSTRUMENTS IN
VAGINAL GYNAECOLOGICAL OPERATIONS
UTERINE SOUND
T his long, fine instrument is used LO confi rm tlte length of
uterine caviL)' and its d irect.ion before insertion of Cop per-
T, before EA, D&C, hysteroscopy, etc. It can a lso be used to
locate a misplaced Cop per-T if strings of are not
visible on per speculum examination (refer chapter 42,
Fig. 42.12).
Comf>liwtion: lt ma) lead to perforation of uterus.
BLUNT AND SHARP CURETTE
This metal instn.1ment has blum and sha•·p curette at two
ends. lt is used to curette endomeu·ium in ID naecological
ru1d obsteu·ic conditions. Gene•-ally, blum is performed for
548 SHAW'S TEXTBOOK OF GYNAECOLOGY

a soft, pregnant uterus, whereas sharp end is used to cureue operation. It is a necessary instrume nt in any operation
for gynaecological conditions (refer chapter 42, Fig. 42.7). (Fig. 11.5).
ComplicatiotM: Perforation of ute rus, haemorrhage and
excessive curettage give rise to ad hesion formation in endo-
melrial caviL) (Asherman S) ndrome).

TUBAL INSUFFLATION CANNULA (RUBIN

CANNULA)
It is used to inu·oduce d)e in uterine ca,·ity during hystero-
salpingography or diagnostic laparoscopy (Fig. 11.3).

'
'------
. Figure 44.3 Rubin's Cannula.
• ., BABCOCK FORCEPS
Figure 44.5 Artery Forceps.

T his necessary insuwn ent is used for a va•iety of purposes.

However, tl1e most commo n usc is to ca tch fallopian tube in
INSTRUMENTS NEEDED FOR ALL
GYNAECOLOGICAL OPERATIONS tubectO my operati on. Its e nds are no ncntshing, he nce useful
(ABDOMINAL OR VAGINAL SURGERIES) to catch o tl1er su·ucw res (Fig. 44.1)).

SPONGE-HOLDING FORCEPS
T his instrume nt is needed in a ll abdo mina l and vaginal op-
erations. A gauge piece held at the Lip of this forceps is used
to clean operative field with solution (Fig. 41.2 ).
In aclclition, this instrument is also used for a variety of
other purposes during operations sud1 as displacing blad-
der downwards awa> from cervix in caesarean, hysterecto my
and other operations. In vaginal operation, it ca n be used to
catch the anterior lip of cervix in a pregnam State; a polyp
of cenix can be held with this insu·ument, twisted LObe able
Figure 44.6 Babcock Forceps.
LO catch pedicle of pol) p. For removal of Copper-T, threads
of Copper-Tare held with sponge holder and pulled clown-
wards. ·w hile doing D&C for incomplete abor-
tion or missed abortion, tissue visible at extemal os can be
HYSTERECTOMY CLAMP
held with sponge holder. Available as straight or cu•·ved-Lip instrument, it is extremely
useful in performing abdominal and vaginal hysterectomies
(Fig. 11.7).
ALLIS TISSUE FORCEPS
Avai lable in various si:tcs, 6, 8 and 12 inches lo ng, this instru-
ment is used to ca tch edges of rec tus sheath and edges of
tissue being dissec ted. It is not used to cateh vessel wall or
soft structure as it wi ll puncwre them (Fig. 44.4) .

Figure 44.7 Hysterectomy Clamp.

Figure 44.4 Allis Forceps.

TISSUE-CUTIING SCISSORS (METZENBAUM
ARTERY FORCEPS SCISSORS)
It is a\<ailable in \'<llious lengths and siLes \lith su-aight or Avai lable as slightly curved near Lip, this instrumem is used
cun·ed ends and is used to catch bleeding points in abdominal to cut rectus sheath, pa•·ietal peritoneum, tissues during
 CHAPTER 44- INSTRUMENTS USED IN GYNAECOLOGY 549

hysterectomy, and surgery on fallopian tubes and ovaries
(Fig. 11.8).
To avoid bluming of cutting edges, this instrument is
sterilized b) Cidex solution or E20 sterilized. AuLOclaving
will lead to blunting of cut edges.
hospital with considerably less postoperative pain. However,
all laparoscopic procedures require use of specially de-
signed equipmenL Most of these equipment are imported,
are costly and require a vel') careful handling (Fig. 11.10 ).
SOURCE OF C02 GAS

8
It includes large or small-si.t:ed C) linders.

# ( AUTOMATIC PNEUMOINSUFFLATOR
It indicates showing volume of gas insufflated, intraabdomi-
nal pressur·e and facility for automatic cut-off in case pres-
Figure 44.8 Metzenbaum Scissors. sure becomes too high (Fig. 11. 11 ).

SUTURE-cUTTING SCISSORS (MAYO SCISSOR) ENDOVISION DISPLAY SYSTEM

Available in various si:tcs, this insu·um e m is used LO cut the
ends of a Lied suwre. It is also ste rili zed by or Cidex
solu tio n. Autoclaving is avoided as it may result in blu nting
of cut edges (Fig. '1'1.9 ).
It includes hi gh-resolution TV monitor, a laparoscopic camera
and a camera con trol unit (Fig. '1'1 .12 ).
VERESS NEEDLES
Veress need les are used for insufflations of pneumoperito-
neum.

TROCAR AND CANNULA

UsLtally a trocar with 10- 11 mm diameter is used for intrO-
duction of telescope and a 5-mm trocar and cann ula is used
Rgure 44.9 Mayo Sdssors.
for introduction of ha nd instrume ntS (Fig. 11.13).

INSTRUMENTS USED IN SPECIALIZED

PROCEDURES
MYOMECTOMY CLAMP AND MYOMA SCREWS
These ar·e needed at limes while perfor·ming m>•omecLOmy
operation (refer d1apter 13; Fig. 13.20 and 13.22).

TUBOPLASTY PROCEDURE INSTRUMENTS

These are fine instruments used to hold tubes while rean-
aesthe ti:£ing cut edges of tubes.

INSTRUMENTS IN VESICOVAGINAL FISTULA

REPAIR
These curved fine instruments a re used for exposure of
margins of fistu la, for dissec tion of b ladde r mucosa awa>' Rgure 44.1 0 Instruments needed for diagnostic laparoscopy.
from vaginal mucosa and for clos ure of fistu la.

ENDOSCOPY INSTRUMENTS
These are described in the chapte r 41 on Endoscopy.

INSTRUMENTS USED IN LAPAROSCOPY

Laparoscopic procedur·es ha'e gained a lot of popularity
in modem ID naecology. They allow early discharge from Rgure 44.11 Cold light source.
550 SHAW'S TEXTBOOK OF GYNAECOLOGY

TELESCOPES
Telescopes of 10-11 mm diameter are used for visualization of
pelvic and alxlominal organs. Thinner telescopes of mm
diameter can be used for )Ounger patientS and for diagnostic
procedLu·es on I).

COLD LIGHT SOURCE

For visualilation of intraabdominal organs, a cold light
source of xenon light is used.

HAND INSTRUMENTS
A variety oflaparoscopic hand insu·uments are used depend-
ing on tl1e procedure being undertaken. These include
graspers, claw forceps, laparoscopic needle, laparoscopic
Babcock, etc (Fig. 11.1 1).

VESSEL SEAUNG DEVICES

Figure 44.12A Endoscopy cart.
In advanced laparoscop ic proced ures such hyste rectOmy,
there is often a need for using Camery so urce wh ich may
seal not onl>' small size vesse ls blll also medi um s i:te vessels.
For this p urpose a number of equi pments are availab le,
these include hanno nic scalpel, ligasure and 0 1.her similar
devices as shown in Figs 11. 15-11.1 8.

Figure 44.128 Endoscopy display system. Figure 44.14 Instrum ents used for operative laparoscopy.

Figure 44.13 Disposable trocar and cannula. Figure 44.15 Vascular sealing device.
 CHAPTER 44 - INSTRUMENTS USED IN GYNAECOLOGY 55 1

INSTRUMENTS USED IN HYSTEROSCOPY

AND HYSTEROSCOPIC OPERATIVE
PROCEDURES

Close to list of equipment used in laparoscopy, a variety of

eqLLipmem are LLSed in diagnostic and operative hysteroscopy
(Fig. 11.19).

TELESCOPES
These are generally 1 mm in diameter and are inu·oduced
wilh outer metal sheath. Mostly, t11e outer sheath has an
inlet for introducing a distension medium. For oper·ative
hysteroscopy, an additional side channel may be available
Rgure 44.16 H.,.-monlc device.
for introducing Aexible instrum entS such as brush and
biopsy forceps.

COLD LIGHT SOURCE

Some cold light so urces used in lapa roscopy ca n be used for
hysteroscopy.

ENDOVISION DISPLAY SYSTEM

A system which is used for laparoscopy can also be used for
hysteroscopy.

ENDOMETRIAL CAVITY DISTENSION MEDIA

Both saline and nonionic gi)Cine are tLSed as distension
media dLU;ng h)Steroscop). A check should be kept on the
amount being pLLShed in and tl1e amount which relllrns.
A Auid deficit of more than 600-800 mL, especially if it is
glycine solution, can lead to pulmonaq• oedema.

Figure 44.17 Unipolar and Bipolar Cautery.

Rgure 44.18 Vessel sealing device. Rgure 44.19 Instruments used for hysteroscopy.
552 SHAW'S TEXTBOOK OF GYNAECOLOGY
AUTOMATIC FLUID INFUSION PUMP (HYSTEROMAT)
SPECIAL INSTRUMENTS FOR HYSTEROSCOPIC
SURGERY
A varieL) of insLruments are used for hysLeroscopic proce-
Lhese include Collin knife, TCRE resecLoscope Ioupe,
ball e leCLrod es, graspe rs, eLc.
STERIUZATION OF LAPAROSCOPIC
AND HYSTEROSCOPIC EQUIPMENT
Because of risk of damage LO fine optics and fine instru-
me nts, auLoclaving is noL preferred. There are special de-
vices which are used Lo sLerili£e e ndoscopic insu·ument; one
such device is called 'plasma'.

A 86, 90, 94-95, 233,275
Atxlo min a I hysce recwmy, I 84, 456
in endometriosis, 183
Abdominal mass. 351
in fibrom)omas. 155-171
in genital tuberculo.i.s, 35 I
Abdominal pain. 96
in cndometriosi>, 174-185
in pchic tuberculosis, 3, 248
in PIO, 337-343
in puberty, 75-86
Abdominal sling operations, 297-298
in genital prolapse, 28!>-30 I
Abdominocervicopcxy
in genital prolapse, 28!>-30 I
Abnormal bleeding, 2, 123t,
128-140. 130f, 147, 192,218,241,
263,463.510,514,525,528-529
Abon ion. 303
Acne. 120
sten<»is. 214
14 if
Acute pchic pain. 245-247, 251
Actmqmycts, 346
Actinom)dn 0, 488, 492
in trophobl..,tic diseases, 491 t
Acut c salpingitis, 339-340
Add·hack tl1crapy, 198
Addi$!Hl's disease, 95
Adenocarcinoma, 409f
Adenohypophysis, 50
Adenomatous polypus, endometrium, 139
Ade nom}omatous polypi, uterus, 139
Adenom)OSis. 162, 174-187
clinical examination, 185-186
diagnosis. 179
>)mpto•m of. I 78-179
treatment, 18&-187
AdcnOill)O>b uteri, I 86f, 248-249
Adherent placenta, 284
Adnexal rna.., !>-6, 179,351,510
Adol e.ccncc su puberty
Adolescent conU"dccption, 84-85
Adolescent gynaecologic problem>, 75-86
Adolescents, 82, 275,457
contrdception for, 275
hormonal contrdceptive>, 275
I CCO, 275
Adrcnogcnital syndrome, I 14-116
tre.umcmof.ll6
AID$.255.346.365-366
Aldo>terone. 114-1 I 5
in .idrenogenital S)ndrome, 114-115
in 126
Alii>' forcep•. 26(}...261, 281
dru!,'S, 390
in incontinence. 388
Alpr.ttolam, 127
in PMS, 127
Alpn>stadil (prostaglandin), 212
in male infertility, 203-212
Altheimer disease, 89
Index
Azithromycin, 361
cugonadotropic, 141-142 in AIDS,
imestig.ttions in, 149-154 in lymphogranuloma \Cncrcum. 360
managementof, 144-146 Azoospermia, 207
primary, 141- 146 management of, 210
classification of, 141-142 Azygos arteries, 29
secondary, 14&-154
aetiolog); 14&-149
iiH'('Stigations in, 149-154 B
treatment of, 150 Backache, 2, 89, 178-179. 184-185,250-251,
Ampicillin, 333 291,302,303,343
in urct hrit.is, 376 Bacterial vaginosis, 330
Anaesth<-">ia, 372-373 characteriStiC> of, 330
in retention of urine, 372-373 treatment, 331
Androblastomas, 463 Bactericidal cre-ams, 334
Androgen insensiti•ity >yndromc, 108 stt-<J/so in vaginitis, 334
1es1icular feminizing ))rndrome Baldy-Webster opemtion, 304
191-192 Ball's operation, 321
in impro,ing libido, 191 Barium enema, 510
Andro>tenedione, 46, 54 Barium meal follow through. 510
Anorexia nen"OSa, 83 in o'arian ntet"Qtatic dbcaM"". 510
Ano\'ulation, 40, 4!>-46 Barr bodies, 109-110
management of, 222-223 Bartholin's absce», 320, 362-363
Ano\'ulawry menstruation, 59 Bartholin's cyst, 319
Antifibrinolytic agents, 136 Bartholin's gland, 15
in menorrhagia, 130 Bartholin's gland tumour. 478
Antihistamine>, 320 Behcet;yndromc, 321
in pruritus vulva, 320-321 Benign ovarian cysts, 444, 452-456
Anti-M1illerian hormone (AM II), 54, 86 differential diagnosis, 454-455
Anti-o<.-strogens, 192 invesligalions in, 455
Antiprog<--sterone, 195 ph}sical signs, 453-454
Aparcunia, 214 symptoms, 452-453
gland$, 13 tre-.ument,
in hidr.tdenoma of mlva, 13-15 Beta-hCC, 483
Applied anatOmy, 33-35 Bethesda dassif1Cation, 409
Arias-Stella reaction, 46 in dysplasias, 409-410
Arrhenoblaswma, 66 Bicornuate uten1>, 70. 163
Arterial embolization, 51 (}...511 Bilateral salpingo-oophorectOill) (BSO). 470
in trcaunem of bleeding, 511 Billings or o\'ulation method, 253-254
Artcriograph); 510-511 Birth control, 252-263
Arthriti>, 88, 89 need of, 2:52
Artificial insemination, 203, 210 Bladder
in 203 anatomy, 24
technique> used for, 210 fist.ula, 3 79-395
Artificial urinary sphincter (AUS), 390t injury, 380
Artificial vagina, I 16 stress incontinence, 374
Ascites, 162 Blocked fallopian tubes, 210
>yndrome, 350 Blood sugar e>timations, 538
Aspirdtion of pouch of Dou1,>1as B. melaninogenicus, 338
se culdocentesis Boari-Oap operation, 384
reproducti\-e technique> (ART). 203 in ureteric llstula, 384
in female infertility, 212 S)"Slem, 345
in male infertility, 203-212 of prognostic ""'ltouion. 34:5
Atheru.clcrO>i.s, 89 in PlD, 345
Atrc.ia recti, 73 Bone mineral den,ity >tudy. 90f
At)pical squamous cell ofundctcrmin<-d Bonney's test, 388
>ignificance (ASCUS), 9t in stress incont,i ncncc, 388
Augmentation 'clam' cystoplasty, 394 Bowen's dise-.a.se, 475
Autosorn<-'S, 109 B. proteus, 375
Autoimmune diseases, 95, 322 Br.tchytherapy, 495-497
Avascular necrosis (AVN), 209 Br...tin met.astas.t:.-s, 491
Ayrc 's spatula, 7 Bmxton Hick$ contractions, 4
553
554 INDEX
Brea.>t cancer, 91, I 02-105
in' I I 04
progn<»b, 105
I 04-105
Breast lump. 99
im I I 04
trt:'.tunentof. 104-105
Breast tcndcmcs:.. 181-182
Breast. 99-105. 254
benign tumour. of. 100-102
changes in. 79
congenit.tl defomliti<.'> of,
examination. 99
Breastfecding. 99, 459
Brenner tumour, 96, 444
Broad ligament, 21, 308
haernatoma of, 309
Broad lig-.unent cyst>, 308-311
par.to\arian cysa., 308-309
Bromocriptinc , 99, 199,209
in ano"Jlatory infcnility, 199
in cyclical mastalgia, 199
in PMS, 126
in supprc.,ion of lactation , 199
Burch colposuspcnsion, 39 1
Buscrclin, 198
c classification of dru!,>S, 501-503
Cae.arean >tar e-ctopic pregnancy, 243
Cae.arean >L'Ction, 402. 405
Cakarc'Oll> degener.1tion, 159,449
Calendar method, 253
Call-Exner bodic">, 38
Cutter
of the \'uh·.t, 472-480
actiolog). 473
das:.ifJCation. 4 73
clinical feature.. 473
incidence of. 473
imcstigation>. 473-474
management. 4 74
preim'aShe. 4 73-475
staging, 475
Cancer cervix. 420-429
clinical ft:'.tlllrc'>. 421-422
diagnosis. 424-425
pat holo)O'· 4 20
st..ging. 422
lre-.uuH::ru, 426
Candida! \".tgi nit is, 365
clinical feature">,
diagnosis,
risk factotll, 365
treauncnt, 3f.J.:j
Candidiasis, 1-2, 7
Capsular haemorrhage, I() I
Carcinoma, 4721'
of cervix, 378, 480
aetiology, 473
clinical features, 479
differential diagno>b. 422
epidemiology. 475
rnanage::n'lcnt, 474
>taging of, 475
of uteri, kt
of endometrium,
Ctntnculae m}Ttiforme>, 21 !l, !l96
Cauterization tcdlnique, 27!1-274
failure r-.tte. 27!1
Ca\'aterm balloon thcr.tp), 136
CD, count. !l66
Ccfotetan. !l44t
Ccfoxidn. !l63
in !,'Onococcal \-.tginiti>. !l62-!l63
Ceftria.xone, 361 Clomiphene citrate (Cqlltillu,d)
in chancroid, 361 in 192
Centduornan, in 'itro fcrtilir..alion, 192
contraindications of, 270 Clue cclh, 330
in emergenq,. contr.tception. 270 Coelomic metaplasia theory, I 74
pregnancy rate, 269 Coincident rurcinoma of uterus and
side effectS, 268 •1&1-'165
Central nervous system {C:\S). 141 Coittl>, 212
Cephalosporins, 376 Coittl> 206, 2.?:lf
in urethritis, 376 Coll.ttcr.tl ancrial ciratlation, 3 It
Cerazeue, 266 Colour flow Doppler, 208, 455
Cenical cap, 399 Colpocente.b, I 7
Cenical d)osplasia, 409 Colpocleisb, 299
Cenical d)'Stocia, 396 Colpoperineorrhaphy, 294
Cenicalllbroid, 157-1 61 Colpo;ropy, 10, 479
Cenical glands, 19 Colpo>ttSpCnsion, 391
Cenical intraepithelial neoplasia (GIN). 9t Combined oral pill,
Cenical mucus, 46 b<=nelia. of, 264
fern test, 46 contrdindications of,
Cenical pr(:!,'llan(.y, 242 >ide dfccts of,
treatment, 242 Complem ent fixation test, 360
Cervidt is, 256 Comput cl'assistcd sem en ana lysis (CASA),
Cervix, I:>- I 6 22:;
descent of, 287 Conception, 11 2, 203
dong.u.ion of, 290 Condom s, 252, 254-255
Chassar Moir technique, 383 advancagcs, 255
Chemotherapy, 494 dis.advanlagcs, 255
for gynaecologic cancer, 500-505 Con dylomata acuminata, 357-358
diagnosis of, 358
t.um<>ur cell kinetics, 500-50 I trcauncn 1, 358
Chlamydia trachomatis, 363 Cone biop>)', 414
Chlamydia, Congenital adrenal hyperplasia, 76
diagnosis, 364 Contact \'uhitis, !l20
treatment, 364 examination, !l20
Chlarnydial infection, 7, 363 Contiform. !l90
diagnosis, 330 Contmception, 252, 257
treatment, 331 a woman hith medical disease, 276
Chocolate LJSt, 130 for women O\Cr the age of35 )ears, 276
Cholecystitis, 34 2 l.lctdtional amenorrhoC"a, 27:>-276
Choriocarcinoma, 481 method. of, 276
'cannon hair metastases in lungs. 490 po>tcoital contracep1ion, 270
differendal diagno.is of, 490-491 >uppre..ion of
inddence, 489 O\'\tlation,
signs of, 490 >pennatogenesis, 277
symptOms of, 490 >uJl.,.;Cal >terili1.ation, 271
treatment of, 491-492 Con1if1Cation index, 327
chemotherapy, 491-492 Conntal re.ection, 272
surgery, 492 Corpu> luteal haematoma, 235
Chorionioillus biop;y (CVB), 109-110 Corpus luteum, 313
Chromosomal sex, hy.tlin i1.a1 ion, 40-4 I
Chronic interstitial salpingitis, 340 of pregnanty, 40
Chronic pelvic pain ;;yndrorne (CPPS), 249 of the menstrual 41
Chronic pelvic pain (CPP), 247-251 rc trogn:ssion of, 40-41
aet iology, 247-248 (.orticostcroid thcmpy, 95
history, 249-250 in autoilmllll llC disease. 95
investigations, 250 (,ortisol thcmpy, 11 !>-116
management, 250-251 in postnatal adrcn ogenital syndrom e,
Chronic pyosalpinx, 340 11 5- llfl
Cicatricial stenosis, 373 Coue 's ope rat ion, 12fi
Cimetidine, 120 Cracked nippk-s, 99
in acne, 120 Cn:acti\'C protein, 343
Cipn:>Ooxacin, 361 Crimin al abort ion, 284, 338
in chan(.Toid, 361 Crohn's dise>t.SC, 321
Clear cell cardnoma, 444 Cryptomenorrhoea, 142
Climacteric, 86-87 CT .can, II. 151
cancer, 437t Clindam ydn, 331,344 Cubittl> mlgus, 112-113
in dllarnydial infeL'lion, 363 in 1\1mer's >}11drorne, 112-1 13
Clitoris, 398 Curnulu> oophortl> s" !,<r.taf.an follicle
Clitoroplasty, 115 Cti>CO'> >pL'CUIUtn, 4
Clomiphene citrate, 192-194. 222 Ctl>hing'• >)11drome, I 15-1 16
in ano\'ulation, 223 C)clO>porin, 209
in ano\'ulawry inferulity, 222 in male infcrtilit), 210
in female infertility, 212 Cyproterone acctue, 118, 196
in male infertility, 203- 212 in hir>utism, 191,315
in pol)'C)'SliC o''arian disease (PCOO). 35 Cyl>l ic h)perplasia, 133
 INDEX 555

C}'>tOCch:, 287-290, 291 Dysm enorrhoea, 34, 124-126 Endoscopy, in gynac,'Oiogy,

C}'Stadcnocarcinoma, 442 aetiology, 124 Entcrobitl> \ crmiculari$, 320
Cj-'>tO>Copy, 374 clinical fe-auues, 124-125 Enterocele. 287, 298
C}-stOu n:thrography, !l89, 510 investigations, 125 immunosorbent assay
C}tOhormonal cmlu:uion, 10 treatment, (ELISA), 337, 364
C)-•tolog)'. 328 Dyspareunia, 2, 212, 376 Epidid)mal or te>tkular a.spir".ttion (:\fESA,
of \'agina, 328 causes of, 213 PESA), 211
due 10 male partner, 213 Epimcnoni>OC:I, 2, 123
due 10 female partner, 213-214 Epoophoron, 23f
D investigations, 214 Erogenic are-.t>, 202-203
Danazol. 90. 99. 191 treatment, 21 4-220 El')1hroc)1C .edimentation rate (ESR), 351
in AIDS. Dysp la.ias, ce nix, 409-4 18 El')throm)cin, 361, 362, 364
in bre-..st disc aM.'>. 99 diagnosis, 411-412 in !,'T.tnuloma in!,'ltinale,
in decre-..sed libido. 191 !,'l":tded as, 409-410 in lpnpho;,rr.muloma """"ettm, 360
in dysmenonilOc.t, 124-126 treatment of, 414-418 U.ure de,ic.e, 274
in 192 Dystrophies •ulva, 319, 322- 325, 323t Ethacridine lactate, 283
in fibrocp.tic of brc:-.ts, 192 Dysuria, 89, 376 in MTP, 283-284
in gynaecoma>tia, 192 Et hinyloc>tr.uliol (EE1), 263-265
in mak infertility, 192 E Evening primrose oil, 99
in PMS, 126 E. coU, 333, 337,375 in breast diseases, 100
l}drifct>acin , 394t Econazole, 321 Extern al iliac glands, 32f
in inc.:ontincncc, 384 in pruritus vulva, 320-321 Extern al urin ary meatu s, 14- 15, 24
Decubitus ulcer, 290 Ectopic gestation, 228-244, 342
Dchydrocpiand rosten e dion c ( 0 I I £A), aetiok>!,'Y of, 229 F
116 caesarean scar, 243 Faecal incontinen ce, !18
Delayed puberty, 82 differential diagnosis, 234-235 Fallopian tube, 2 1-!13
causes of, 82 incidence, 228-229 ftmbtial end of, 2!/f
Denver •Y•tcm, 109f investigations in, 236-237 layers of, !12
Dcrm uid cy.t of ovary, 44 6f ovarian pregnancy, 230-232 lymph atics of, 2 1
Dctruwr in•tability (0 1), 393-395 tubal prct,'ltancy, 230 methods of testing paten cy of, 22-23
in 393 persistent ecwpic, 243 normal, 20
•Y"' ptom>, 393 physical signs of, 234-235 parts of, 2 1-!1!1
treatment, 393-395 •ymptorns of, 233 ampullary, 22
Dcxametha><>ne, 209 treatment of, 23 7-240 22
in hir.uthm, 116-120 !)pes of, patency of, 22
in male infertility, 203-212 un ruptured, 240 Fallopian tube cancer, 469-471
Dcxarnetha>onc ACfll lC>l>, 118 treatment, 241 clinical fc•llure., 470
Oiabcto. 1-2 Ectopic pregnancy S« ectOpic gc.tation >Urgical >Ulging, 470
Diagnostic laparO>COp) m laparO>COp) Ectopic ureter, 73 Faii<»<:Op), 530-5..'11
Oiathcrn>) cxci>ion. 376 Ectropion, 326, 329 Falopc ring>. 525
Oiqclominc, 394 Electromyelography, 403 Famil) planning
in stress incontinence. 384 Elephantiasis \Uha, 325 methods in, 270-271
Dienoestrol cream. 189 Embolization of uterine artery. 168-169 Fcinbell{-\\'hiuin!,'lOn medium, 7
in senile vaginiti>. 87-88 Emergency contraception, 275 Fem.tle (!,oenilal) O'l,>ans, 6 1--64
Difficult coitw.. 214 preparations a'ailable for, 270 De\clopment, C. I
Dilatation and curcu.tge (O&C), 96-97 End-t<>-<:nd anastOmosis, 405, 526 extental genitalia, 107, 110
Discus proligcrw. sl'!'gr.tafian follicle Endocenical cancer, 419 b'Onad, 65-66
Disst:minalt..'"tl coagulation Endoderrnal sinus tumour, 461 M Ctllerian duets, 66--6 7
( DI C), 246 Endometrial cancer, 163, 166, 432- 438. 448 dc,elopmental defects, 66
Di,·cniculitis, 342 clinical features, 434-435 h ermaphroditism, 66
DNA study. 474 differential diagnosis, 436 MCtllerian duct anomalies, 66
DNA virus, 368 managem ent of, 493t rectum and an al can al, 73
Dodcrlcin 's bacilli, 7, IG, 326 St"!,>ing, 436 renal tract anomalil$, 5 10
DonoV'.tn bodic:; stt 1-,rranlalom a ing,ainale Endom etrial hyperplasia, 134f, 139 Wolffian duct anomali<:s, 73
Doppler uhr.JM>und , 237, 249 Endom etrial laser intrauterine therapy, I !l8 Female infertility Sl'f infertility, female
for pelvic congestion, 250 Endom etrial polyp, 172 Female orgasm, 20!1-203
Dox En dometriosis, 46, 174-185, 224, 325, !JSO Female pseudohermaphroditism, 108, 116
in chronic PIO, 343 aetiology, 174- 175 1nanagcmcnt of, 116
in lymp hogranuloma venereum, 360 classification of, 176-177 Feminism,ll2
Dro1avcrinc, 125 American Fen.ility Societ y, 177t male pseudoh ermaphroditism, 108
Dry day., 253-254 clinical features, 178 supcrfcmale, 113
Dry vagina, 89, 333 differential diagnosis, 179 1\trncr's >)'ndromc, 112- 113
Dual-energy X-ray ab>orptiomctry im·estigations, 180 Fcm;hicld, 256
( DEXA), 89 man agernentof, 180-184 of, 25 7
Dual photOn den>itometry. 517-5 18 drug treaunent, 180-183 failu n: r.ttc, 256
Duma. cap, 256 minimal in,-asi\'t: 183 ':,operation, 213
Dupha.ton, 92 physical findings, 179 Fent lC>l, <16, 220-221
conu·..indication>. endocrinologic abnom>alitio. I 79 FertiliJation, <16-47
failure r".tle of. prophylaxis, 180 procc» of, <16-47, 106, 202,211
in>ertion of. 255 Endometriotic cyst, 335, 342 Feta! los., 2 I I
D)drogcstcronc. 151 Endometrium Fetal 0\<11'), 37
D)e tesL 22 of the uterus, 41 Fibroadcno.i>. I 00
D)ing cells. 500 in proliferati,·e phase, 41-42 Fibroid, 91, 24:>, 343,507
D)-saesthetic \'\thodynia in secretOry phase, 4 2-43 mirror imaJ.,re. 516{
D)'>gemtinoma. 463 menstruating, 43-44 image, 5 16f
556 INDEX
Fibroid> complicating pregnancy, 171
Fibroma o\·ary, 449-450
Fibrurnyont:..b, utcnt!), 155
aetiology. 155
ccnical. 157
complication> of,
differential diagno.b, 162-163
imestig.uion> in. 16S-1&1
ph)',ical sign> of. 162
secondal') chango in. 158-160
atroph)'· 158
calcareous degcncnuion, 159
red degencr.uion. 159-160
sarcom.uous dungc, 160
sym p10ms of, I 62
lrt:'dln>clll, 164-171
FlCO scaging, 4301, 4661, 49 II
Filshie clips, 273-274, 52.?
Firnbrieccomy. 272
Finasceride, 119, 196
in hirsucism. 116-120
a>pir'dlion
514
' Firsl pa,s· <:ffecl, 92
Fi st.ula-in-ano, 6
Filz-l h.rbth-Curcissyndromc, 363
anlibody
absorpcion lcsl, 362
Fluoxccinc, 127
in PMS, 126
Flutamidc, 119, 196
in hirsutbm, 116-120
in pro>tatic hypcrphuia and cancer, 196
Fok-y catheter, 218
Folic acid, 483
Follicle atre>i a. 39
Follicle-otimulating hormone (FSII ), 39
Follicular C)'>l>. 312-!ll!)
Follicular haem atom a>. !ll!)
Folliculostatin stt: inhibin
Forbcs-Aibrighc >)1ldrome, 142
Forceps delhel'). 40!)
Fossa na,icularis. 13
Fothergill's repair opcnuion, 146
in genic.dl prolapoc. !lOO
Frankenhauscr plcxu.. 29
Frei 1es1. 360
Frohlich S)'lldromc, 142, 145
Fro>.c n pchis. 343
G direc1 craurna, 398
Galac10rrhoca. 100
U'laJ'Iagcmcnt of, J{)()
Game1e incmfallopian 1ransfcr {C IF'T)
cechniqu<:, 210
indicalions fl>r, 210
Gamma benzene hexachloride, 35f>-357
in pcdiculo>i> pubis, 356-357
Gamma-linoleic acid (CLA), 99
in PMS, 126
Garcnerc)'>t, 73
Ca. ernboli>tn, 526
Ccner'dti\'e organ>, 61-64
of, 73
Gene therapy, 503
Genetic "'"• 106
Genital cancer. 402
Genital fistulae. 379-!l84
classification of. !lSO
clinical feature> of.
causes of. 380
imestig.uions in. !l82-!l8!l
rnanagemenc of. !l8!l-!l84
poscoperati\ e managcmcm, !lS!l
Genital organs, 13, 402 Gilliam'$ opcmtion, 304
Bartholin's gland, 15 in n:tro\ crsion, 304
bladder, 23 Gimbcnl;.U':, lig.uncnt, 32
blood \'CSSCis in, 28 Gland of Cloquet. !l2
developm ent of the lower, 63f Gland of Ro.enrnirller, 32
fallopian u rbe, 22 Glucocorticoid>, 194, 196
parts of, 21 - 22 in :drcnal h)pCrpl:uia, 196
labia majora, 33 in hil'>uti>m. 50, 116-120
labia minora, 24 in infcrtilit). 188
l)mphatic dntinage, 33f in PCOD, I!H-195
nene supply, 24 Gl)CCI')IIrinicr.ue, 12.?
of che child, 18 in 12.?
o'ary, 20f Gl)cinc' 527
pehic cellular tissue, 2S..29 Conadocropin-rele-asing hormone (Gn RII),
pehic musculacure, 25-28 48,200
urecer, 30 acciono of, 197
urelhr.t, 2S-24 197
urogenit.tl diaphr.tgm, 26-28 analogue•, 197-200
ucerus, 19 in corpus luceal pha.,;e deficiency, inferrilicy,
layen; of, 22 190, 199
posicion of, 28 in CI')'[>IOrchi$m, 197
(FNAC), 100, vagina, 34 in d)l>fun clion al ul erin e bleeding, 128
relac ions of, 23-24 in d)l>m cnorrhoca, 124- 126
vuha, in early aborlions, 197
Ge nital prolapse, 285-301 in cnd01nctriosis, 190
aec iology of, 287 in hypothalamic 197
classification of, 287-291 in hypolhalamic h ypogonadal infcnility,
differential diagnosis in, 292 197
in\·(."Stigdt.ions in. 292 in induction ofnn rhiplc ovulacion, 197
of JX>$terior vaginal wall, 290 in PMS, 126
of uterus, 290, 292 in prt-<:ocious pu bercy, 197
•ym pc<nns of, 291-292 in preventing O\'Uiation. 55-56
treatment of, 29S-301 in primary and st'<.-ondary 197
Genital ridge, 61 in >hrinkage of endom etriosis, 50
Genital tract, 7, 32S..329, 472 in :,upprc).')ing menstruation, 49
abnonnalities, 524 •ide of, 50
bacterial examination, 7 Gonadal dy•gcnob SNTumer's S)ndrorne
congenital defects in, 214 Gonadal .ex, II 0
de\·elopmem, 61-64 Gonoc:occal nrhontginilis, 362-363
396-397 363
direct trauma, 398 diagno.h, 364
due 10 coitus, 397 cpidemiolol!). 366
due tO foreign bodies and inscruments. labordlory ime.tigations, 363
398- 399 manaf.,retnent, 369
creacment, 399 Gonorrhoea Sf<' sexually cransmiued diseases
laparosoopic appearance of, 521 f (STD.)
obscelric, 399 Co>erclin, 50, 197
Cenicalcract cancen;, 4 72 C<»>ypol, 277
Cenitalcracc injuries, 396-406 cn.aftan follicle, 39
chemical bums, 406 face of, 39
coical injuries, 397 layers of, 40f
shape, 38
forei&., body injuries, 39S..399 Crdln 36 1, 363
inscrumencal crauma, 396-397 in&•trinalc, 32 1
mucilacion, 398 Cr.m11IOS<1 cciiiUmollr, 447-448
obscecrical injuries, 396-397 Craves' disease, 148
Gcnitalcuberculosis, 139,207-208,229,25 1, Cravlec 's jel wash cr, 97
522f Griseofulvin, 319-320
differential dia&.,osis, 352-353 in tin ca cruris, 3 19-320
invesc.igdc.ions in, 351-352 Growth h ormon e, 5 1, 155
mc:>de of spread, 34 7-348 Cynat'<.'Oiogical diagnosis, I- ll
prognosis. 354 cchical in, I
•ym pt<nns, 350 ill\c.stigation.s in, 6-11
treatment, 35S-354 rt:<:tal cX<:unimuion , 6
chemotherapy, 35S-354 hb tory. 1-3
s urgel')·, 354 p;ut and personal, 1-2
Genuine stress incontinence (GS I). ph)-sical examination, 3-4
385-!l86 pre>cnt ill no>, I
Geren cell u rmour, 444-447 206
Gestational trophoblastic dbcasc (GTD) C)1landrobla>loma, 449
stt: trophoblastic disease>
Geslrinone, 183, 192
Giani cells, 348 H
Gifl, 192, 210, 211, 225, 524 ll.tbitt••l aborcion>, 535
Gigantism, 147f ll.tcm.uocolpo>, 68f
 INDEX 557

Haem oglobin pcrccmagc, 488 Hydrosalpinx, 340 Interferon. 321

llaemophilu> ,-,.gin alb, 3!l0 17-1Iydroxyprogesterone, 114-11 5 lnter>ex. I 08-109
Haemorrhage, 274, 526 in female pseudohennaphroditi>m, 116 cht» i lit'<l , I08-109
Haemorrhoidal 'cin>, 31 in \irilism , 114-116 ime,ligation:, in, 116
llaemo>ta>b, 398 H}men, 14f lnter.titial libroid uteru>, 157f
llalban '> dbca.c. I 39 imperforate, 67 lnter.titial pn!gnan<:), 240
llanging drop prcpar.uion, 7 I Iyperprolactinaernia, 117 Intertrigo, 319-321
llcparin, 87. 90 lh)TOid tests, 222 trc;nmcnt of, 321
llcpatitis B. 210 treated "ith, 222 lntc.tinaltr.tct, 39&-406
llermaphroditbrn. 66 ll)perstimulation syndrome, 193 fat'Cal incontinence, 403-404
llerpes genitalis (Ccnit.tl herpc>), 359f I I)pertension, 89 cau.>e>, 403
symptoms of. 36<1 lltperthecosis, 117 itl\atigations in, 403
treatment. 365 ll)pOmenorrhoea, 2- 3, 123 S)111ptonl>, 403
llerpes simplex, 473 lltpothalamus, 48 1real men I, 403-404
lie rpcs zos tcr, 150 llypospadias, 66, 205 types of, 405
Het.e rowpic pre),'IMncy, 243 llyskon, 527, 530 '"b<inal delivery, 403
lligh density lipopr01cin (IIOL), 50,90 llysterecto my, 240 lnt mcywplasmic semen insemination (ICSI).
Hilus cell tumour, 116, 449 in interstitial 232 207-208
Hirsutism, 50. 114, 116-120 llysterosalpingos;r.tphy ( IISC), 216-217, indicated in, 207-208
causes or. 117 507-511 h aemorrh age, 234
clillical 117- 11 8 advantage of, 217-218 ln tr.uucrinc contracept ive d evice (IUCD), 2,
endocrinology, I Ui-117 bicornuate ute rus, 21 if 19, 2:;7-263
invt.-stig... tion:; in, 11 8 bilate r.il hydrosalpinx, 217f of, 262
management , 118-119 complications of, 217 carrying d cvict'S, 257
llis tolob'Y• 101; 37-47, 352, 41!4 findings in, 217-218 and lcvonova, 258
cndonH:trium, 45 genital tuberculosis, 509 complication s of, 261
ovary, 39-40 indications for, 509-510 concmindications of, 266
vagina, 45 1nullerian anomalies, 516 mechanisn1 of ace ion, 261
IIIV 473 normal, 220-221 tech niqu c of insert ion, 260-261
hMC, 222-223 patent fallopian tubes, 508-509f ln tmutcrine growt h retardation ([UCR), 482
ill male infcrti lity, 203-212 technique of, 219 lntmvcnous ( IVP), 164, 3 10,
llodge !l04f Hysteroscopic endometrial ablation, 136 538
in dy>parcun ia, 213-226 Hysteroscopic m yomectomy, 167 lntr.t\ cnou s urogmphy (IVU), 509-510
llolleymoon pycliti>, 397 Hysteroscopy, 527 indications, 509-5 10
I Ionnonal a>>a)'>, II complications of, 530 precaution> and contmindi cations, 5 10
llonnollc replacementthcr.tpy (IIR'T) , 91 con tact, 52 7 lntroittt>, 212
cardioprot<'Cthc clfcct of, 91-94 diagnostic, 527 mole, 483
dosagc.92-94 distension media in, 529-530 lmer.ion, !l04-!l06
dnogs. 92-94 indications for, 528-529 .!Cute, 30<1-!l05
ill Alzheimer di>ea.c, 91 operative, 530 treatment, 305
in menopaustl women, 91 llysterowmy, I 74 chronic, !l()j
in osteoporosi>. 95 treatment, !lOG
route ofadmini>tr.ttion, 92-94 oft he men1>, 304-306
Hot nushes. 88 lmitro fenili1.ation (IVF), 2 10-211 ,218,225,
II-P-O a.xis. 49 niOCOCC}"gellS -""pchic muscles 366
11-P-0 pathWa)'· 5:;...56 Imaging modalities in gynaecology. 506-518 coni r.;indicated, 222
II-P-O uterine axh, 55 hysterosalpinS,'O),'Taphy, 519 in a1oospcrrnia, 2 10
IIPV \'accinc, 503 uhr£ono1,..-aphy, 523 indications for, 211
lluhncr's WM, 207 Imidazole , 321, 365 in female infertility, 212
Hulka-Cicmcns clip, 273f in candidiasis, 1- 2 Iron d clkiency anaemia, 321
!hunan chorionic gonadotropin (h CC), 463 in pruritus mlva, 1-2, 320-321 Irregular bleeding, 181- 182
in male infertility, 208-209 Imipramine, 394t Irregular ripening, 138- 139
Ilun'lan iuun,anodcli cicn <.y vin1s, 365-368 in detrusor instability, 393-395 Irregular sh edding, 139
diagnosis, 36&-3(j 7 Immunoth erapy, 503 l.s.aac·s :-.spir. uor, 435
cpidemiolob'Y• 3fi(j Im pcrfi:>rate anus, 73 lschaemic h eart disease, 87,89
managemt:nt , 369 Im pcrfi:>rate hymen, 142 Isoniazid , 35S
microbiology, 36G hnpt:>tence, 205, 212, 213 in tubcreulosis, genital tract, 353t
natur.tl COII r.le of d1c d isease, 366 Infertile couple, 211 Isthmu s, 19
lluman papilloma virus ( JI J>V) infect ion, 10 inveSt.i),>at.ions in, 206-208 IUCD pcrfomtion , 257
11-Y antigcll, 106, 109 Infertility, 303, 315, 339
I Iydatidifonn mole , 481 female, 212
complicuion> of. 485 aetioi<>!.'Y· 212 J
diagno>b of, 485 itwestigations in, 214 Jon c> d<lSSilication, 66
differential d iagno>i> of. 485 management of, 219-220 jtl\cnilc diabelt'S, 142, 145
illcidence of, 483 incidence of, 203
in, 485-486 issu es involved in, 203
placental >itc trophobla.tic tumour, male, 203- 212 K
483-488 aetiological classification of. 20:;...206 Kallman '• >yndrome, 143, 145
n'Current mol.tr pregnant). 488 faults in the male, 205 Kapo>i'> MII'COilla, 366
spnptom> of. 484-485 im·estigations in, 20&-208 Kannan cannula, 281f, 486
treatment of. 486 management of, 208-209 KatjOP) knotic index, 10, 52, 53
ll)drocorthonc, 114-115,319 P>·rchological considerations in. 211-212 Kcll) ·, repair, 391
in folliculiti>. 319-321 treatment, 209 in urimtr) incontinence, 384-395
in intertri),'O. 319-321 Inguinal glands, 32 Kctoron:t7ole, 321, 334, 365
ll)dronephrosi>. I 79 lnhibin, 54 in cmph)'>Cmatous \'ll),<initis, 334
558 INDEX

Khan.na'• ,ling operation, 298 Liquor folliculi, 39 Mcmtnoal cycle, 39, 55

in gcrtiLal prolap><:. 285-30 I Lithotomy position, 400, 509 muctl> ><.-<:rction during, 221 f
Kidhutd'• forCeJl>, 400 l.i\'er function te;;t (LIT), 353, 492 Mcmtnoal C)dC irrcgularitie;;, 122
Klincfdtt:r'• 114, 205 Loperamide, 403 amcnorrhoc01, 122-123
Kobt:lt> tubule., 308 in faecal incontinence, 403 123
Koch·, di>c:t>c, 522-523f Low density lipoprotein {LDL). 19 L 192 intcnncn>truOII bleeding, 122
Kraurosis. 2 I !l Lugol's iodine, 328 menometrorrhagia, 122
Rmkenbt:rg tumour. 464 Luteal phase defect {LPO), 43 menorrhagia. 122
of the O\"olt). 464 Lutein cysts, O\"olt)', 313 metrorrhagia. 122
Rulchitsk) cells. 447 Lu teinized unrupwred follicular (Lt:F) syn- olit;,'Omcnorrltoc-d, 122
R-Yjelly. !158 drome, 224 polymenorrhoc-.t, 122
Kyphosis. 5!1 Luteinizing hormone {LII), 50-51 po;rcoital bleeding, 122
Lymphaticsyslem, 3 1-33 precociotl> menstmation, 122
of !,>en ita! organs, 31 MenMnral rq;ulalion S)linge, 28 If
L LyrnphO{..'T·illuloma ,·e nereum, 360 MenMnral.i on, 41-42, 55
Labia majOI"d, 13 nc uroendocrine e<ml rol of, 58f
consis1 or. 13 po>lponemenl of, 191
Labia minol"d, 13-15 M S)'IUpiOm>, 179
Laparoscopic ch romo1uba1ion, 22-23 Mackenrodl 's lig-.tmenl, I 7, 24, 28-29 M<.-;o(lennallumour, 439
adv..nr.agc of. 2 17 Madl ene r oper.ttion, 272 Mcl a>l,.,cs, 465
indica1ed in, 217-2 18 Magne1ic re;;onance imaging, 516-517 in opcrfuion scars, 465
in palcn ty IUbt:, 22-23 Magnos cope, 412 in uu.:n as, 465
Laparoscopic t'Oip<»ll>pcnsion, 39 1 Malaria, 239 Mccascatic carcinom:u, 464
Laparoscopic hy>lcrccwmy (I.AV II), 138 Male inferlilily, 203-212 MclhOircxalc (mTX), 237-239
Laparoscopic lymphadcncclom y, 426 Malformed fe1us, 203 in cc10pic g<-.uuion, 240-241
Laparoscopic myom celom y, 167-1 f>S Malignant melanoma, 478 Mc1hylcnc blue ICSI, 381
Slcps of opcra1ion, I GSf Mammography, 90, 102-103 M cc ronid azoic, 365
Laparoscopic OV"drian d rilling, 22S in breast, 99-105 in crichomoni;k$i$, 3fi4-3fi5
Laparu.copic >lcriliJ.alion, 2 7S-274 Mana1,>eme1ll of azoospermia, 210 Mc1ropa1hia hacmorrhagica, 134f, 139
ad,a•Hag<-'> of, 274 operation see Fo1hcrgill'• repair clinical his10ry of, 139
complication> of, 274 operation >ytnpiOIIl S, 133
comraindication> of. 274 1e;;t, 351 Metrorrhagia, 2-3, 123
di .ack .tnmg<-'> of. 274 aii and Bonney's t('St, 388 M. hommis, 337
Lapart.heopic ncnc ablation opcr.ttion, 391 Miconatolc, 32 1
(LL'NA), 525 114 in pruritll> vulm, 320-321
237 Klinefelter's S}1ldrome, 114 fcrtilit.alion techniques,
ad,antagc. of. 527 o'arian tumoun.. 117 210
complication> of. 526 I 02f proge.terone pe;;saf), 127
diagnostic. 519-524 treatment of, 102 in PMS, 126
indication;. 519-525 index S« ka..,X>P)knotic index Micro.urgical cpidid)1nal >"Pem1 aspiration
for genital fhtul.t. 522-523f tansl..·y-KUstcr-llauser S)1ldromc. (MESA). 210
in ectopic pregnanq. 228 67-68 endometrial ablation
in 0\"olrian and paro,arian pathoiO{..'Y· 52 If syndrome, 84 1!17-1!18
in pehic inn.. mm.uory di>ea.e, 524 320 Mictu rition 389
in u1erine and 1ubal pathology, 522f in lhreadworms, 320 Mif<.'Pri>lone {Rt:, 486), 16.?, 195,270,282- 283
suspec1<.'<1 adncx.tl 524 ofprq;nancy in QJ,hing's >)1>drome, 195
<-'Ciopic prqptancy, 524 279-284 in pregnancy, 195
opel"dli\e, 524-52.? grounds for perfonning, 279-280 in fibromyomas, 524
indica1ions. 524 la1e sequelae of, 284 in 195
role of. 519 me1hods of, 280 in prcven1.i ng pregnan cy, 270
u:chniquc of, 52.?-526 place for performing, 280 in ripening of 1he cervix, 195
Li1hopacdion . 2S2 Medroxyproge;;1eron e, 93, 150, 250, 313 Millcr-Rul?rok ICSI, 207
Lcp1in, 58, 60, 80, 3 14, 543 in chronic pehic pain, 245-247 Minilap:trolomy, 272-273
Large loop excision o fc hc cnmsformacion in endornecriosis, 24 7 Minipiii/ POP, 266-267
zone (LLI!:TZ), 414 in 312- 313 of, 266
Laser lltcrapy, 399, 474 in ov<drian di.orders, 523 drawbacks, 2f>f>
La1zko proccdu rc, SSS Mefenamic acid, 125 side elfeels of, 267
in VVF, 386 in PMS, 126 Minoxidil , 117
syndrome, 142 Mciosis, 204 mlc in hirsulis m, II f>- 120
Lt:<.-ch-Wilkin.on cannula. 2 16 Mcloxicam, 125 Mircna, I S6, 182f
Lt: Fon'• repair, 297 in dysmenorrhoea, 124f Mboproslol, 283
Lcbhnlan .">tain, 3&4 115 in 283-284
Lt:trozolt:, 194 o' arie;; Mbplau:d IUCD, 261-263
in ano\'ulation, 223 8&-96 ctu><.'ll of, 26 1
in fcmale infertility. 212 a!."' of, 87 Molar pregnancy, 486
in cndon'lctrio.">b. 224 a1tatornical change;; in, 87-$8 Molltl>CU tn contagiosurn , 35 7
Lt:ucorrhoea, 329 featu res of, 95 clinical feature>, 357
Lc\ator mt..cle>. 25-26 honnone le.·els in, 87 diagno.i>, 35 7
LL')dig cell(>), 65. 205, 208 management of, 90 treatment, 357
Lc)dig cell d)'> function. 208 S)mptorns of, 86 .\fonilid>b snc;mdidi;l>is
Libido. 5!1. 89. 275 2, 122, 303 Mon> pttbb, 4, 14f, 15, 80
loss or. 150. 196. 277 Cali SC$, 128-131 Mon> \Cncri>, 13, 32
Lichen sclerosu>. 213. 321 ime;;tigations in, 11!1, 144
Linea nigl"d. 4 treatment of, 135-138 Mo;chro\\il7'> repair, 298
Lipid profile, 90. 93. 190 ther.tP)' used, 133 in genital prolapse, 298
 INDEX 559

Mo\'ing.,trip tc..:hniquc. 499 Organ of RosemnO:oller, 61 Peak day, 221 f, 253-254

MRI, 69, 72, 97, 517 Osu:<Jporosis, 50, 89- 90 Pearl index. 25S
conLr'd.ind 51 7 of lhe vertebral column, 89f Pediculosb pubis, 35f>-357
idemif}ing brea.>t CilllCCr, 4 28 risk factOrs, 89--90 dinical features, 356
in adrenal 116 Ovarian cancer, 465 di.tf,'llOSb, !l56
indication;, 516-51 7 clinical features, 465-466 treatment, S56-S57
in endometri.tl •I!H--•1!15 criteria for diagno.-is, 460 Pe hie !l6!l
in intestinal tract il"!iuric>, 402 in\'estigations, 466-467 Pchic adhesion>. 2, 524
of fibroid, 516 management, 467 Pchic blood ws.ch, 29--!11
technique. 517 Ovarian qst, 194,235, 453, 520t Pchic cellular U..ue, 28-29
C)Motdenoma, 44!1f, 44;;..446, 0\arian endometrio.-is, 176{, 312. Pchic Ooor, 21, 26,28
447.450 0\arian function, 45-47,86, 192. 275t of, 27f
pol)pi. !129 0\arian hyperstimulation >yndrome l.l)er':> of, 26
Mucus method. 25!1-254 (OIISS), 193- 194 Pc hie haematocele, 233
Mullerian 66-67 dassif>Cat.ion of, 190 Pchic inOammatO')' disease (PID), chronic,
aplasia, 66 complications of, I 92 2,35,162,214,260,337-343,
h)poplasia, 66 medicalthempy, 194 399,524
Mounps. 141. 205 pret·en 1ion, 194 aetiology, S!l7-339
M. urc'Qlyticus. 337 Ovarian ligamentS, 21 diiTcrcntial diagnosis, 341-342
Myomatous polypu;,, 305 O'arian remnant. ;,yndrorne, 456--457 investigations in, 342-343
Myomectomy, 168f Ov·arian tumours, 444 prognosis, 345
com pi icat ion>, 170 complications of, 450-452 proph ylaxis against, 346t
preoperative rc"<(Uisites, 166 differential diagnosis, 454-455 >yrnptoms an d signs, 34 I
techn ique, I tifi-1 ()7 investigations, 455 treat men 1, 343-345
Myom etrium stt u teru s ph ysical signs, 453-454 Pelvic inn ervation s, 33
Myolysis, 165t, 167-1 GS, 170 symptoms, 452-453 Pelvic kidn ey, lfi3, 310, 5 13f
lap, 165t treatm ent., 455-456 Pelvic muscles, 25
MRI b"-•id cd, 169 WIIO classification of, 442t 1nusck-s, 25
lapotro.copic, 170 o,ariotomy, 456 urogenital diaphr.;wn, 25
o ,ary, 46, 116,317 Pc Ivic oo-gan prolapse, 287f
acLh·e hormones of, 51 Pelvic pain, 124,245-251
N de,·elopment of, 64- 73 Pchi>, 373
Nafarclin, 50,125, 183, 198 disorders of, 312- 318 >pact"()CCttpying lt">ions in, 3 73
Naproxcn, 127 lutein cystS, 312t Penicillin, S!l4
in PMS. 127 function of, 45-47 in >yphilb, !l62
Natur.tl killer (NK) cclh, 175 of adult, 37 Pcrcutan•'Ou> dr;tinage (PAD), 345
la;,cr, 170. I 83 of netvbom, 37 Pcrcutan•'Oll> epidid)mal sperm aspimtion
:\cis>eria gonorrhoea, !162 steroid secretions, 48 (PESA), 210
:\com)cin. !123. 40 I. 40.1 0\l>testis, 110 Perimetrium sn utcnt;
in perineal injurie.. 399-400 0\'ulation, 39-41, 183, 220-221. 265. 266 Pcrinc-dllacerations, 400
in rc'ClO\<tginotl fi;tul.t. 40.1-405 occurs, 39--40 tear, 400
:\eurohypoph)':>i>. 51 suppres.ion of, 277 lir':>t 399-400
hormones secrete'<! from, 51 tests of, 220- 223 old.. runding complete tears, 400-401
X.cken.on-S.tboumud medium, 7 BBT..-ecordings, 220 S)1nptom>, 401
X.pple disch.trgc. 100 endometrial biopsy, 220 treatment, 40 I
481 fern test, 220- 221 >c-cond 400
!l:orplam, 268, 268f hormonal study, 22I - 222 third 400
!\'SAID. 99, 12.?t, 131, 135 ultrasound, 221 Pc d 224
in dysmenorrhoea, 124f Omsrick, 5(}...51 ther.;py for, 224
in irregular shedding, 139 Oxybutynin HCI, 394 Pc riu reth r.;l abscesses, 24
in mt:norrhagia, 13.1) in stress incontinence, 390t Pcr..istcnt ectopic pregnancy, 243
Nullipotrity, 102 Oxyt<xin, 51 Pcr..istcnt trophoblastic dise-ase (f'fD), 488
Nystatin, 334 Pcr..onll, 25!l
Pc.s>arics, 332
p introduction of, 335
0 Pacey's repotir, 391 Pessary treatmen t ofpmlapse, 293
Obesity, 112, 542-545 in stres> incontine nce, 39 1-393 Ph th:tlyl sulp hat hiazolc, 404
Occlusive diaph ragms, 255-257 Paediatric f:ynaecological problems, 75-86 in rcctovagin al fistu Ia, 404-405
contraind ication$ to, Paf,"'t's disease, 3 19, 321, 472f Pigmented mole or naevi, 325
type'S of, 255 Palliative therapy, 503- 505 Pipcllc aspiration cytOk>f,')', 435
Oestradiol, 51-52.92. 225 PALM-COErN dassifica1ion, 132-133 Pipen11in c, 320
functions of, 57f Pap smear, 4, 46, 86,474-475 in thrcath...·orms, 320
Oestrogen, 45-46, 51-53,90 Papotnicolaou test, 7-8 Pituitary gland, 50-51
ad\".tntagc'l>, 92t for cancer, 7- 8 :ullcrior (adenohypophysis), 5(}...51
delicicn(;y, 150 Par.;colpos, 28, 286 honnont'S, 50
disack.tnrugc.,, 92t Par.trnetritis, 309- 310 posterior (neurohypophysis), 50
effect. 91-94 symptoms, 309 50
in lhmer'> >}ndrornc, 112-IIS treaunent of, 309 Pituiml') infantilbm, 148f
prcpar.ttion>. 190 Parametrium S« utenas Pl.tcenwl alklolinc phosph:uase (PLAP),
source of >uppl) of. 51-52 Paroophoron, 23 •(ol •1-•145. 4 55
thcl"dp). 92 Paro\'arian qst, 308 Pldccnwl pol)pi, 489--490
Oestrogen dcficienq \<tginili>, SSS treatment, 309 Pldccnwl >itc trophoblastic tumour, 483-488
Oestrogen nithdr.m,tl bleeding, 41 Parturition, 328 acliolog) of, 483-484
Oligospemli.t. 207 PCOD/PCOS, 314-318 imc.ligalion> in, 485-486
Oocpe fusion defect. 225 treatment of, 316--317 trC'o\ltnCnt, 486
560 INDEX

Pla.rna proge>terone, 53, 221-222 Pr<>Static cancer, 50 Rctrovcrsion, 302-!l(H

carinii pneumonia, 366 Prostatitis, 20:>--206 actiolOI,'Y· 302-303
POP-Q>}'>tem, 287f Pruritus vuha, 320- 321 diagnosi>. 30!l
Pol}t}'stic O\'.trian di>ea><' or >}11drornc treatrnem, 321 >}111ptorn• of, 303
(PCOD/ PCOS). 2-3, •15-46, 54, SIS, Pseudoq·csis, SSt treatment, 30!l-!l<H
523 S}11drome, 4 pe.s:t'). 304
Pol)111Cnorrhagia. 2. 123, 175 Pseudomyxoma periwnci, 444. 456 >ll rge'), 3().1
Pol)1nenorrhoca. 2. 1231 Pseudomonas pyocyanea, 375 Rctro\ grmid uten1>, !l7S
Pol)111CI".tSc chain reaction ( PCR) tc.t. 7 Pseudopregnancy, ISI-182 Rctro' utcrtl>, 175, 303
Positron cmis>ion tomogr-.tph), 517 Psoria.-is, 320 replacement of, 304f
Postcoital contmccplion S<'t emergenq con· PS}·chologkal sex, II 0 Rifampicin, 265, 353
Puberty, 75-86 Ring pe.sary, 96, 390
PostcoitAl dyspareunia. 214 del:l)• of, 82 R:>:A. 495
Postcoital test. 206 investjgations, 83 Roden 1 ulcer, 4 78
Postpartum (PPII), S, 18, 150, manaj,>ement of, 82 Round lig-.;me 111, 2 1
215. 49(}...491 neuroendocrinologic control of, 76f plicat.i on of, 304
Pouch of Douglas, 17, 218f,524 physiological changes, 82 Rupture, chocolate cyst, 235
aspirdt ion. II Puberty menorrhagia, 85 Ruptured endometriotic cyst, 342
inspection of. 524 Puberty, 75-86
Poupart's lig-.tment, 29, 32 anomalies ofgonaddl function, 82--84
Precocious puberty, 83 precocious puberty, S3 5
caus..-s of, 83 Pubococt.ygeus muscle see pelvic m usck-s Salkylic acids, 319-320
Prednisolone, 115, 223 Puerperium, 326 in t.i nca cruris, 3 19-320
in adrcnog.:nital syn drome, 114-116 Pyelonephritis, 376 Salpingo-oophorccwmy, 184, 239, 342, 399
in anovulation, 222 treatment, 376 Salpingo-oophoritis, 4-5, 13(}...131, 214,310
in female infert.ility, 212 Pyometra, 90 Salpingosmpy, 530-531
Pregnancy, 46, 135, 378 Py<:»alpinx, 6f Sampson's implantation theory, 174
Pregnancy-induced hypertension (Pill), 485 Pyrazinamide, 353 Sampson's the-ory of retroj,>-radc
Pregnancy lc'l>t, II in tuberculosis, genital tract, 35(}...351 nlclutruation, 174
Premature ejaculaIion. 213 Pyridiurn I.CSt, 73 Sarcoma, 439
Prernawre menopause. l).l-95 of cervix, 156-157
Catt><-'l> of, 95 of 0\'otry, 463-464
complication> of. 95 Q of the uterus, 4!lS-439
in, 95 Q-tipped C()llOn S\>ab Stick tL'l>t, 38S of ''uha, 478
rnanagcrncnt of, 95 141
Premature mpture of mcmbr.mc Sc-.tbic>, 321
331 R Schauta operation, 427
Prcmenstrual>)11dromc Recurrent molar pregnancy, 488 Scbact'Ol'> ')'>t, !l25
12&-127 Radiation therapy, 49-1-495 Sck-cti'e oc.trogen receptor modulatOr
aetiolog). 126 clinical applications of, 49S-500 (SER.\1). 9!l-!H
clinical feature.. 126 complications of, 498 Sck-cti'e .croton in reuptake inhibitors
diagnosis. 126 technique, 496 (SSRI), !261
treatment. 126-127 methods, 495-496 in PMS, 126
Presacr.tl neurectOlll)'· 250 Paris technique, 496t Semen anal)">i>, 206
Primolut, 92 phrskal principles of, 49-1-495 Scmin.tl Ouid, 202, 207
Primordial follicle. 37 basic physics, 49-1-495 Senile endometritis, S33
Procidcn ti a. 4, 290 brachyt.herapy (internal), 495-497 Senile 87-88, 96, 288-290, 333
Proctitis. 360, 498 sources, 495-497 aetiology, !l!lS
Proctoscop)'• 404 teletherapy (external), 497 dia1,mosis, S3!l
Progestascrt, 12.? Radiation 'ul,itis, 321 ··ymptom> and signs, 333
in dysmenorri1oca, 124f Radiofrequenc)'-induced endometrial ablation treatment, !l!l!l
Progesterone, 40, 53, 192 (RITEA), 137-138 Septate uterus, 217,260, 514,524,528
in bredSI malign:mcy, 115-116 Radio labelled white cell scans, 517 Septic abortion, 342
in corpus luteal phase deficiency (CLPD), Radionudide irna1,ring, 517 Serous 442
190 Radiopaque dye, 216, 404 Sertoli cells, 65, 106, 109
in detecting ovulation, 40 Radiotherapy, 91 Sertoli -Leydig cell tumours, 463
in premenstrual phase, 47 Radiation menopause, 90 Sex chromosomes, 106
in threatened and recurrent abortions, Razz and Stamey modifications, 391 Sex cord stromaltumOtH'S, 447,463-465
190 in stress incontinence, 374 Scx determination, I 09-112
in uterine 1nalignancy, 116 Rectal absces., 402, 404 Scx hormone binding globulin (S IIBG),
side effc'Cl> of, 50 Recwcele, 290 51-52, 183, 188, 3 14, 316
ther.tpy, 115-IHi Rcct.t)\aginal endometriosis, 175t, 176, 184, Scx Organs, 106-108
Proge>tcrone challcngc test. 144, 15(}...151, 187, 250 determination, I 09
152t RectO\aginal fiswla, 73, 334 dc,clopmcnt, II If
Progcstogen-only pill (POP). I 00, I29t, causes, 406 differentiation, I 08
26&-267 treatment of, 404-405 fcrninbm. 112
in benign brea.t tumour., 10(}...102 Relaxin, 54 hir.utbm, II &-120
in irrcgular ripening, ISS-139 Renal function test (RIT), 4 i9 Oll.bCU1in"m, 114
Prolactin. 145. 198 Reproducthe endocrinology-<hildhood. 75-76 ,;ritbm, 114-116
Prolactin-inhibiting factor (PI F'), 48 Re.idualtrophoblastic disease (RTD) _481 Sexual aberration>. I 17f
Prolapse. genital S<"tgenit.tl prolaP>e Re.idual O\arian S}11drome, 249 Scxu.tll) tra11>mit1ed Di>C"OiSCS (Infections), i9
ProstaC)clin. 43-44. 59 Re.-istant O\arian S}11drome, 144 \aginitb- gonococcal, chlamydia!, 337
Prostaglandin. 270 Retrograde ejaculation, 206 Scxu.tll) transmitted dise:tSes (STDs), 1-2,
Prostaglandin synthet.t>e inhibitor., 125 Retroperitoneal wmours, 310 82, 3!17, !156
in dysmenoni10ea. 124 classified as, I 77-1 i8 AIDS, !165-366

Sexu.tlly tr.ulSrniued diseases (Contmttm)
bacterial \'aginosis, 330-331
chancroid. 361
clinical ft:'dtures, 361
d iagno.i>, 361
trcatn'lcn t, 361
cond yloma acurninata, 325, 357-358
colpo.copic findings, 358
diagno.is, 358
crcacmcnt, 358
!.'ranuloma inguinale, 359-360
clinical featurt"S, 360
diagnosis, 360
treatment. 360
herp<.-s genitalis, 359f
clinical features, 359
com plica lions, 359
di.l!,tnosis. 359
treatment. 359
lpnphogr-.tnuloma n::nereurn, 360
clinical featurt"S, 360
complications, 360
diagno;i;, 360
in vcsdgacions, 360
p:ul10physiolo!,'Y• 360
risk factors, 360
mollu.cum cont.,giosum, 357
clinical fe-.JturL"S, 357
dia!."'osis, 357
35i
pediculosis pubis, 35&-357
clinical fe-.ttures, 356
di.l!,'llOSis. 356
treatment. 356-357
.cabic., 357
clinical features, 357
diagno.i;, 357
trcauncnt, 357
syphilis, 361-362
clinical feat urL"S, 361-362
labor.Jtory invL-stigations, 362
trichomoniasis, 364-365
diagnosis, 364
>ymptoms, 364
1real men 1, 364- 365
Shcch.tn •rndrome, 3, 147, 148
hirodkar"s abdominal sling, 297
icklc edt disease, 24 7
ila.tic \<lginal rings (SVR), 268
ad\'antotges of. 269
di>ad,·antag<=> of, 269
Sildenafil (Viagra), 209-21 0
in male infertility, 203-212
Silicon tylinder prosthesis, 212
Simmond"; di;ea;.e, 142, 147, 150
Sims·l luhncr test, 303
Sims' vaginal spc<.:ulum, 4
Sion K"lil see sonosalpingography
Skene's tubules, 16-17
Soluble antigen Ouorescence antibody
(SAFA). 352
Sono><tlpingography, 2 I 8
Specul<»eOP)'. 412
SpeCirO>COP)'. 412
Spermatogenesis. 204, 209, 253, 277
di>ordcn of. 205
endocrine control of, 205
>Uppre;;ion of, 277
Spenniddal agent>, 255
Spenn penetr.Jtion test, 207
Spironolactone, 118, 127, 196
in 196
in I'COS, 314-318
in I'MS, 126
Squamocolumnar junction, 17
INDEX 561
Staph)loooccus au reus, 334 ThtToid stimulating homlonc (TSII). 50,
Stcin-Lcn::nthal S)ndrorne, 314 484-485
Stcrilir.ation, 271 Tibolone, 93
complications of, 271 Tietze ·s S)ndrome, I 00
female, 272-275 Tiludronate, 94
methods of, 272-275 Tine-a tTuris, 319-320
>urgicaltcchniques of. 273f treatment, 319
male, 271 Tinidazolc, 365
V'.J>eCtorny, 271 in tricho•noniasis, 364-365
sequelae of, 271 Today, 256, 2i'i7f
Strangury, 375 Total abdominal hysterectomy, 345
Str.Jwberry vagina, 364 Total tumour cell kill concept. 500
"Stre-ak" gonad, 112-113 Toxic shock >yndrome (TSS). 255-256, 334
S trc-ak o\'ary, I I 6 Tr.msabdominaluhm;,onogr.Jphy (TAS). 511
Streptococcus, 310, 332 Transcenica.l resection of endotnccrium
Stress urinary incondnence, 384-395 (fCRE), 136t, 405
in,estigations,382-383 Trans,aginaluhrasound (fVS). 237
S)mptOm of, 383-384 Trachelectom), 426f, 429. 525
treatment, Treponema pallidum, 361
surgical procedures, 391-393 Trichomona;. 'aginali;, 320
Stromal endometriosis, 187 Trichomonia;.is s"sexually
Strurna o\'arii, 447 diseases (STDs)
Subdermal 267-268 Trichophyton rubrum,
ad,<lntages, 268 Trimethoprim, 361
disadvalll.a!,reS, 268-269 in chancroid, 361
Norplant I, II, 268 Tripha;.ic combined pills, 265
insertion of, 268 Triple X syn drome supcrfemale
remo,al of, 268 Trophobla;.tic dise-ases, 481-493
Subm ucou;. myoma, 156 categorized into, 481
Subnucle-ar 'acuolation, 42-43 WHO prognosis scoring ;,y.tcm for, 4911
Substance abuse, 208 Tro>pium chloride, 394
Sub>.onal inseminadon (SuZI), 211 in stress incontinence, 384-395
Sulphamethoxazole, 361 Tme hermaphrodite, 120
in urethritis, 375 Tubal abortion, 230
Superfernale, 113 Tubal cannulation, 529
S\\)er"> 112, 141 Tubal pregnanq, 228, 35<1
S}phili> see sexually tran•rniued di.ea>c> Tubernolosis, genilaltnoct stt genital
(STDs) tuberculosi$
Systemic lupu> eryt.hernatosocs (SLE) Tubercuk>sis ofgcnitaltr.oct, 347-355
syndrome, 150-151, 322 clinical fCatUrL"li, 350-351
differential diagnosis, 352-353
!,renit.al tract lesions, 34S-350
T investi!,r..ttions, 351-352
T;unoxifen, 102f, 194-195, 503 pathogenesis, 347-348
in brea;.t cancer, 195 prognosis, 354
in male infertility, 211 >ur!,>el)', 354
in PCOD, 194-195 treatment, 353-354
Tanner and classification, 80-82 Tuberculous endometriti>. 349f
Tanner e.-aluation, 141 Tuberculous P)OS<tlpinx, 349f
Teletherapy St!l' radiation ther.op) Tu!Jo<),arian absces., 339, 339f
Temper.tttore method, 254 Tubopla>ty, 273, 345
TcrdLOrna, 445 risks of, 274
Terconazole, 321 Tumour markers, 4()3
Te>tes, 204f Turners >yndromc, 99, 112-113, 142
anatomy of, 204f deformitiL-. of, 112-113
Testicular disorders, 205 incidence of, 113
Testicular feminizing syndrome, 113 1\vist.ed ovarian cyst, 2S5, 245, 342
TL"Siosterone, 53, 113, 116, 191, 196,
277, 324
in Klinefelter >yndrome, I 14 u
in male infertility, 203-212 Ch.rasound, 6, 86, 114-115, 117. 343, 470,
TeiJ"'dC)'eline, 331, 346, 363 51 I
d•lam)dia, 363-364 diagnostic indication>, 514
in chancroid, 361 in ectopic pregnane)•, 236
gonococcal 'aginitis, 362-3()3 in endometrio.i>, 17•1-185
in grmuloma inguinale, in g)naecological diagno.i>. 1-11
in lpnphogranuloma \enercurn, 360 in hirsutism, 118
in PID, 246 in hydatidifonn mole, 485
in urethritis, 375 in measuring bladder \Oiume and n-.idual
Thayer-Martin medium, 363 urine, 389
Theca cell tumour, 448 in PID, 228
Threadworrns, 320 therapeutic applications of, 514
ITeallllenl, 319 Undescended lt"SI<"li, 201!
Threatened abortion, 485 Unexplained infertility, 224-225
Thyroid function tests, 150 Unicomuare uren.1s, 65
562 INDEX

Unrupwrc-d c"t:topic gc>tation stt ectopic U terine i•yury, 402 Von Willebrand 's disease, 128
gt.-station U terine polyp;,, 172 Vubc llum forceps, !l05
Un:apla>ma ttrcalyticum, 2 14 Uterine prolap;,e, 3 77 Yuh·,,, !1 19-325
Urett:r. 24-25 Uterine rupture, !196 benign condi tion• of, 3 19
rdation. of. Uterine sarcomas , 4!18 inflammatot} lesions,
t:rctcric cathctcri7.ation , 383 incidence of, 437 ulcer., !121-322
Ureteric fistula. !188-!184 treatment of, 439 '"· 32 1
im estig.uion>. !182-!18!1 types of. 4!19 tr.,.dtmt:nt. !l21
spnptorns of. !188-!184 Uterine S)nechiae, 528 \ 'uh'al !121, 473,475, 477,478
treatment of. U 1e rosacral ligaments, I 7 imr.tcpithelial, 472f
Ureteric obstruction. !177-!178 U ten•s, 18-20 \'ul\'al 325
Urethr'.tl caruncle. 21!1 perforation of, 402 \'ul\'al d)lMophie., !121
treatc>d by. 376 mpture of. 402 .urophic, !122
Urethr-.tl di\erticulum, 377 hypcnrophic, !122
lre"".tlnlent, 3ii Vuh-;tlmelanoma, 478
Urethr-.tl prolap.c, 377 v pain ;yndrome, 322
Uret hr-.tl steno;,i;, !177 Vacuum evacuation, 281-282 CIUM.'i> of, !122
sit e> of narro"ing, !177 complications of, 280-281 ITt:'dllllCnl, !122
lrt:'dUilt:lll, 377 mortality rate, 282 Vuh,al \'CStibulitis, !122
Urethr-dl>yndromc, 89 Vagina, 14-15, 52, 397 Vulvit i>, 2 I !l
Urethritis, !164 of, 326-329 Vulvov.;gin:tl hacmatoma, 398
376 chemical and other bums of, 399 Vulvov-.;ginitis, 190, 333, 376
symptoms, 376 diseases of, 323 in ch ildrcn , !120
tre:::-auncnl, 376 in fee• ions, 329
Uret hroccle, 287 in nam mations of, 332-334
Urethrocystometry, !189 d iaf,'11<>Sis, 332 w
Urethroscopy, 388 symptoms and signs, 332 Wand ering fibroid , 160
Urethrovaginal fistula, 384 treatment, 330 Weight bearing 90
Urge incontinence. SSG pll of, 16 Weight change and am enorrhoea,
Urinalysis, 538 radiation, 335 Weight gain , 1!151, 18 1- 182
Urinary calculi, 373-374 rclati ons of, 16-18 Wcnhcim 's operation, 35, 214, 381
Urinary r..wlac, 377 Vaginal bums, 399 \Vcrthcim 's r,ldical abdo•ninal hysterec1.orny,
cla»ific-<1 as, 377 Vaginal cancer, 478-480 525
Urinary incontinence, 5 10 clinical features, 479 White leg, !ll 0
Urinary malfunction>. 372-376 diagnosis, 479 Withdrd\\"dl method, 254
L)">titi>. 374 management of, 4 79-480 \\'olffian duct, 2 11, 73, 308
ltt:'.tttnenl, staging of, 4 79 \\'olffian duct anomalies, 73
incontinence of urinc, 37•1-375 \ 'aginal cysts, 335 \\'uchc!l! ria b•Utcrofti, 325
micturition. difficult. Vaginal discharge, 326, 333, 334
cause of. 374 Vaginismus, 212-213
treatmcnt. findings, 212-213 X
P)elonephritis (P)cliti>). 376 treatment, 213 X chromo>Ome, 46, 113
treatn>ent. 376 \ 'asec:tomy, 208 X..-d)'· 89, 149f, 494, 509
retention of urine. 372-!173 \ 'asopressin, 51 dl<.'i>l, 5!18
causes. 372 in detnJSOr instability, 393- 395 ofpituitaryfossa, 147f
urethr-.tl sp>dromc. !17!1 Vault prolapse, 298 XX d>romosome, 106
Vrinary rea.enaion srt urinary malfunctions VDRL testing, 362, 5!18 XXV c h romO>Ome, 205
Urinary lr'dCI, !l 77 Venete'al dis<!".t>e, 205 Xylocainc, !188
infection (UTI), !177 Venere-cil w·c1r1s seecondylorna1a acuminat'.t
injuric>. 396 Ventilation perfi•sion scans,517
obstnJCIion in , 291 Vesicouterine fistula, !184 y
Urine cu hu re. !182-!18!1 diagnosis, !186 Y chromos<.>mc, 661
Uri path, 364 ;ym pt<>rns of, 383- !184 Yolk sac, 1umour, 65
Urispa;,, 394 Vesicovaf,.;n.al fistula (VVF), 381, !181 f Yousscrs •rndrom c, !184
in strt.-ss inconcincncc, 393 treatment,
Uronowmetry, 389 Vestibule, 14- 15
Urogenital dinCrcntiation , 65 Vibra aspirator, 97 z
Urogenital system, 62f Vicryl '0' su tures, 400 Zidovudinc, !167
Uroprofilomctry, !189 Virilizing rnesenchyrnorna, 448-449 Zona drilling (2:0), 211
Uterine anery embolit.ation , 168-169 Virilism, 114- 116 Zona pellucid a binding dcfc"t:l, 206
Uterine cavity aspimtion. 97 clinical features, 114 Zona penetration 206, 211
Uterine cramps, 124 \'arieties, 114-116 Zona ,·,tseulosa, 37
Uterine dc-.ccnt, 287 Virkud 's sling operdtion, 298 Zonal dissect ion, part.ial (PZT), 21 I
Uterine fibroid, 215, 2!15 Vitamin A and B,., deficiency, 32 1 Zygote inlr,tfilllopi;u• tr.msfcr (ZTFT), 197, 225