Reproductive Physiology

HPO Axis 01:08

Hypothalmus → Pulsatile GnRH +ve Feedback

Leptin
Glutamate
Kisspeptin
Pituitary → FSH, LH

-ve Feedback
GABA
Neuropeptide Y

Ovary → E2, P

2 Cell 2 Gonadotropin Theory 03:34

LH

THECA CELL GRANULOSA CELL

CHOLESTEROL
3 BHSD Pregnenolone FSH
Progesterone
17 OHP AROMATASE
ANDROSTENEDIONE ESTRONE
17 βHSD
Testosterone ESTRADIOL

OVARIAN CYCLE 04:46

I. Preantral phase – FSH independent = 84 days

II. Antral phase – FSH dependent = 14 days

FOLLICULAR PHASE OF OVULATION CYCLE

DAY 1-3 : Recruitment

DAY 5-8 : Selection (dependent on max level of FSH receptor)
DAY 13-14 : Dominance → GRAFFIAN FOLLICLE

GRAFFIAN FOLLICLE = 20mm

ANTAL FOLLICLE = 2-8mm
PRIMORDIAL FOLLICLE = 0.02mm
HORMONAL BASIS

FSH dependent
-ve feedback

Granulosa cell

Estradiol Inhibin B

200pg/ml & lasts for 48-50hrs

LH surge

LUTEAL PHASE

• CORPUS LUTEUM : Yellow coloured

d/t deposition of lipids, carotene pigments
• Causes leutenisation of granulose cells
• Releases :
1) Progesterone
2) Estrogen
3) Relaxin
4) Inhibin A
• Max activity of Cl is on day 8 after ovulation (D22)
• On day 22 – Sr. Progesterone > 5ng/mL Ovulatory cycle
< 3.5ng/mL Anovulatory
(< 1.5ng/mL) – In ovulatory cycles sr. progesterone
not 0 as small amounts released from adrenal glands

• Life span of CL if not fertilized = 12-14 days – CORPUS ALBICANS

• Life span of CL if fertilized = 10 weeks

UTERINE CYCLE 18:44

I. Proliferative or Follicular phase II. Secretory phase

• Estrogen causes •  Progesterone + estrogen

proliferation of maintain endometrium
endometrium • Progesterone inhibits E2
receptor on endometrium
• antimitotic to endometrium
• Long term progesterone →
ATROPHY

ENDOMETRIAL CHANGES
‐ Post ovulation- Endometrium thickens + fluid in pouch of Douglas

ANOVULATORY CYCLES

• Unopposed estrogen (E2) → Proliferation of endometrium

• Irregular cycles
- Prolonged amenorrhea
- HMB (Heavy Menstrual Bleeding)

When endometrium overgrown spiral arteries

Heavy menstrual bleeding

PGE2
Withdrawal of progesterone → Prostaglandins
 PGF2
Painful Menstruation

1° spasmodic dysmenorrhea

No progesterone → No formation of PGs → No Pain

= ANOVULATORY CYCLES
 Anatomy
Uterus 01:09

• Anteverted – Angle between cervix and vagina - 90⁰

• Anteflexion - Angle between uterus and cervix - 30⁰
• It is pyriform in shape
• Position: MC is anteverted and anteflexed
• Anteflexion is at the level of the internal OS
• Parameters; Length | weight | capacity
- Nulliparous: 50-70gms | 6-8cm | 10ml
- Multiparous: 80gms | 10cm
- Pregnant uterus at terms: 1kg | 35cm | 5000ml

RELATIONS
LAYERS

• Uterus consists of:

i) Body
ii) Isthmus
iii) Cervix
• Innermost layer - endometrium
- Stratum basale
- Stratum functionalis

BLOOD SUPPLY

• Main artery - Uterine artery – Arcuate artery

• Supplied by ovarian artery – Basal artery
Spinal artery

• Lymphatic drainage;
- The obturator and the internal & external iliac nodes

NERVE SUPPLY

• The uterus is innervated by fibres of the uterovaginal plexus at Frankenhause

Ganglion
• These fibres travel along the uterine arteries & are around in the connective tissue
of the cardinal ligaments
• Nerve supplies: T10-L1

Cervix 05:07

• Lowermost part of the uterus

• Extends from histological OS to the external OS
• Cylindrical in shape measuring 3cm in length and diameter
• During pregnancy - 4cm in length
• Before puberty cervix is larger than uterus
• Ectocervix lining - Stratified squamous epithelium
• Endocervix lining - Simple columnar epithelium
• Junction of ecto & endo cervix - Transformation zone
– Metaplasia of columnar to squamous
• Transformation zone - dynamic
• 1st site of HPV infection & CA cervix

• Body / cervix ratio

- Before puberty - 1:2
- At puberty - 2:1
- In adults reproductive age - 3:1 or 4:1
- After menopause whole of uterus and cervix - 1:1
• Blood supply - descending cervical artery -> branch of uterine artery

LYMPHATIC DRAINAGE

• Internal iliac LN
• Hypogastric iliac LN
• Obturator LN
• Paracervical / parametrial LN
• Exterior iliac LN
Fallopian Tube 07:58

ADENEXA

• Interstitium - Narrowest
• Isthmus - 2.5 cm
• Site of tubectomy

• Ampulla - 5 cm
• Site fertilization

• Infundibulum - 2.5 cm
• Pick up ovum

• Cells - Ciliated columnar epithelium

• Peg cells

• Blood supply
- Medial 2/3rd by uterine artery
- Lateral 1/3rd by ovarian artery

• Lymphatic drainage - Paraaortic lymph nodes

• Medial part + Cornu -> Supraingual LN
• Nerve supply - T10, T11, T12
Vagina 09:45

• The canal is directed upward and backward, forming an angle of 45⁰ with the
horizontal in erect posture
• Looks 'H' shaped on transverse section
• L of anterior wall - 7cm
• L of posterior wall - 9cm

RELATIONS

• Anterior upper 2/3rd - bladder, lower 1/3rd - urethra

• Posterior upper 1/3rd - POD, middle 1/3rd - rectum, lower 1/3rd - perennial body
• Lateral support;
- Mackenrodt's ligament or pelvic cellular tissue
- Levator ani muscle
- Bulbocavernous muscle
- Vestibular bulb
- Bartholin's glands

• Cervix and all 4 are related to To Q - Water under the bridge

- Uterine vessels - above
- Mackenrodt's ligament – in between
- Ureter - below
• Vaginal epithelium has 3 types of cells
1. Basal/Parabasal cells → abundant when there is no hormonal predominance
(before puberty, after puberty)
2. Intermediate cells are seen when there is increase progesterone during
pregnancy and 2nd half of Menstrual cycle
3. Superficial cells are seen in 1st half of Menstrual cycle and abundant when
estrogen increases

• Maturation index: P/ I / S
- Before ovulation: 0 / 30 / 90
- After ovulation: 0 / 60 / 40
• Vaginal pH
- Maintained by Döderlein’s bacillus
- Glycogen → Lactic acid
- pH: 4.5 to 5.5 → Reproductive
- Menopause/Before Puberty - alkaline = 6-8
- At puberty - Shifts from alkaline to acidic
- Pregnancy: 3.4 to 4.5 – Most acidic
- Menstruation > 7

BLOOD SUPPLY

• From 3 arteries;
1. Descending vaginal artery - branch of Uterine Artery / Internal Iliac Artery
2. Internal pudendal artery
3. Middle rectal artery

• Lymphatic drainage of vagina

1. Upper - External & Internal → Iliac
2. Middle - Internal Iliac
3. Lower - Super Inguinal

• No mucus secreting glands

Ovary 14:48
• Blood supply - ovarian artery
• Nerve supply - T10
• Lymphatic drainage - Paraaortic LN
• Venous drainage ;
- Left side → Left renal vein
- Right side → Inferior vena cava

Bartholin’s Gland 16:00

• Homologous to Couper's gland & bulbourethral gland in males

• 2 in number and of racemose type
• Lie in superficial perineal pouch embedded in the posterior part of vestibular bulb
• Glands are oval in shape and are of the size of pea
• Duct 2cm long
• Opens into vestibule, outside hymen at junction of anterior 2/3rd & posterior 1/3rd
- In grove between hymen & labia minora
• Function: produce abundant alkaline mucus during sexual excitation
• At greater vestibular gland

• Bartholin's cysts - Formed when Bartholin's duct is blocked

• MC Cause - E.coli
• MC Site - Fluctuant, tender
- Swelling present on inner side of junction of anterior 2/3rd with
posterior 1/3rd of the labium majora
• TOC – Marsupialization

• Bartholin's abscess - When infected

• Mx : Incision and drainage
• MC Cause - E.coli > N gonorrhoea
 AUB
menstrual cycle 00:20

N PARAMETERS OF MC:

International Federation of Gynaecology and Obstetrics (FIGO) system for abnormal

uterine bleeding: Suggested “normal” limits for menstrual parameters for uterine
bleeding

Clinical dimensions of Descriptive term Normal limits (5th-

menstruation and 95th percentiles)
menstrual cycle

Frequency of menses, Frequent < 24

days
Normal 21-35 days

Infrequent > 38 / > 35 days

Regularity of menses : Absent No bleeding

cycle-to-cycle
variation over 12 Regular Variation  2-20
months, days
Irregular Variation > 20
Duration of flow, days
Prolonged > 8.0

Normal 4.5-8.0

Shortened < 4.5

Volume of monthly Heavy > 80

blood loss, mL
Normal 20-80

Light < 20
AUB

• Bleeding from uterine corpus that is abnormal in;

1. Regularity
2. Volume
3. Frequency / Duration
4. Occurs in absence of pregnancy

• Acute causes
- That which is insufficient in volume as to, in the opinion of the treating
clinician, require urgent or emergent intervention

• Chronic causes
- AUB present for most of the previous 6 months

ETIOLOGY

• P - Polyps
• A - Adenomyosis
• L - Leiomyoma
• M - Malignancy & hyperplasia
• C - Coagulopathy
• O - Ovulatory dysfunction
• E - Endometrial
• I - Iatrogenic
• N - Not defined
• PALM – Structural abnormalities
• COIE – Functional abnormalities
 Diagnosis and Evaluation

Through History Preliminary assessment Investigations

(Grade A ; Level 4) (Grade A ; Level 4) (Grade A ; Level 4)

Menstrual a) Duration Assess pallor, weight, features

pattern b) Amount suggestive of PCOS, thyroid
c) Cycle length disorders
d) Regularity
Abdominal Palpable uterus
e) Intermenstrual
examination
bleed
Per speculum Cervical
Pain a) Dysmenorrhea,
examination lesions,
spasmodic or
discharge
congestive
b) Intermenstrual, Per vaginum Uterine size,
chronic pain examination contour
c) Dysplasia consistency,
tenderness,
Concomitant a) Anti coagulants
adnexal mass
medications b) Tamoxifen
or tenderness
(Grade B ; c) Hormonal
Level 4) contraceptive
d) Anti 1) Laboratory testing
depressants 2) Imaging
and anti 3) Specialized tests
psychotics 4) Endometrial
e) Corticosteroids histopathology
 Imaging

Ultrasound Magnetic Resonance Hysteroscopy

Imaging-mandatory Imaging-optional
Not
indicate
Doppler Suspected AV for ALL
a) Map exact
Sonography malformation, AUB
locarion of
malignancy cases fibroids before a) Direct
and to differentiate planning visualization
between fibroid and conservative (Grade A ;
adenomyomas (Grade surgery and prior Level 1)
B ; Level 3) therapeutic b) Facilitates
embolization for directed
3D USG For evaluating intra
fibroids biopsy
myometrial lesion in
selected patients for b) To differentiate

fibroid mapping between fibroids

(Grade B ; Level 4) and adenomyomas

SIS If intracavitary
lesion is suspected
and hysteroscopy is
not available (Grade
A ; Level 1)

Endometrial Polyp 04:01

• Localized hyperplastic overgrowth of endometrial glands & stroma

- Forms projection from surface of endometrium
• Clinical presentations
- Asymptomatic
- Intermenstrual bleeding
- Heavy menstrual bleeding
- Post-menopausal bleeding
- Prolapse through cervical ostium
- Abnormal vaginal discharge

• Risk factors
- Diabetics
- Hypertension
- Obesity
- Hormone replacement therapy
- Tamoxifen therapy

• 1st line - TVS → Homogenous, Echogenic

• IOC (gold standard) - Hysteroscopy
• Rx: Hysteroscopic D&C
• Delineated in saline infusion sonography

• Endometrial polyp
- Echogenic/White in color
- Projects in endometrial lumen
- Stalk may be identified by saline infusion sonography
- Feeding vessel sign
• Fibroid
- Hypoechoic/Black
- Distends the uterine cavity
- Broad based
- Peripheral vessels

FEEDING, VESSEL SIGN POLYP

Adenomyoma 06:42

• Presence of functioning endometrium in myometrium

• 35-45 yrs
• Clinical presentation
- Congestive dysmenorrhea
- Heavy menstrual bleeding

• On examination
- Uterus will be uniform globular enlarged
- Max - 14-16 weeks sign

• 1st line investigation –TVS

• IOC - MRI → Junctional zone thickness > 12mm
• Gold standard - HPE
• Treatment:
- 1st line - Lng IUCD, Alternative - Gnrh agonists
- Definitive - Hysterectomy/Endometrial ablation
 CUT-SECTION ADENOMYOMA ADENOMYOMA USG

FIBROID – UTERUS

AUB-C 09:38

Puberty Menorrhagia

In women with AUB due to coagulopathy

(AUB-C)

Non hormonal treatment – Hormonal treatment –

Primary option Secondary option

Tranexamic acid 1g QID COCs/LNG IUS is recommended

(Grade A ; Level 2) (Grade A ; Level 2)
Following consideration have to be taken care of:

• In refractory cases von – Willebrand disease with uncontrolled uterine bleeding with
above medical management, specific factor replacement where possible or
desmopressin to be given in consultation with haematologist
• When surgical interventions are indicated for appropriate pre-intra and post-
operative management of bleeding – Factor replacement/desmopressin

AUB-O 10:20

Treatment Guidelines: AUB-O

• In women not desiring conception presently, COCs can be used as first – line
therapy for 6-12 months (Grade A ; Level 1)
• Cyclic luteal – phase treatment in women with AUB-O (Grade A ; Level 1)
• Norethisterone cyclically (for 21 days) is given as initial therapy in acute episodes
of bleeding for short–term management of 3 months (Grade B ; Level 4)

ETIOLOGY

• PCOS
• Hypothyroidism
• Hyperprolactinemia
• Stress
• Obesity
• Excess weight loss
• 1st line - combined oral contraceptive pills
- Uterus will be uniform globular enlarged
- Max - 14-16 weeks sign

AUB-E 10:20

• Primary disorder of the endometrium

• Same treatment
• Affecting haemostasis of endometrium due to deficiency of local vaso-constrictors
(pgf2 alpha, endothelin)
• Excess plasmogenic activator
• 1st line - COPC (Combined oral contraceptive pills)
• Acute bleeding - cyclical norethisterone x 21 days - 3 cycles

AUB-I 11:26

• Iatrogenic
• Breakthrough bleeding
• Estrogen breakthrough
- Threshold of estrogen low
- Suprathreshold bleeding
• Progesterone break through bleeding
- High progesterone results in atrophy and altered endometrium
- Bleeding occurs from unsupported endometrial vessel

AUB-N 12:12

Not specified
Treatment Algorithm: AUB-N

Surgical treatment (such as

In women with AUB ablation) – If fails or is
(not yet defined - N) contraindicated

Medical Management GnRH agonists along with

add- back hormone therapy
are recommended
Women desires contraception (Grade B ; Level 4)

LNG IUS is recommended as COCs are recommended as

1 line therapy
st
2nd line therapy
(Grade A ; Level 1) (Grade A ; Level 1)

Non hormonal option such NSAIDS and

For AUB that is mainly
Tranexamic acid are recommended
cyclic or has predictable
(Grade A ; Level 1)
 In women with AUB
(not yet defined - N) –
AV Malformation

1) Uterine artery embolization is

recommended
2) Hysterectomy is the last resort
(Grade B ; Level 4)
 Embryology and Uterine Malformations
Q) SRY gene is located on:
a) Short arm of y chromosome
b) Long arm of y chromosome
c) Short arm of x chromosome
d) Long arm of x chromosome

Ans : a) Short arm y chromosome

Embryology 01:50

1) GONADS

Bipotential Gonads At Around 5 Weeks

SRY gene on short arm of y chromosome

if present if absent

Gonads develop into Testis Gonads develop into ovary

For growth  SOX – 9 gene For growth : WNT4 gene &
RSPO 1 gene
2) INTERNAL GENITALIA

Males

Testis

Serotoli cells Leydig cells

Secrete AMH Secrete testosterone

(Anti Mullerian Hormone)
5- reductase
leads to
Converted to
(Para Mesonephric duct) Dinydrotestosterone
Regression of Mullerian duct (DHT)
REMNANTS  Prostatic utric
Appendix of testis Growth of Wolffian duct Growth of External
(Mesonephric duct) genitalia of male

Seminal Vesicle
Epididymis
Ejaculatory duct
Ductus deferens

Females

No SRY Gene

Ovary No Testosterone Wolffian Duct Regresses

Remnants Of 

No Amh Proximal Part Of Mesonephric Tubule – Epoophoron

Distal Part Of Mesonephric Tubule - Paraphoron

Mullerian Duct Grows (Block In Paraphoeon

Parovarian Cyst)
 Wolfian Duct – Gartner’s Duct
(Gartner’s Cyst)
Gartner’s Duct Vs Cystocele

• Irreducible • Reducible
• Tense & Shiny
• Vaginal • Vaginal rugosities
Rugosities Lost Present
• No Cough • Increase On
Impulse Coughing

Bartholin’s cyst – Posterolateral vaginal wall

Gartner’s cyst – Anterior vaginal wall
GROWTH OF MULLERIAN DUCT:

Fusion : Begins by 7-9 weeks & is completed by 12 weeks

Disolution : Initially When The Two Mullerian Ducts Fuse, An Intervening Septa Is Later
by 5th Month Of Intrauterine Life, It also disappears

Mullerian Duct → Proximal Part Of Both Fallopian Tubes

Uterus
Cervix
Upper 2/3rd Of Vagina

Urogenital sinus → Lower 1/3rd of vagina

3) EXTERNAL GENITALIA

DHT No Testosterone

Male Penis Genital Tubercle Clitoris

Scortum Genital Swelling Labia Majora

Penile Urethra Genital Folds Labia Minora

* Prostate Gland In Male Is Homologous Too : Skenegland In Females

* Bulbourethral Gland In Male Is Homologus Too : Bartholin Gland In Females

 In Utero Exposure To
Testosterone In Females (46xx)

Lead To

Male External Genitalia

K/As : Ambiguous Genitalia

Mcc = Congenital Adrenal

Hyperplasia (Cah)
(21 Hydroxylase Deficiency)

No In Utero Exposure To
Testosterone In Males (46xy)

Lead To

Female External Genitalia

K/As : Ambiguous Genitalia
Mcc = Androgen Insensitivity Syndrome (Ais)
 STRUCTURE FEMALE DEVELOPMENT MALE DEVELOPMENT

Wolffian duct / Mesonephric Remnant – Epoophoron, Epididymis, Vas deferens

duct Paroophoron & Gartner’s & Seminal vesicle
duct

Mullerian Fallopian tubes, uterus, Remnant – Appendix of

duct/Paramesonephric duct cervix, upper 2/3rd of testis
vagina

Urogenital sinus Lower 1/3rd of vagina, Cowper’s gland &

Bartholin’s gland, skene prostate
tubules, bladder & urethra

Genital tubercle/Mullerian Clitoris Penis

tubercle

Genital swelling Labia majora Scrotum

Genital folds Labia minora

Congenital Mullerian Malformation 21:11

AMERICAN FERTILITY SOCIETY (AFS) CLASSIFICATION:

Complete k/as: MRKH syndrome

I) Mullerian agenesis
Partial
II) Unicornuate (40% are associated with Renal anomalies) (MC) – Rudimentary
horn- communicating→ Risk of ectopic pregnancy
III) Didelphys (=2 uterus + 2 cervix)
Bicollis → Septum in cervix
2 cervical cavities
IV) Bicornuate (=2 uterus + 1 cervix)

-Absence of cranial fusion Unicollis → Single cervix

• MC uterine anomaly
V) Septate
• MC associated with infertility
• MC associated with abortion

VI) Arcuate • Heart shaped

• BEST prognosis

VII) Diethyl stillbestrol exposure • T shaped uterus

• Vaginal adenocarcinoma
In utero

Q) Bicornuate uterus id due to:

a) Incomplete fusion of uterine cavity
b) Incomplete fusion of paramesonehric duct
c) Incomplete fusion of mesonephric duct
d) Incomplete formation of vaginal

Ans : b) Incomplete fusion of paramesonephric duct

Investigations 29:59

IOC : MRI / 3DUSG

Gold Standard : Hysteroscopy or Laproscopy

Leech Wilkinson’s Cannula

NOTE : No role of HSG

IMAGES:

Management 34:37

Q) Most important indication for surgical repair of a bicornuate uterus is:

a) Infertility
b) Dysmenorrhea
c) Menorrhagia
d) Habitual abortion

Ans : d) Habitual abortions

Indication : (MC) Recurrent abortions

• For Bicornuate or Didelphys uterus : UNIFICATION SURGERY

AKA : Metroplasty
Jones Metroplasty

Strassman’s Metroplasty

(MC done now)

• For Septate uterus : Hysteroscopic trans cervical septal resection

 HYSTEROSCOPE FLUID DEFICIT

(Distension Medium)

• Normal Saline : Conducts electricity 1500mL

• Glycine
: Does not conduct electricity 1000mL

Cemployed while using MONOPOLAR cautery

Also causes hyponatremia

 Primary Amenorrhea
HPO uterine axis 00:34

• Hypothalamus → Pulsatile GnRH (+) pituitary

• Pituitary → FSH, LH (+) ovary
• Ovary → Estrogen (+) uterus

• Defect - abnormal functioning of uterus

• Compartments - I, II, III, IV

Primary amenorrhea 01:37

• In absence of secondary sexual characters - no menses till age 13yrs

• In presence of secondary sexual characters - no menses till the age of 15yrs
• True or false (cryptomenorrhea) amenorrhea
• MC cause Turners

ETIOLOGY

• Compartment IV
- Hypothalamic defect
- Kallmann syndrome - absence of production of GnRH & craniopharyngioma
- Hypogonadotropic hypogonadism
• Compartment III
- Pituitary gland defects
- Hypoprolactinemia
- Hypothyroidism
- Pituitary tumors
• Compartment II
- Ovary defects
- Hypergonadotropic hypogonadism
- Ovarian agenesis
- Ovarian dysgenesis – Turner’s syndrome
• Compartment I
- Uterine defects
- Absent uterus - Mullerian agenesis
EMBRYOGENESIS

• External genitilia - neutral

• DHT+ → Male
• No DHT → Female

Cryptomenorrhea 06:18

• False primary amenorrhea

• Congenital → Imperforated hymen
• Acquired → Transverse vaginal septum
- Partial vaginal agenesis
- Cervical stenosis

• Imperforate hymen
- Eugonadotropic eugonadism
- Phenotype - Female
- Karyotype - 45 XX
- Gonads - Ovary → Estrogen
- Uterus - Present
• Clinical presentation
- Primary amenorrhea
- Cyclical pain abdomen
- Acute retention of urine
- PR- uterus is felt

• Local examination - A tense bluish bulging hymen

• Dx : USG
• Mx : Incision on hymen - cruciate / x-shaped
Turner Syndrome 06:18

• MC cause primary amenorrhea

• Gonadal dysgenesis → Streak ovaries
- No production of estrogen
- SSC - Absent
- Uterus - Infertile
- Female exterior genitalia
- Karyotype - 45x | 46xx, 45x | 46xy → Gonadectomy
- Mosaic from secondary amenorrhea
• Mx
- Deficiency of estrogen → Give supplements
- Hormone replacement therapy (Estrogen + Progesterone)
- Conjugated equine estrogen 0.625mg
- Medroxy progesterone acetate 10mg
- IVF with donor Oocytes

Swyer Syndrome 12:35

• Gonadal dysgenesis
• SRY gene mutation
• Karyotype – 46XY
• Streak gonads →
- No estrogen → SSC absent
- No testosterone → Wolffian duct regress
- No AMH → Mullerian duct (uterus present)
• Mx
- Hormone replacement therapy (E + P)
- IVF with donor oocytes

Mullerian agenesis 14:10

• At Mayer–Rokitansky–Küster–Hauser Syndrome
• Karyotype - 46xx
• Gonad - Ovary → Estrogen
• SSC - Well developed
• Phenotype - Female
• Absence of uterus, cervix, upper 2/3rd vagina, fallopian tube
• Exeternal genitalia - Female
• PR - Not felt
• Dx : USG
• Associated skeletal & renal anomalies
• Rx : Vaginoplasty just before marriage
- Mechanical dilatation with Trank dilator
- Williams vulvo vaginoplasty
- McIndoe vaginoplasty
• IVF - followed by surrogacy

AIS 15:25

• At testicular feminization syndrome

• At Androgen insensitivity syndrome
• Karyotype - 46xy
• Gonads - testis
- Testosterone → Wolffian duct regress
- AMH → Mullerian duct (uterus present)
• Testosterone receptor defect: Testosterone → Estrogen
• Estrogen → Female SSC
• Female breast development
• External genitalia – Female
• Rx : Vaginoplasty just before marriage
- Mechanical dilatation with Trank dilator
- Williams vulvo vaginoplasty
- McIndoe vaginoplasty

• Gonadectomy after puberty & SSC development

• Post-gonadectomy - Hormone replace therapy
• Partial AIS - Scanty axillary
• Riefenstein Syndrome - Ambiguous genitalia

Causes 17:21

• Pituitary
- Prolactinoma
- FSH, LH < 5
• Craniopharyngioma – Tumor of connecting pathway

• Hypothalamic
- Kallman syndrome - gene Kal1 mutation
- No GnRH production
- No olfactory placodes - anosmia
- Male > Female
- Hypogonadotropic hypogonadism
- Female karyotype - 46xx
- Phenotype - Female
- Ovary present - No estrogen
- SSC not developed
- Uterus present
- External genitalia - Female
- Tall Height
- Rx : Inj. Pulsatile GnRH, Inj. HCG, Inj. FSH
 Secondary Amenorrhea
DEFINITION :

Absence of menstruation for 6 months duration or 3 previous regular cycles in a woman

who was previously normally menstruating

• MC physiological cause : Pregnancy

• MC Pathological cause : PCOS

Compartment 1 : Uterine abnormalities

Asherman Syndrome / Uterine Synchiae

Causes : Post Tb
Overzealous Dec
C/F : Amenorrhea
IOC : HSG = Honeycomb Appearance
Gold Standard : Hysteroscopy
Mx : Hysteroscopic adhesiolysis

Cu – T (To prevent

re-adhesion)

Estrogen + Progesterone

For first 21 days Last 10days

Compartment 2 – Ovary
MC cause = PCOS
 Premature Ovarian Failure Savage Syndrome

FSH receptors mutation

FSH > 40 IU/L FSH > 40 IU/L
E2  E2
ON TVS :  Follicles  Antral follicle count

AMH :  (<1) 

Rx : Oocyte donation Oocyte donation

CAUSES : Turner’s syndrome
Oophoritis
Fragile syndrome

Compartment 3 - Pituitary

PROLACTINOMA - MC - PITUITARY ADENOMA

Microadenoma < 1cms
Macroadenoma > 1cms →Can press on optic chiasma

C/F Amenorrhea /Hypomenorrhea

BITEMPORAL
GALACTORRHEA
HEMIANOPIA
Infertility /  libido

IS Fasting Serum Prl > 30G/Ml → Take Serum TSH

> 100g/mL → MRI

RX DOC : Cabergoline
NOTE : DOC in infertility & pregnancy : Bromocriptine

SHEEHAN’S SYNDROME

• Post PPH – Pituitary necrosis

• 1st hormone lost – GH
• MC presentation – Failure of lactation post delivery

Rx : Lifelong administration of estrogen, progesterone thyroxine, cortisol

Compartment 4 – Hypothalamus

- Athletes
- Excess exercise  Leptin
 GABA →  Pulsatile = Amenorrhea
- Eating disorders GnRH
- Stress
- Pseudocyesis

WORK UP

→ 1st – UPT
→ Serum, TSH, Serum PRL
→ Progesterone challenge test
5 days of medroxy progesterone acetate & withdraw

No Bleeding Withdrawal Bleeding Seen

Estrogen + Progesterone challenge test ANOVULATORY PCOS

Bleeds No withdrawl bleeding

Serum FSH ASHERMANN SYNDROME

< 5IU/L > 40IU/L

Hypothalamo Ovarian
pituitary failure

Q) Secondary amenorrhea after 3months of abortion is due to? (Serum FSH = 6IU/L)
a) Sheehan's Syndrome
b) Fresh pregnancy
c) Premature ovarian failure
d) Asherman's syndrome

Ans : d) Asherman's syndrome

 PCOS & Hirsutism
PCOS 00:54

• Also Stein Levinthal Syndrome

• Etiology - multi factorial and polygenic
• MC endocrine disorder (15-25yrs)
• MC cause of anovular infertility
• Treatable cause of infertility

PATHOPHYSIOLOGY

• Insulin resistance
• Increase insulin & IgFI → Theca cell hypertrophy → Inc. testosterone
• Increase in free testosterone → Fat cells
• In fat cells → Less potent estrone
• Estrogen → +ve feedback on LH
• Inc. estrogen → dec. FSH
- Defect in follicular maturation
- Anovulation

• LH to FSH ratio = 3 : 1
• To curb the insulin resistance - metformin
• Peripheral conversion (-) - Weight loss
CLINICAL PRESENTATION

1. Prolonged amenorrhea - heavy menstrual bleeding

2. Androgenic SE - hirsutism, Acne
3. Anovulation - infertility

• HAIRAN SYNDROME - Hyperandrogenism | Insulin resistance | Acanthosis Nigricans

• Dx - Rotterdam criteria (2 out of 3 +ve)

1. Anovulation / oligovulation - amenorrhea / oligomenorrhea
2. Hyperandrogenism - clinical / biochemical
3. On TVS → 12 follicles (2-9cm), peripherally arranged

ACANTHOSIS NIGRICANS

INVESTIGATION
• FSH
• 75 gm gtt
• Fasting lipids every 2 yrs
• Vit.d measurement
• Insulin resistance calculation - serum fasting blood sugar / serum fasting insulin
• A valve of less than 4.5 thickness resistance

MANAGEMENT

• Diet + lifestyle modification

• 10% weight loss improves ovulation
• Insulin sensitizer - Metformin 500mg - 150mg/day, myoinositol
SE- Lactic acidosis
REGULARISING CYCLE

• COCP
- Cycles regularise
- Inc. SHBC
- Helps reducing hirsutism
- Reduced menstrual blood loss

• Withdrawal bleeding
- After 30-45 days of amenorrhea
- Inc. medroxy porigesterone pacetase x 5-7 days

• Ovulation - regulation induction drugs

- DOC - Letrozole → aromatase inhibitor
- Prevents conversion of testosterone to esterdiol
- Alternative - Clomiphene citrate, gonadotrophins, Laparoscopic ovarian
drilling

LAPAROSCOPIC OVARIAN DRILLING

SURGERY FOR PCOS

• LOD or Laparoscopic electrocoagulation of ovarian surface

• Monopolar current is passed
• To destroy ovarian theca cells
• On female who are
- Resistant to ovulation with gonadotrophin
- High doses of gonadotrophin
• Advantage - no risk of OHSS
• Disadvantages
- Risk of premature ovarian failure
- Excessive ovarian tissue is damaged
- Adhesion formation post surgery

HORMONAL REVIEW

Hormones Increased Hormones Decreased

• Androgens • Follicle stimulating

(testosterone, Andostenedione & hormone
DHEAS) (due to oestrogenic
• Luteinizing hormone feedback)
(LH > 10 IUI ml) • Progesterone
• Estrogen (due to anovulation)
(Estrogen > Oestradiol) • SHBG
• Insulin (due to hyperandrogenism)
(> 10 m IU/L due to insulin • HDL and apoprotein A1
resistance)
• Prolactin (in some patients)
• LDL/cholesterol and triglycerides

LONG TERM CONSEQUENCES

• Risk of cardiovascular diseases

• Diabetes
• Endometrial cancer
• Ovarian cancer
• Breast cancer
• Anovulatory infertility
• Risk of depression & mood disorders
• Diseases associated with metabolic X syndrome
Metabolic X Syndrome and PCOS 15:07

• PCOS related to metabolic x syndrome

• Any 3 of the following should be present
- Abdominal obesity (> 88cm or 35inches)
- Triglyceride > 150mg / dl
- HDL- cholesterol < 50mg/dl
- BP > 130/85 mm Hg
- Fasting blood sugar of 110-126 mg/dl & 2hr - 140-199 mg/dl

Hirsutism 16:06

• MC cause PCOS
• Other causes – (adrenal, adenoma), adrenal carcinoma, testosterone producing
ovarian tumors, drugs, CAH

• Investigation;
1. Serum testosterone (ferrimen gallaway scoring) - < 150 ngm→ PCOS
2. >150 ngm → USG, DHEA
3. Increase in serum 17hydroxy progesterone (21alpha hydroxylase
deficiency)

• DOC - OCP containing cryproterone acetate

• Alternatives - Flutamide, Spironolactone, 5 alpha reductase inhibitor
 Infertility
Infertility 00:33

• Defined as inability to conceive inspite of 1 year of regular unprotected intercourse

• Primary: NEVER CONCEIVED
• Secondary: Conceived in the past (irrespective of outcome of that pregnancy)

NOTE : If age of woman > 35years & has inability to conceive inspite of 6 months of

regular unprotected intercourse should be investigated for infertility

Causes: Male Factor (30-40%)

Female Factor (40-50%)

Unexplained Infertility (10%)

Combined Factors (10%)

Female Factors 02:27

Ovarian Factors – 30%

Tubal Factors – 30%

Uterine/Cervical Factors – 15%

Unexplained Factors – 15%

Ovarian : MC PCOS

Ovarian Factors 04:23

WHO CATEGORY FOR ANOVULATION Rx

I) Hypothalamic pituitary failure → Eg : Kallman’s Syndrome Pulsatile Gnrh

II) Hypothalamic pituitary disturbance / PCOS Ovulation Induction
III) Ovarian failure → POF/ Savage Syndrome
Oocyte Donor
IV) Hyperprolactinemia
Doc : Bromocriptine
 INDICATORS OF OVULATION

Direct Indirect Conclusive

Laparoscopic Visualization Pregnancy

of Corpus Luteum

HISTORY INVESTIGATIONS

• Regular cycles (Better) > 5g/mL-Ovulatory

• Milteschermz pain • D22 – S. progesterone 3-5g/mL–Anovulatory
• Primary dysmenorrhea > 25g/mL–Pregnancy
• PMS • Urinary LH – LH surge
• TVS – Rupture of dominant follicle
Fluid in pouch of Douglas
Endometrium : Triple line appearance
• Endometrial biopsy – D22 – Secretory
Endometrium

- EARLIEST SIGN
Subnuclear basal vacoulation

• Vaginal cytology – MATURATION INDEX

Post ovulation  Parabasal cells = 0
Superficial cells decreased
Intermediate cells increased

BEST TEST FOR OVARIAN RESERVE

- Serum AMH (1st Best) : < 1mIu/mL = Poor ovarian reserve

OTHER TESTS

• D2 S. PSH, S.E2, S. Inhibin B (2nd Best)

• D2 – TVS – Antral follicle count
OVULATION INDUCTION AGENTS

1) Clomiphene citrate
2) Letrozole, Anastrozole, Tamoxifene
3) Gonadotrophins

Enclomiphene

(Most potent) LETROXOLE

CLOMIPHENE CITRATE

Zuclomiphene

1st line drug 1st line drug for PCOS, Obesity

Either is used for controlled ovarian stimulation

SERM Aromatase inhibitor

MOA : Inhibits E2 receptors on pituitary Inhibits :

 Testosterone Estrogen
No negative feedback  Increased FSH Increased FSH

DOSAGE : D1/D2 OD x 5 days D1/D2 OD x 5 days

50mg – 150mg/day 1.5-5mg/day

Pregnancy rate = 40%

Ovulation rate = 80%

S/E : Pain abdomen, hot flushes Teratogenic ? (CVS anomalies)

Visual disturbances

Decreased endometrial thickness

Ovarian cancers

Ovarian Hyperstimulation Syndrome (OHSS)

Multiple pregnancies
GONADOTROPHINS

• Superovulation → IVF cycles

• Human menopausal gonadotrophins - Urine – FSIU FSH + FSIU LH
• Recombinant FSH, LH, injection hcg
• DOSE = FSIU/day – 450 IU/day
• S/E : Twins (15-80%)
Epithelial ovarian cancer
OHSS

TVS GUIDED FOLUCULAR STUDY (Ds)

Also measure- Serum estradiol levels

When we have a follicle of 18mm


Injection HCG /  LH

36hrs

RUPTURE → Support cycle with progesterone

Q) A patient treated for infertility with clompihene citrate presents with sudden onset
of abdominal pain & distension with ascites, the probable cause is :
a) Uterine repture
b) Ectopic pregnancy rupture
c) Multifetal pregnancy
d) Hyperstimulation syndrome

ANS : D) Hyperstimulation syndrome

Release of cytokines & inflammatory mediators

HIGH R/F

VEGF 1) PCOS
2) Young girls
Damage to vessel wall

Third space loss

PREDICT  Sr. Estrogen (>2500pg/mL)

PREVENT  • Stop the cycle
• Retrieve follicles
• Withdrawal injection HCG

Rx  Symptomatic treatment

Tubal Factors 30:36

• INV : 1st line = HSG  discharge : B/L corneal spasm


False positive result

Gold standard = LAPROSCOPIC CHROMOPERTUBATION

HSG

LAPROSCOPIC
CHROMOPERTUBATION Methylene blue dye used

ADVANTAGE DISADVANTAGE

• Diagnostic & • Invasive,

Therapeutic expensive
• Adjacent • Uterine cavity
structures NOT visualized
visualized

MANAGEMENT OF TUBAL FACTORS

1) Corneal block : Corneal catheterization of cannulation (operative hysteroscopy) to

remove the blocks
2) Mid segmental tubal blocks : Tuboplasty
3) Distal tubal block : Mild – fimbrioplasty
Severe – IVF
TUBAL RECANALISATION

• Method of sterilization – Reversal best with clips (1 cm) > Falope rings (3 cm) >
Modified pomeroy > Cautery
• Length of tube > 4cms
• Isthmo-isthmic anastomosis
• Age <35yrs

Q) Lady with infertility with B/L tubal block at cornea ; best management is :
a) Laproscopy & Hysteroscopy
b) Hydrotubation
c) IVF
d) Tuboplasty

Ans : c) IVF

Q) An infertile woman has B/L tubal block at cornea diagnosed at

hysterosalpingography. Next step in treatment is :
a) IVF
b) Laproscopy & Hysteroscopy
c) Tuboplasty
d) Hydrotubation

Ans : b) Laproscopy & Hysteroscopy (to confirm)

CERVICAL FACTORS

Post coital test/Sims conner test

Rx : • Treat underlying cause

• IUT
 MALE FACTORS 37:45

Seminiferous tubules

Epididymis

Vas deferens
NORMAL ANATOMY

SEMINAL VESICLES PROSTATIC SECRETIONS

Ejaculatory duct

CAUSES :

Pre testicular : • Kallman’s Syndrome

• Erectile dysfunction
• Ejaculatory dysfunction
• Drugs

Testicular : • Trauma
• Torsions
• Tumors
• Kline felter syndrome
• Heat radiation
• Varicocele
• Cryptorchidism

Post testicular : • Vas deference obst.

• Ejaculatory duct obst.
• Congenital absence of vas deferens
• Post vasectomy
SEMEN ANALYSIS

- 3 days period abstinence

- Sample to be brought to hospital within 45 minutes

SEMEN - WHO 2010

Normal Value = 1.5mL Total count = 40 million/ejaculate

Normal Count = 15 million/mL Normal Morphology = 4%

Leukocytes <1 million/mL Normal motility = 40%

Round cells < 5 million/mL 32% → Progressive

Agglutation <10%

Vitality = 58%

* 2 Samples tested 6 weeks apart should be abnormal  INFERTILITY

ASPERMIA : Absence of sperm

AZOOSPERMIA : Zero sperm count

ASTHENOSPERMIA : Less than 40% motile spermatozoa

OLIGOZOOSPERMIA : Count less than 15 million/ml

TERATOSPERMIA : Less than 4% normal forms

Rx

Multivitamins & antioxidants for sperm

count to increase
given for 3 months

Clomiphene citrate
Also given
Inj FSH

Carnitine can increase motility of sperm

Q) A 25 year old male underwent semen analysis. Results show : Sperm count –
15million/mL pH – 7.5 ; Volume – 2mL ; No agglutination is seen. Morphology shows
60% normal & 60% motile sperms. Most likely diagnosis is :
a) Normospermia
b) Oligospermia
c) Azoospermia
d) Aspermia

Ans : a) Normospermia

AZOOSPERMIA

Peripheral smear Serum TSH, Prolactin Serum FSH

Leukocytes
  N
Culture S. Testosterone  S. Testosterone  S. Testosterone (n)

TESTICULAR ABNORMALITY PRE TESTICULAR POST TESTICULAR

  
Testicular biopsy Injection hcg TRUS
 Pulsatile GnRH 
Sperms present (Kallman’s Vasal Reconstruction
 syndrome) 
Sperm extraction – ICSI Fails

PESA : Percutaneous epididymal sperm aspiration

MESA : Microscopic epididymal sperm aspiration

TESA : Testicular sperm aspiration

TESE : Testicular sperm extraction (testicular biopsy)

Q) Which of the following is true about obstructive azoospermia :

a)  FSH, &  LH
b) Normal FSH & Normal LH
c)  LH, Normal FSH
d)  FSH, Normal LH

Ans : b) Normal FSH, Normal LH

Assisted Reproductive Technology 55:33

- IUI - ICSI
- IVF - PICSI
- ZIFT
- GIFT

IUI

Q) Intrauterine insemination means implantation of :

a) Semen
b) Washed Semen
c) Million of sperm
d) Fertilized oval

Ans : b) Washed Semen

IMP Pre-requisite Atleast 1 fallopian tube must be patent

Swim up
Procedure – Semen washed Swim down
Density gradient

0.5ml of highly motile sperms

injected into uterine cavity at time of ovulation

36hrs Post LH surge/Injection hcG

INDICATIONS - MALE FEMALE

• Epispadias / Hypospadias • Retrovertal uterus

• Retrograde ejaculation • Mild endometriosis
• Impotence • Antisperm antibodies in cervix
• Oligospermia < 15 • Vaginismus
million/mL

MAX – 6 Trials
SUCCESS RATE – 10-15%

IVF

Q) Artificial insemination with husband’s semen is indicated in all of the following

situations, except :
a) Oligospermia
b) Impotency
c) Antisperm antibodies in cervical mucous
d) Severe Rh isoimmunisation

Ans : d) Severe Rh isoimmunisation (Use DONOR Semen)

INDICATIONS - FMALE MALE

• Tubal pathology/blocks • Oligospermia

• Severe endometriosis • Unexplained in fertility
• > 6 IUI failures
• Decreased ovarian reserve
• Mullerian agenesis

Q) At what size of follicle, the following procedure performed ?

a) 12-44mm
b) 20-22mm
c) 16-18mm
d) 18-20mm

Ans : c) 16-18mm
 STEPS : • Ovarian stimulation with gonadotrophins & folliculate monitoring
• Oocyte retrieval (Ovum pickup) done through TVS guided needle
• Fertilization : 50,000 to 1.5 lakh sperms are put on each oocyte
retrieved
• Embryos kept in incubator for 48-72hrs
• Embryo transfer (ET) on D3 (72h) after oocyte retrieval
• Generally, 3-4 embryos are transferred in the uterine cavity via
catheter & deposited 1.5-2cms below fundus
• Success rate of IVF per cycle is 50%

ICSI

INDICATIONS : 1) For severe oligospermia, sperm count < 5 million/mL

2) Motility of sperms <5%
3) Morphologically (N) sperms <1%
4) Whenever sperms are retrieved surgically using techniques of :
MESA, PESA, TESA, TESE
5) In case of IVF Failure

SUCCESS RATE = 50%

Q) A 36yr old woman attends the infertility clinic. She is of (N) weight & gives H/O
regular menstrual cycles. However, her periods are heavy & are associated with
seven pain that outlasts hey periods. Hormonal tests reveal (N) LH, FSH, PRL & D1
progesterone levels. She recently had laprscopy & dye test that showed pelvic
adhesions with an absence of dye spill in both fallopian tubes. Her partner's semen
analysis is (N). Next step ?
a) ICSI
b) IUI
c) IVF
d) OI with gonadotrophins

Ans : c) IVF
 Contraception
Type of Birth control 00:22

• Natural family planning method

• Hormonal
• Barrier
• IUD
• Permanent Sterilization

Q) Pearl index is:

a) Failure rate / 1 woman years
b) Failure rate / 10 woman years
c) Failure rate / 100 woman years
d) Failure rate / 1000 woman years

Ans : c) Failure rate / 100 woman years

• Pearl index indicates effectiveness of contraceptive failure

• Expressed in teams of failure rate / 100 woman years of exposure
Total accidental pregancies X 1200
• Failure rate per HWY =
No.of patients observed X months of use

• Withdrawal Method → Coitus Interrupts  C/I : Premature ejaculation

Rhythm / Calendar Method 02:45

• Ogino Kaus theory

• Acc to this, ovulation in patient with 28 days is 14  2 days
• Sperm life span : 72hrs
• Ovum life span : 24hrs
• Therefore, unsafe is 8-18 days
• Avoid sex during day 8-18 (Failure Rate = 25-35%)
• Avoid sex during day 7-21 (Failure Rate = 10%)
• In irregular cycles,
Shortest cycle – 8 is 1st Day of Abstinence &
Longest cycle – 11 is Last Day of Abstinence
• Perfect use failure rate : 10/HWY (WHO 2015)

Standard Days / Tirumala Method 03:59

• Cycle beeds keep track

• Can be used in women with cycle between 26-32 days
• Failure rate : 2/HWY
Cervical Mucus Method 05:35

Basal Body Temperature Method 06:07

• Progesterone is thermogenic
• After ovulation, temp raises by 0.5°c which persist for 3 days
• Safe period begins from 4th day (after ovulation) to last days of next period
• Perfect use failure rate : 1/HWY (WHO 2015)

Sympothermal Method 06:49

• Combination of cervical mucus method & basal body temp. method

• Perfect use failure rate : 0.4/HWY (WHO 2015)
Lactational Amenorrhea 07:13

BELLAGIO CRITERIA
All postpartum women in whom :

• Menstrual cycles are not resumed

• Infant is fully or nearly fully breastfed, day & night
• Infant < 6 months

Pregnancy rate : 1/HWY in first 6 months

Barrier Methods 07:44

• Spermicides
• Hole condom
• Diaphragm
• Cervical cap

MALE CONDOM

Types

• Latex, polyurethane (thinner, hypoallergic), Vylex, Polyisoprene

• 15-20cms in length
• Typical average failure rate of condom = 18/HWY
• Perfect use = 2/HWY

NON-CONTRACEPTIVE USES

1) After vasectomy to be used till semen analysis confirms azospermia

2) As condom catheters in males
3) After vaginoplasty
4) As condom tamponade for managing atonic PPH
5) In patients with antisperm antibodies present in cervical mucus
6) On TUS probe
FEMALE CONDOM

• Made as an alternative to male condoms

• Polyurethane
• Physically inserted in the vagina
• 15cms long & 7cms in diameter
• Woman can use female condom if partner refuses
• Reusable
• Typical failure rate = 21%
• Perfect use = 51/Hwy

DIAPHRAGM

Q) All are C/I of diaphragm except :

a) Multiple sex partners
b) Recurrent UTI
c) Uterine prolapse
d) Herpes vaginitis

Ans : a) Multiple sex partners

• Should NOT be removed before 6-8h of the last act

• Should NOT be kept for > 24 hrs
• The best time to introduce it is from a few minutes to 2hrs
C/I OF CAP & DIAPHRAGM

1) Prolapse
2) Retroversion
3) VVF
4) Badly eroded cervix
5) Recurrent UTI

DIAPHRAGM

CERVICAL CAP

SPERMICIDAL AGENTS

Q) Spermicidal agents are: (PGI June 06)

a) Nonoxynol
b) Menfegol
c) Progestasert
d) Levonorgestrel

Ans : a, b

OTHERS : Benzalkonium

Octoxynol

MOA : Disruption of cell membrane of sperm

SPONGE

Cyproterone acetate

Oral Contraceptive Pills 13:12

Progesterone only Pills Combines OCPs

Monophasic Multiphasic

E+P Triphasic – Triquillar

Quadriphasic – Qlaira

AMOUNT OF ESTROGEN

Standard Dose : 50mg Of Ee

Low Dose : 30-35Gm Ee

Very Low Dose : 15-20Gm Ee

TYPE OF PROGESTERONE

1st Generation Pill : Norethindone

Norethisterone Androgenic S/E

2nd Generation Pill : Levonorgestral

3rd Generation Pill : Desogestral S/E : Venous

Thromboembolism
Gestodene

Norgestimate Anti androgens

4th Generation Pill : Drosperinone

 NO COST

FREE BY GOVT : Mala N

30gm EE + 150gm LNG
Mala D

₹2

MOA E+P→ -VE FSH & L+I →

• Anovulation
• Endometrial thinning
• Cervical mucus thickening
• Start on D1 of cycle / within 5 days of cycle X OD daily at same time for 21 days

POSITIVE BENEFITS

• Prevents pregnancy • Decreases incidence of ovarian cysts

• Eases menstrual cramps • Prevents ovarian uterine, colorectal cancer
• Shortens period • Decreases acne
• Regulates period • Benign breast disease
• RA
• Fibroids
• Endometriosis
• HMB

MINOR S/E MAJOR S/E

• Weight gain • Thromboembolism

• Acne, Hirsutism • Stroke
• Mood swings • Increased risk of coronary artery
• Melasma disease
• Headache • Gall bladder disease
• HIV • Increased risk of hepatic adenoma
• Breast pain • Adenocarcinoma of cervix
• Breast cancer
C/I “The left heart is best magnetic door for HTN”

• Thrombosis / Thromboembolism • DM with vasculopathy

• Active liver disease • HTN > 160/110mmHg
• Ischemic heart disease / Valvular heart disease • Pregnancy
• Breast CA • Postpartum 6 weeks
• Migraine with aura • Age > 35yrs
• Smoking > 15 cigrattes/day

PROGESTERONE ONLY PILLS

• Cerazette – Desogestral 0.75mg

• Lactational pill
• 1° MOA – Cervical mucus thickening

ORTHO EURA PATCH

• E+P
E : EE 20gm
P : Norelgestromin 150gm
• Apply patch for 3 weeks followed by 1 week patch free

• Advantage :

- Better Compliance

- Avoids 1st pass metabolism

• Disadvantage :
- Less Effective In Obese
NUVA RING

P – Etonogestral 120Gm

E – Ee 15Gm

Placed in vagina for 3 weeks & 1 week free of ring

• Advantage :

- Better Compliance

- No Systemic S/E

• Disadvantage :
- Leucorrhea

INJECTABLE CONTRACEPTIVES

DEPORMEDROXYPROGESTERONE NORETHISTERONE
ACETATE ENANTHATE

(Anthara)

150mg i.m once in 3 months 200 mg i.m once in 2 months

MOA : • Anovulation (1°)

• Endometrial thinning
• Cervical mucus thickening

ADVANTAGE DISADVANTAGE

• Contraceptive of choice in – • Initially I/t irregular bleeding

SICKLE CELL ANEMIA • Long term – ATROPHY
• Raises threshold of seizures • Weight gain
• Postpartum 6 weeks to 6 months • Bloating
• Acne, hisutism
• Osteoporosis
• DM
• Mood swings
• Breast tenderness
• Return of futility delayed by 12 months
(MAX – 18 months)
LARC 25:20

1-6 CAPSULES

NORPLANT LNG

11-2 capsules

• Implants
IMPLANON – 67 mg of Etonogestral released in 3yrs
• IUCDS - Least failure rate of 0.5 HWY
- Radio opaque = NEXAPLANON

IUCDS

1st generation 2nd generation 3rd generation

Lippes loop Cu releasing • Progestasert

• LNG/IUCD
Inert Freedom 5 Freedom 10 52mg - 20gm/day
5-7years
MOA FB reaction • Cu 375 • Cu 380A
• 5years • 10years MOA FB reaction

Endometrial thinning
Cu → Increasing Fallopian Tube
Cervical mucus
Motility

Spermicidal Thickening

Fb Reaction

LIPPE’S LOOP LNG-IUCD (MIRENA)

TIMING OF INSERTION
48hrs to 4 weeks insertion =
• Post placenta (3rd stage of labor)
ABSOLUTE C/I
• Postpartum – within 48hrs of delivery
• Interval – after 4 weeks of delivery 4-6 weeks = RELATIVE C/I
• Post abortal

C/I

“Please Don’t Use in Cancers”

• Puerperal • Distroted • Undiagnosed • Cervical cancer

sepsis uterus vaginal bleeding • Endometrial
• Post abortal • Fibroid cancer
sepsis • Uterine • GTN
• Current PID anomalies • LNG = Breast &
• Postpartum Ovarian CA
upto 4 weeks

Cx :

1) MC – Increased bleeding
2) Pain – MC reason for removal
3) Expulsion
4) Misplaced IUD d/t perforation (1 in 1000)
5) Infection (within 2months) within 7-9 weeks Actinomyces
6) Ectopic pregnancy
Clinical

1st Ix : Usg

X –Ray With Uterine Sound

Myometrium Peritoneum

Hysteroscopic removal Laparoscopic removal

 IUCD With Intrauterine Pregnancy

Remove The IUCD

Could’nt Be Removed
TERMINATE CONTINUED

MTP • Spontaneous abortion

• Preterm labor
• Infections

GYNE FIX –

• Frameless & Flexible

• Less pain & bleeding
• Non biodegradable suture thread 6 Cu tubes (5mm X 2.2mm)
→ Surface area 330mm2
• Suitable for nulliparous

Emergency Contraception 36:01

AKA : Morning after pill / Interception / Post coital pill

• Most effecrive : Cu T within 5 days

2nd : Ullipristal acetate 30mg within 5 days
LNG Mifipristone
3rd : 1.5mg 600mg (RU 486)
within 72 hrs within 72 hrs

• Others : Saheli – Oymelexifene 50mg

Yuzpe – 2 tab 50g EE + 250g LNG stat

2 tab after 12hrs
Permanent Methods 38:02

VASECTOMY – No scalpel vasectomy

• Failure rate = 0.1 HWY

• 70% chance of reversal
• Additional contraception till No sperms in ejaculate

FEMALE STERILIZATION
Least Fr – Uchida
• Minilaprotomy Fr of Pomeroy – 0.2 Hwy

Highest Fr – Kroeney Fimbriectomy

• Laproscopic tubal ligation – clip & rings

SITE : Isthmus 1cm 3cms of tube damaged

REVERSAL

BEST = CLIP

RING

POMEROY

LEAST =
COAGULATIO
N
TIMING OF TUBECTOMY

• Minilaprotomy : Post delivery after 24hrs upto 1 week post delivery

Interval > 6 weeks
Concurrent with CS
Post abortal

• Laproscopic : Interval > 6 weeks

Post abortal (1st trimester)

• Hysteroscopic tubal ligation

- Microcoil of nickel & titanium alloy

ELIGIBILITY CRITERIA FOR CLIENTS UNDERGOING FEMALE STERILIZATION

• Should be married
• Age : 22years - 49yeaes
• Should have atleast one child > 1yr age
• Spouse / partners must not have undergone sterilization in the past
 Menopause & HRT
Menopause 00:27

• Permanent cessation of menses for 1 year

• Physiologically correlations
- Decline in estrogen secretion
- Loss of follicular / ovarian function

• Age group - depletion of oocytes for 6 months

• In India - 48 yrs
• In developed countries - 52 yrs

• Earlier menopause ;
1. Nulliparous women
2. Tobacco smokers
3. Hysterctomized women

SYMPTOMS

• Hot flushes / Vaso motor - Sudden sensation of heat

• Estrogen withdrawal - Coincide with LH surge
• Osteoporosis
• Urogenital atrophy - Dysuria, Dyspareunia
• Dementia
• Mood swings
• Risk of coronary artery diseases
• Wrinkling of the skin

DX CRITERIA

• Cessation of menstruation
• Menopausal symptoms
• Vaginal cytology 100/0/0
• Serum esterdiol < 20pg/ml
• Serum FSH and LH > 40 miU/ml
HORMONE REPLACEMENT THERAPY (RX)

• Estrogen - Conjugated equine estrogen

• Progesterone - Depo Medroxy progesterone acetate / nor ethisterone enanthate /
Levonorgestral IUcd
• Uterus present - E + P
• Uterus absent - only E
• Indications
1. Vasomotor symptoms
2. Vaginal dryness
3. Prevention & treatment of osteoporosis

• Not to given for primary prevention of Heart diseases

• Risk
1. CHD
2. Breast cancer (> 5yrs)
3. VTE
4. Cholecystitis
5. Ovarian cancer (> 10yrs)
• Use minimum possible dose - max 5 yrs

• HRT not given for

1. Urogenital atrophy
2. Vasomotor symptoms
3. Prevention of osteoporosis
4. Prevention of coronary heart disease

• Contraindications
1. Thrombosis / Thromboembolism
2. + Liver disease
3. Ischemic heart disease
4. Breast cancer
5. Migraine with aura
6. Diabetes mellitus with vasculopathy
7. Severe Hypertension > 160/110 mm Hg
• Alternative for HRT

Hot flushes treatment

- Black cohosh
- Isoflavanes (100mg/day)
- Soy milk
- Vitamin E
- E+P
- P
- Tibolone (STEAR)
- Clonidine
- SSRI
- Gabapentin

Osteoporosis treatment :
- Bisphosphonates (first line)
- E+P
- Raloxifine
- Tibolone
- Denosumab
- Teriparitide : Recombinant PT
- Calcium
- DEXA Scan for BMD

HRT Indication 11:32

• Indications of E and P in hysterectomized women

1. Past history of endometriosis
2. Supracervical hysterectomy
3. Adenocarcinoma of the endometrium
4. Endometroid tumors of the ovary
 Fibroid
clinical 00:21

• Benign smooth muscle tumor of the uterus

• MC benign solid tumors in females
• MC pelvic tumor
• Monoclonal origin
• MC age group affected - 35-45 yrs
• Estrogen + Progesterone dependent
• MC seen in nulliparous female

CLASSIFICATION

• Uterine
1. Submucosal
2. Intramural (70% & MC)
3. Subserosal
• Extrauterine
1. Cervical
2. Abdomen
3. Broad ligament

FIGO CLASSIFICATION

• 0 : Pedunculated intracavitary
• 1 : SM, < 50% intramural
• 2 : SM, > 50% intramural
• 3 : Intramural but contacts endometrium
• 4 : Intramural
• 5 : Subserosal, > 50%
• 6 : Subserosal, < 50% IM
• 7 : Subserosal pedunculated
• 8 : Others, cervical abdominal

• Hybrid – 2 to 5
ETIOLOGICAL FEATURES

• Genetic : > 50%

• Obesity
• Family H/o
• Nulliparous
• Early menarche
• African American race

• Protective factors
1. Exercise
2. Smoking
3. Menopause
4. Multiparity

• Changes
1. Degeneration - MC hyaline degeneration
2. Red degeneration - MC in pregnancy, c/s - red beefy appearance
3. C/P - fever & pain, MC in 2nd trimester

• Rx : Self limiting, analgesics & antipyretics

• LC type degeneration - sarcamatous degeneration
• Subserous fibroid - calcareous degeneration (wombstone appearance)

CLINICAL PRESENTATION

• Asymptomatic > 50%

• Submucosal fibroid - HMB, Recurrent abortion
• Intramural fibroid - Congestive dysmenorrhea
• Subserosal - Pressure symptoms
• Pedunculated subserosal - Torsion
• Anterior cervical fibroid - Irritates bladder
• Trigone - increase frequency of micturition
• Post cervical fibroid - Acute retention of urine
• Fibroids - Infertility
• IOC - USG → Homogenous hypoechoic
MANAGEMENT

• Asymptomatic
1. Regular supervision
2. Surgery - Dx uncertain, pedunculated subserosal, unexplained infertility

• Symptomatic
1. Medical
2. Surgery

• Medical
1. Bleeding - Tranexamic acid, NSAIDs, COCP, progesterone
2. NSAIDS - To reduce pain
3. Decrease in size, pain & bleeding - GnRh analogues, danazole, gestrinol,
mifipristone

• Surgical
1. Myomectomy - Only in nulliparous fibroid
2. Minimal invasive surgery
3. Hysterectomy

• Prerequisite
1. Husband semen analysis - N
2. Endometrial biopsy to rule out cancer
3. Consent for Hysterectomy

Clinical Approach 08:40

• Methods to decreased bleeding during Myomectomy

- GnRh agonists
- Timing in postmenstrual phase
- Use of vasopressins or adrenaline infiltration
- Mechanical methods : Torniquets & Bonneys clamp
UTERINE ARTERY EMBOLOZATION

HIGH FOCUSED ULTRASOUND

 Endometriosis
Features 00:36

• Occurence of endometrial tissue outside the uterus

• 1st MC site - Ovary – Chocolate cyst
• 2nd MC site - Pouch of Douglas
• It can occur in any part of body
• MC in nulliparous females
• MC in High socioeconomic group due to late marriages / Late child births
• Familial predisposition and is E dependent

RISK FACTORS

• Nulliparous
• Early menarche, Late menopause
• Short cycle
• Family H/o
• High socio economic status
• Obesity
• Late marriage
• Late child birth
• Mullerian anomalies
• Imperforated hymen
• Transverse vaginal septum

PROTECTIVE FACTORS

• Pregnancy
• Lactation
• Multiparous
• Exercise
• Smoking
PATHOGENESIS 03:35

• Sampsons retrograde menstruation theory – Most acceptable

• Coelomic metaplasia (Meyer & Ivanoff)
• Direct implantation
• Lymphatic theory
• Vascular theory
• Genetic & immunological
• Environment theory

CLINICAL PRESENTATION

• Dysmenorrhea (painful) – Triple dysmenorrhea, Progressive dysmenorrhea

• Infertility
• Dyspareunia

Ovarian dysfunction Tubal dysfunction Others

• Endocrinopathies • Altered tubal • Dyspareunia (poor

- Defective
folliculogenesis
- Anovulation
- Luteal phase defect
- LUFS
- Hyperprolactinemia
• Oocyte maturation defect
• Luteolysis due to  PGF2a
motility coital function)
• Pelvic • Abnormal peritoneal
adhesions, tubal fluid
obstruction • Abnormal systemic
• Distortion of immune response
normal tube • Increased sperm
and ovarian phagocytosis by
relationship macrophages
• Impaired pick • Fertilization and
up of oocyte by implantation failure
the fimbria • Early miscarriage

SIGNS

• Fixed retroverted uterus

• Firm fixed adnexal mass (endometrioma)
• Tender nodularity of uterosacral ligament (cobble stone appearance)
• IOC (gold standard) - Laparoscopy
• Early lesions - Petechia
• Late lesions - Gunshot
• USG ground glass appearance

Management 09:45

• Expectant
- Asymptomatic
- Pregnancy
- Menopausal
• Medical
- Temporary
- Symptomatic
• Surgical

• Pseudo-menopause drugs

- GnRh analogue - agonist & antagonist

- Agonists - Leuprolide acetate, Nafarelin, goserelin
- Antagonists - Cetrorelix, ganirelix , oral Belagolix

• For side effects

- Hot flushes
- Osteoporesis – Add back therapy with E + P
• Pseudo-pregnancy drugs
- COPC continuously x 6 months
- Progestin x 6 months
- Lng IUcd
- T. Dhydrogestrone 10mg BD
- Norethisterone enanthate
- Medroxxy Progesterone acetate

SURGERY

• Indication
- Non responsive to medical Mx
- Acute intolerable pain
- Bowel / Urinary injury
- Chocolate cysts
• Rx
- Adhesiolysis
- Fulguration of implants - laser / cryoscope
- LUNA Hysterectomy & B/L salphingo opheractomy

• Cysts < 3cm – Laparoscopic drainage and electrocoagulation

• > 3cm - Laparoscopic cystectomy
• Mild endometriosis - Infertility → IVI
• Severe - Infertility → IV
 Vaginitis & Vulval Ulcers
Vulvovaginitis 00:34

• Inflammation of vulva & vagina

• Physiological
- Prepubertal Vulvovaginitis
- Postmenopausal / Atropic / Senile Vulvovaginitis
• Pathological / infectious
- Trichomonas
- Candidiasis
- Bacterial vaginosis

TRICHOMONAS VAGINITIS

• Organism – Trichomonas Vaginalis

• STD
• Symptoms
- Greenish coloured vaginal discharge
- Itching
- Dysuria
- Dyspareunia
• Signs
- Punctate spots
- Strawberry vagina
- Angry looking vagina

• IOC - Saline microscopy

• Gold standard - Feinberg Whittington Media / Diamonds media
• Mx : DOC - Metronidazole
- 2gm Single dose or
- Tinidazole 2gm PO single dose
- Metronidazole 500mg BD x 7 days
- Mode - Both partners

• Pregnancy
- 1st trimester - Metronidazole pessary
- 2nd & 3rd trimester - Metronidazole 2gm stat dose or
- 250 mg TDS x 5 days
Candidiasis 03:29

• Etiology - Candida albicans

• LC by candida glabrata, Candida tropicalis
• MC Vaginitis - Pregnancy, Diabetic, Immunocompromised
• Only vaginitis which flourished in acidic media

• Clinical presentation
- Curdy white discharge
- Cottage cheese discharge
- Pruritis +++

• On examination - White colored punctuate spots on vagina

• IOC - Saline microscopy - Pseudo hyphae see
• Gold standard - Culture on sabouraud agar
• Mx : DOC azole group such as fluconazole 150mg stat
• PAP smear – Sheekh kabab appearance

RECURRENT VULVOVAGINAL CANDIDIASIS

• 4 or more episodes of candidiasis in a year

• Mx : Fluconazole 150mg every 3 days for 3 doses
• Followed by 150mg weekly x 6 months - Maintenance therapy

Bacterial 05:38

• Alteration in the microbial floor of vagina

• Etiology
- Gardnerella vaginalis (MC)
- Mycoplasma
- Peptostreptococci
- Bacteroides

• Symptoms - Dirty white/Grey malodorous discharge, No itching

• Dx :
- Dirty white foul-smelling discharge
- pH .4.5
- 10% KOH to discharge - fishy odour is present whiff
- Test +ve
- Clue cells are seen
• Nugent scoring - Lactobacillus decrease & gardenerella increase
• Rx : Metronidazole 500mg BD x 7 days

Cervicitis 08:01

CHLAMYDIA

• Etiology
- Chlamydia trachomatis - Obligate intracellular organism
- Preferential infection - Columnar & Transitional epithelium
• Clinical features
- Asymptomatic (80%)
- Mucopurulent endocervical discharge
- Urethral syndrome - dysuria, frequency, pyuria, no bacteria
- Pelvic pain
- Postcoital bleeding / intermenstrual bleeding
• Investigations
- Nucleic acid amplification test
- First void urine sample / vaginal swab
- PCR
- Culture on McCoy cells / Hela cells
• Rx
- Doxycycline 100mg BID x 7days or azithromycin 1mg single dose
- Both have similar results
- Treat partners simultaneously
• In pregnancy
- Azithromycin, No Doxycycline
- Azithromycin - 1g in a single dose or Amoxicillin 500mg TID x 7days
GONORRHEA

• Etiology - Neisseria gonorrhoea (gram -ve)

• Clinical features
- 50% asymptomatic
- MC symptom - excessive, irritant vaginal discharge
- Lower abdominal pain, urethral infection manifesting as dysuria

• MC site - endocervix, bartholin gland, urethra & skene gland

• Gonococcal vaginitis occurs in newborn females
• Investigations - gram stain culture
- Acute phase - Bartholin's gland & endocervix
- Gram -ve intracellular diplococci on staining
- Culture - Thayer-Martin medium

• NAAT
- On urine & endocervical discharge
- First void morning urine sample preferred
- Sensitive & specific
• Rx
- Single dose Inj Ceftriaxone 125mg IM stat or
- Cefixime 400 mg oral stat or
- Ciprofloxacin 500mg stat
- To treat Chlamydia - Add Doxycycline / Azithromycin
- If pregnant - Cephalosporin regimen
- Allergic to beta-lactam antibiotics - 2g spectinomycin IM

Vulval ulcers 12:18

PAINFUL

• Herpes
- HSV2
- Vesicles
- Multiple
- Erythematous base
 - Edge - erythematous
- LN - B/L tender
- DOC - Acyclovir 400mg TDS x 7-10days
• Chancroid
- H. ducreyi
- Papule
- Multiple
- Greenish exudate
- Edge - undermined
- LN - U/L tender
- DOC - Azithromycin 1gm PO

PAINLESS

• Syphilis hard chancre

- Treponema pallidum
- Papule
- Single
- Edge - Punched out
- Rubber non-tender LN
- Inj. Benzathine, Pencillin, 2.4 million IU
• LGV
- Chlamydia trachomatis
- Papule vesicle
- Single
- Edge - elevated
- Tender LN
- DOC - doxycycline 100mg OD x 21 days

• Granuloma inguinal
- Klebsiella granulomatosis
- Papule
- Single / Multiple
- Red velvety base bleeds on touch
- Edge - elevated
- Pseudo Bubo
- DOC - Doxycycline 100mg OD x 21 day
Endometrial Hyperplasia and Endometrial Cancer
Endometrial Hyperplasia 00:30

Risk factor-estrogen

FEATURE EXPLANATION PROGRESSION

TO CANCER

Simple Simple Hyperplasia 1% (Least)

Antimitotic
without
No Dysplasia  Block Estrogen
Atypia
Receptor
A.K.A Cystic Mx → Progesterone
Glandular - Medroxy progesterone
acetate
Hypertrophy
- 10 mg bd Cyclical-
Complex Complex 3% Last 12-14 day
Without Hyperplasia or continuous
Atypia - Norethisterone
No Dysplasia enarthate
Simple with Simple Hyperplasia 8% - Levonorgestrel
Atypia IUCD (Best)
Dysplasia Cells
Mx - Hysterectomy
Complex Complex 29%
with Atypia Hyperplasia (maximum)

Dysplastic Cells

- Young girls with atypia  T. megestral acetate 160mg/day

3-6 month

Endometrial biopsy
Endometrial cancer/hyperplasia 05:10

-High estrogenic state

RISK FACTORS PROTECTIVE FACTORS

1. Obesity 1. Combinal OCP
2. PCOD 2. Artificial menopause
3. Estrogen secreting tumor 3. Multiparity
4. Nulliparity 4. Exercise
5. Early menarche Smoking ( estrogen)
6. Unopposed E2 in HRT
7. Tamoxifen
8. Infertility and menstrual irregularities

Family History

1) Lynch syndrome (Chr.5) – MLH, MSH2, MSH6, PMS2

2) Cowden Syndrome (Chr.10) – PTEN Mutation

If family H/O present:

• Routine surveillance may consist of yearly USG and endometrial biopsy commencing
at the age of 30-35
• Best method to prevent endometrial cancer in patients of HNPCC is prophylactic
hysterectomy and oophorectomy

→ Corpus cancer syndrome : DM + HTN + Obesity + Endometria Co.

Types 10:00

Features Type 1 Type 2

Ages 50s-60s 70e

Risk Factors Chronic estrogen stimulation, Atrophy

Obesity, Anovulation,
Nullparity, Adult onset
diabetic mellitus, HNPCC

Precuresor Lesions Atypical endometrial Less defined

hyperplasia
 Types Endometrioid endometrial Clear cell and papillary
hyperplasia serous carcinomas

Genetics PTEN mutations, MSI P53 mutations

Metastasis Lymph nodes, Ovarian Peritoneum

involvement

Prognosis Favorable Poor

Type 1 Type 2

• Estrogen dependant • E2 independet

• ER +ve • ER –ve
• Hyperplastic endometrium • Atrophic endometrium
• 50-60yrs • > 70yrs
• Confined to uterus • Extrauterine spread
• Adeno Ca • Clear cell/serous Ca
• PTEN (MC) • MC P53 mutation
• Good Prognosis • Poor Prognosis
• 5yr survival rate – 86% • 20%
• Spreads through – hyphatic, ovarian • Spread through peritoneal spread
spread • Infracolic omentectomy

Symptoms 11:40

1) Premenopausal – Irregular vaginal bleeding

Postmenopausal – PMB (post menupausal bleeding)
2) Foul smelling discharge
3) Dull aching referred pain into hypogastric & Intra fossa → Simpsons pain

 MC cause of PMB – Atrophic endometrium

 MC cancer causing PMB in developed countries – Endometrial cancer
 MC cancer causing PMB in developing countries – Cervical cancer
Investigation 13:20

1st line –On TVS

Check

Endometrial thickness

In Premenopausal InPostmenopausal
If ET > 12mm If ET >4mm (Figo ET >5mm)

Endometrial Biopsy :

IOC – Office endometrial biopsy → opd procedure

Gold standard – Hysteroscopic D & C no anesthesia
sensitivity 92-98%
Increased as 1 line in pin point os
st

Focal thickening ET > 4mm

Patient on tamoximen

→ Mode of Spread – Direct

ENDOMETRIAL CANCER ON USG

Thickened echogenic and heterogenous in echo tecture and contains tiny cystic foci

Figo Staging 16:55

1) Stage 1 – Confined to uterus

IA - <50% myometrial involvement
IB - >50% myometrial involvement
2) Stage 2 – Cervix also involved
3) Stage 3
3a – Adnexa of serosa
3b – Parametrium / vagina
3c1 – Pelvic LN
3c2 – Paraaortic LN
4) Stage 4
4a – Bowel/ Bladder
4b – Distant mets.

Surgical Staging:

• Midline vestiline incision

• Ascitic fluid or paitoneal lavage for malignant cells
• Intra abdominal palpation either clock wise/anti clock wise
• Suspected lesions are biopsied
• Total abdominal hysterectomy + Bilateral alphingo oophorectomy
• LN sampling
• Infracolic omentectomy

Grading:

• Grading is purely pathological

• The cellular criteria taken into consideration is the percentage of squamous
component (squamous cells represent undifferntation of the tumor from columnar
to squamous)
• Though it applies separately to all stages but is clinically relevant for stage I only
• We have 3 grades based on cellular criteria as below
- Grade I : <5%
- Grade II : 6% - 50%
- Grade III : > 50%

Management 20:14

Stage 1a grade 1, grade 2 Stage 1a grade 3

Stage 1b
< 2CM > 2CM
TAH + BSO TAH + BSO 
+ TAH +BSO
Pelvic LN dissection

Pelvic and Paraaortic in dissection

Vault irradiation

Stage 2 Stage 3 & 4

Modified radical Debulking / Cyto reductive surgery

hysterectomy/werthiems
+
hysterectomy
Pelvic paraaortic LN dissection

Pelvic & paraaortic LN dissection

Whole abd or Chemotherapy

Rt Doxorubicin
Post OP whole pelvic radiotherapy
Cisplatin

Adriamycin
 Ovarian Cancer
Q) Ovarian tumors commonly arise from :
a) Stroma
b) Surface epithelium
c) Germinal epithelium
d) Endoderm

Ans : b) Surface epithelium (80%)

Classification 01:17

EPITHELIAL CELL GERM CELL TUMOR SEX CORD TUMORS Causes

TUMOR
Age 15-20 years Hormone producing mainly
MC tumor (90%) tumors menstrual
irregularities
Age > 45 years Age 20-40 years

• Serous (75- • Mature teratoma • Granulosa cell

80%) (MC) • Immature tumors E2 Producing
• Mucinous teratoma • Fibroma
• Endometrial • Choriocarcinoma • Thecoma
• Clear cell • Dysgerminoma • Serotoli cell
• Brenner tumor • Embryonal tumor Testosterone
• Undifferentiated tumors • Leydig cell producing
• Yolk sac tumors tumor
• Hilus cell tumor
• Gynandyoblasto - Produces both
-ma

METASTATIC : Krukenberg tumor

• Primary from stomach

• WORST PROGNOSIS
• B/L & has a smooth surface
• Cut section shows : Signet ring cells

EPITHELIAL CELL TUMOR

• MC Malignant epithelial : Serous cystadenocarcinoma (50% B/L)

• MC Benign epithelial : Serous cystadenoma
• Largest growing : Mucinous (Pseudomyxoma peritonei)
• Endometriod : Precursor of endometriosis
• Brenner : Transitional epithelium / Mostly U/L
• Clear cell : High grade malignant tumor

GERM CELL TUMOR

MC in pregnancy & young girls

• MC benign : Dermoid cyst
(Mature teratoma)
MC to undergo torsion
• MC malignant : Immature teratoma
• Rapidly growing : Yolk sac tumor / Endodermal sinus tumor
• Worst prognosis : Yolk sac tumor
• Most radio & Chemo sensitive : Dysgerminoma → Best Prognosis

Etiology 07:06

“THEORY OF INCESSANT OVULATION”

- More the ovulation, more is the risk of ovarian cancer

RISK FACTORS

• Nulliparous
• Early menarche
• Polymenorrhea
• Ovulation induction agents
• Talc & asbestos exposure
• FAMILY HISTORY :
OVARIAN BREAST
CANCER CANCER

BRCA 1 - Chr 17 mutation 50% 80%

BRCA 2 - Chr 13 mutation 25%

Lynch - Chr 5 mutation 15%

* Prophylactic B/L salpingo oopherectomy should be done after completion of family

* OCPs for 5yrs → decrease risk by 50%

Clinical Picture 10:54

• Asymptomatic
• Nausea, Vomiting
• Early satiety
• Weight loss
• Abd. distension/ Abd. mass

Investigations 11:57

TVS : MALIGNANT BENIGN

• Mutliloculated • Uniloculated
• Thick septations > 7mm • Absent/Thin septations < 7mm
• Heterogenous • Homogenous
• Atleast 4 capillary structures • Smooth surface
on surface
• Increased vascularity • Increased vascularity
• Ascites • Absent
• LN mets • Absent
• Omental caking • Absent
Q) Marker for granulose cell tumor :
a) CA 19-9
b) CA 50
c) Inhibin
d) CA 125

Ans : c) Inhibin

TUMOR MARKERS

OVARIAN TUMOR TUMOR MARKER

1) Endodermal sinus tumor/yolk sac tumor AFP

2) Epithelial ovarian tumors (esp. SEROUS) CA – 125

3) Serotoli cell, Leydig cell, Hilus cell tumors Testosterone

4) Dysgerminoma LDH, alkaline

phosphatase
5) Choriocarcinoma
HCG
6) Mucinous tumors
CEA
7) Granulosa cell tumors Inhibin
FICO STAGING
Mc mode of spread –
“ABC Dub Mash intra extra poda” Transcoelomic

IA Ovary Capsule Intact

A, B, C
IB Both Ovaries Capsule Intact
IC Capsule Bleach
C1 During Sx Capsule Ruptures
C2 Before Sx Capsule Ruptures DUBMASH
C3 Malignant Cells In Ascites
II Intra Pelvic INTRA
IIA Uterus
IIB Other Intra Pelvic Structures
III Extra Pelvic EXTRA
IIIA1 Retroperitoneal Ln (Pelvic & Paradortic)
(I) < 10MM
(II) > 10MM
IIIA2 Microscopic Extra Pelvic Peritoneal Implants
IIIB Macroscopic Extra Pelvic Peritoneal Implants < 2cms
IIIC Macroscopic Extra Peritoneal Implants > 2cms + Capsule Of Liver &
Spleen
IV
IVA PLEURAL EFFUSION WITH THE +VE CYTOLOGY
PoDa
IVb Distant mets

Management 18:50

- Staging Laprotomy

Midline Vertical Incision


• Ascites for malignant cells
• Inspect / palpate intra abd. organs
• Sampling of suspected mets
• LN Sampling
• Infracolic omentectomy
- Stage wise Management

FOR EPITHELIAL OVARIAN CANCERS

Stage IA, IB - Cytoreductive/Debulking Sx

& Borderline

Stage IC – IC - Cytoreductive/Debulking Sx

Post OP Chemotherapy =

6 Cycles of Carboplatin/Cisplatin + Paclitaxel

Note : For Inoperable Cases Of Stage 3 & 4 → Neoadjuvant Chemotherapy =

3 Cycles of Chemo

Surgery

3 Cycles of Chemo
FOR GENERAL CELL & SEX CORD STROMAL TUMORS

Staging Laprotomy

U/L Salpingo oopherectomy

4-6 cycles of BEP chemotherapy

• Bleomycin
• Etoposide
• Cisplatin

Ovarian Cyst 25:59

Perimenopausal / Reproductive woman with OVARIAN CYST

< 5cms 5-7cms > 7cms

Wait & Watch Simple Complex Surgery

 Postmenopausal Women with Ovarian Cyst

Ca 125

< 35 IU > 35 IU

< 7cm > 7cm Sx irrespective of size

W&W Sx

Pregnant women with OVARIAN CYST

< 5cms 5-10cms > 10cms

W &W Simple Complex → Sx in 2nd trimester

 CIN & CA Cervix
HPV 00:37

• HPV infection
• Predisposing factors for Ca. cervix (PGI Dec 08)
- Multiple sex partners
- Genital warts
- HPV 16, 18

• Risk factors for CA cervix / CIN

- Young age at first intercourse (<16yrs)
- Multiple sexual partners
- Cigarette smoking
- Race
- High parity
- Low socioeconomic status
- Human papilloma virus (HPV) infection
- HIV
- Immunosuppression

• HPV 6 and 11(low risk) causes;

- Anogenital warts
- Condyloma accuminata
- Laryngeal papillomatous in new born

• HPV 16 & 18
- High risk
- Most common
- 16 - CA cervix & squamous cell carcinoma
- 18 - most-specific, associated with adenocarcinoma cervix

• HPV 31 & 33 - CIN

• E6 & E7 - Suppress P53 & RB gene of cervical epithelial cells

- P53 suppressed - no apoptosis
- RB gene suppressed - abnormal cell proliferation
• HPV etiology % in anogenital diseases
1. Cervical cancer - ~100%
2. Vaginal cancer - 70%
3. Vulvar cancer - 43%
4. Genital warts - ~100%
5. Anal cancer - 88%
6. Oropharyngeal cancer - 13-56%
7. Penile cancer - 50%

VACCINATION

• Virus-like particles (VLP)

• Purified L1 protein
• From empty shells
• Do not contain viral genetic material
• Non-infectious

1) CERVARIX (not in use)

• HPV 16, 18
• In girls
• Protects CA cervix
2) GARDASIL
• HPV 6, 11, 16, 18
• In girls & boys
• Protects from CA cervix, anal, vaginal & vulvar cancer and premalignant
lesions
3) GARDASIL 9
• HPV 6, 11, 16, 18, 31, 33, 45, 52, 58
• In girls & boys
• Protects - the same as Gardasil

• Given - 9 to 26 years
• Can be given upto 45 years
• 3 doses : 0, 1-2months, 6months
WHO SAGE

• Dosage for 9-15 yrs girl - 1 or 2 doses of HPV

• In India - Cervavac -> Quadrivalent vaccine (HPV 6, 11, 16, 18)
• By Serum Institute of India

WHO Bethedsa CIN Description

terminology terminology terminology
Dysplasia LSIL CIN 1 Dysplastic cells seen in lower
1/3rd of epithelial lining if cervix
Moderate HSIL CIN II Dysplastic cells seen in lower
dysplasia 2/3rd of epithelial lining of cervix
Severe HSIL CIN III Dysplastic cells seen in more
dysplasia than 2/3rd of epithelial lining of
cervix
Carcinoma in HSIL Carcinoma Dysplastic cells seen in the full
situ in situ thickness of cervical epithelium
but basement membrane is intact
Cervical Cervical Invasive Dysplastic cells seen in the full
Cancer Cancer carcinoma thickness of cervical epithelium
with breach of basement
membrane

DYSPLASIA

• Increase in stiffness
• Decrease of cytoplasm
• Mitotic figures & nuclear atypia increases

PATHOPHYSIOLOGY

• Koilocytes -> CIN1 -> CIN2 -> CIN3 -> CA cervix

• Duration;
- Koilocytes to CIN3 - months
- CIN3 to CA cervix - 15-20 years
• Regression percentage
- CIN1 - 60%
- CIN2 - 40%
- CIN3 - 30%

KOILOCYTES

Screening 11:43

• PAP smear
• LBC - Liquid Based Cytology
• HPV DNA testing - best screening method
• VIA - Visual Inspection under acetic acid
• VILI - Visual Inspection under lugots iodine

• VIA
- Most cost-effective method
- Low resource setting

ROVERS ENDOCERVICAL LBC BRUSH

• Timing: day 12-14
• Pap smear Fixative - 95% ethyl alcohol
• LBC fixative - methanol
• Thin layer of cervical epithelial cells
• In LBC - sample adequacy is more (80%)

HPV DNA TESTING

• Hybrid capture method can reliably detect the high-risk HPV types within hours
• Can be done from 25 yrs

VIA

• 3-5% acetic acid

• Cervix examination after 1-2 min
• Normal cervix - unstained
• Malignant cervix - white patch

VILI - Visual Inspection under Lugol’s Iodine

• Lugol’s iodine
• Examination after 1-2 mins
• Normal cervix - Mahogany brown
• CA cervix - unstained
BETHESDA SYSTEM OF INTERPRETATION

• Specimen type
• Specimen adequacy
• General categorization
• Automated review
• Ancillary testing

• General categorization
- -ve for intraepithelial lesion / malignancy
- Other : see interpretation / result
- Epithelial cell abnormality : specify squamous / glandular

Organisms 18:33

TRICHOMONAS VAGINALIS
CANDIDA

CLUE CELLS

ACTINOMYCES
• Trichomonas vaginalis
• Fungal organisms morphologically consists with candida spp
• Shift in flora suggestive of bacterial vaginosis
• Bacteria morphologically consistent with actinomyces spp
• Cellular changes consists with Herps simplex virus & cytomegalovirus

Cell Abnormalities 20:00

SQUAMOUS CELL

• Atypical squamous cell of undetermined significance (ASC-US)

• Cannot exclude HSIL
• Low-grade squamous intraepithelial lesion
• High-grade squamous intraepithelial lesion
• With features suspicious for invasion

GLANDULAR CELL

• Atypical
• Endocervical cells (NOS or specify in comments)
• Endometrial cells (NOS or specify in comments)
• Glandular cells (NOS or specify in comments)
• Endocervical cells favour neoplastic
• Glandular cells favour neoplastic
• Endocervical adenocarcinoma in situ
• Adenocarcinoma
• Endocervical
• Endometrial
• Extrauterine
• Not otherwise specified (NOS)

• Other malignant neoplasm: (Specify)

• Ascus;
- Repeat cytology
- At 6, 12 months
- If –ve -> routine screening
• Ascus → Colposcopy
• HPV DNA testing
- +ve → Colposcopy
- -ve → Repeat cytology at 12 months

• Screening guidelines (ACS 2020)

- Start screening - 25yrs
- 25-65 yrs - HPV testing every 5 yrs (preferred)
o HPV & PAPCO test every 5 yrs
o PAP test every 3 yrs
- 65yrs - stop screening if previous 3 screens are -ve

• On low resource setting

- VIA
- 30-65 yrs
- Every 5 yrs
- Screening - at least 1-3 times in lifetime
- Stop at 65yrs - if -ve in last 15 yrs

• Post CIN Rx
- HPV test - every 5 yr
- VIA - for 20 yrs
- If cervix & uterus removed - no screening

• Confirmatory methods
- Visible lesion -> punch biopsy
- Microscopic lesion -> colposcopy guided biopsy

UTERINE PUNCH BIOPSY FORECEPS

 COLPOSCOPY

• Colposcopy abnormal findings

1. leukoplakia
2. Aceto white patch
3. Punctuation
4. Atypical blood vessels
5. Mosaic pattern

• Not visible transformation zone - unsatisfactory colposcopy

• Next - cone biopsy

CONE BIOPSY
• Indication Dx
1. Limits of lesion not visible in colposcopy
2. The TZ junction not seen
3. Endocervical curettage - histological findings are +ve
4. Microinvasive carcinoma or adenocarcinoma - suspected
5. Lack of correlation between cytology, biopsy and colposcopy results

• Therapeutic
- Cancer in situ in young females
- Cancer cervix stage 1A1 in young females
- Severe cervical erosion nor responding to medication / cauterisation

• Mx
- Do HPV DNA test & PAP smear every 6 months
- If abnormalities persists for 2 yrs -> ablative / excisional procedure

• Prerequisite for ablative

- No evidence for micro / macro invasion
- TZ should be visible
- No endocervical gland involvement
- No discrepancy in cytology, colposcopy & biopsy
LEEP / LLETZ

• LEEP - Loop Electro Excisional Procedure

• LLETZ - Large Loop Excision of Transformation Zone
• A loop of (2cm) of very thin stainless steel wire is used for excision of the
transformation zone
• Blended current (cutting and coagulation), low voltage output is used
• Done under local anesthesia
• Tissue up to a depth of 10mm or more can be removed and sent for
histopathological examination
• Complications are minimal Treatment of choice for CIN 2 and CIN 3 at any age

CA Cervix 30:53

• Age-group - bimodal peak

• 1st peek - 35-39 yrs
• 2nd peek - 60-65 yrs
• Mean age - 52.2 yrs
• MC in low socioeconomic status
• Large cell keratinizing type - MC

• 4 cardinal symptoms
1. Irregular vaginal bleeding
2. Post-coital bleeding
3. Pelvic pain
4. Foul smelling vaginal discharge
• 4 cardinal signs
1. Cauliflower-like hard growth indurated
2. Fixed
3. Friable
4. Bleed on touch

• Complications
- Pyometra
- Uremia (MC cause of death)
- Fistula (VVF)

• Revised staging allows

- CT scan
- USG
- MRI
- PET
- Pathological examination of lymph node

• Staging : I - MV, II - PM, III-VLP, BM

- Stage 1 - confined to cervix
- Ia1 - stromal invasion < 3 mm in depth
- Ia2 – 3-5 mm
- Ib1 - > 5 mm, < 2 cm in size
- Ib2 - > 5mm, > 2-4 cm in size
- Ib3 - > 5 mm, > 4 cm
- Stage 2 – Upper 2/3rd of vagina
- IIa – Without parametrial involvement
- IIa - < 4 cm, IIa2 - > 4 cm
- IIb – With parametrial involvement
- Stage III – Lower 1/3rd of vaginal involved
- IIIa – Without extension to lateral pelvic wall
- IIIb – With extension to lateral pelvic wall
- IIIc1 –Pelvic LN
- IIIc2 – Paraortic LN
- IVa – Bowel & Bladder
- IVb – Distantmets
• Mx;
- Stage Ia - 2a - surgical
- IIa2 -IV - Ib3 - concurrent chemo radiotherapy
- Stage I-IV - CCRT

• Surgery preference over radio therapy

- Ovaries are spared
- Vaginal length preserved
- Tissue available for HPE

• RT
1. Brachytherapy
2. External beam radio therapy
3. Intensity modulated radiotherapy

MANCHESTER TECHNIQUE

CONSERVATIVE SURGERY

• Conisation : Stage IA1

- It refers to the excision of the whole of endocervix and the whole of TZ in
the form of a cone

• Radical Trachelectomy : IA2, IB1, IB2, IIA1

- It refers to the removal or amputation of cervix
- Radical trachelectomy refers to removal of cerviox, parametrial tissues
(mackenrodts ligaments) and vaginal cuff along with pelvic
lymphadenectomy
 Urogynaecology
Q) Most important structure preventing uterine prolapsed is :
a) Round ligament – Prevents AV of uterus
b) Broad ligament
c) Cardinal ligament
d) Uterosacral ligament

Ans : c) Cardinal ligament

Uterine Prolapse 01:41

LEVELS OF SUPPORT OF UTERUS

LEVEL 1 : Uterosacral & cardinal ligaments

LEVEL 2 : Levator ani muscle (pelvic floor)
LEVEL 3 : Perineal muscles forming perineal body

Etiology 06:23

1) Traumatic child birth

• Poor spacing
• Early resumption to work
• Instrumental delivery
• Prolonged Iabour
• Improperly repaired perineal tear
2) Postmenopausal atrophy
3) Increased Intra abdominal pressure
• Constipation
• Large fibroid, Ovarian tumors
• Chronic cough
4) Nulliparous
• NTD
• CTD

Classification 09:16

Universal Classification – POP Q

PELVIC ORGAN PROLAPSE Q

Ant. wall upper 2/3rd defect – Cystocele

lower 1/3rd defect - Urethrocele

Post. wall upper 1/3rd defect - Enterocele

middle 1/3rd defect - Rectocele

lower 1/3rd defect - Deficient perineum

UTERINE DESCENT

Descent of cervix in vagina – 1°

Descent of cervix upto introitus – 2°

Descent of cervix outside introitus - 3°

Entire uterus outside introitus - 4°/procidentia

Clinical Features 11:20

SYMPTOMS

• Mass per vaginum

• Difficulty in walking & coitus
CYSTOCELE RECTOCELE

• Incomplete emptying • Incomplete emptying

• Increased frequency of micturition • Digital correction of pouch to
• On straining, Stream decreases pass stools
• UTI/ Urinary stasis
• Nocturia
• Stress urinary incontinence

Complications 14:31

DECUBITUS ULCER

Venous congestion → Venous stasis → Ischemia → ULCERATION

MC Site : Dependent part of cervix - Posterior lip of cervix

Rx : Reposition of Uterus : Tamponing

For Ulcer Healing : GLYCERINE (hygroscopic)

ACRIFLAVIN (epithelialisation)

BETADINE (antisepsis)

Treatment 17:25

Pessary
I. Conservative
Surgery
II. Radical

Q) A young nulliparous woman had 3° of uterovaginal prolapse without any cystocele or

rectocele. There is no stress incontinence. The uterus is retroverted. Uterocervical
length is 3". All other symptoms are (N). The best t/t plan for her will be ?
a) Observation & reassurance till child bearing is over
b) Shirodhkar's vaginal repair
c) Shirodhkhar's abdominal sling
d) Fothergill 's operation

Ans :
PESSARY

• Diameter = Lower border of pubic symphysis to post. fornix

• On Straining, pessary should NOT fall
• Patient Should be able to pass urine

INDICATIONS

1) Patient trying to conceive with mild prolapsed

2) Early pregnancy upto 18 weeks
3) Puerperium
4) Patient unfit for major surgeries
5) Patient not willing foe surgery
6) Prior to Sx for healing of decubitus ulcer

LIMITATION

• Needs to be changed every 3 months

• Only palliative, never curative
• Vaginitis, ulcers, fistulae
• Vaginal CA (rarely)
• Dyspareunia

NULLIPAROUS PROLAPSE - UTERINE CONSERVATIVE SURGERIES

1) Manchester / Fothergills Operation

• Preliminary D & C
• Cervical amputation
• Advancement of cardinal lig. infront of Cervix
• Ant. Colporapphy (repair vesicovaginal fascia)
• Post. Colpoperiniorapphy (repair rectovaginal fascia)
S/E : Cervical incompetence
2) Modified Fothergilll/shirodkar operation
• Advancement of uterosacral infront of cervix

3) Purandare's Cervicopexy
• Sling is tied from anterior aspect of cervix
to posterior rectus sheath
S/E : Enterocele

4) Shirodkar's Sling Operation

• Posterior aspect of cervix is anchored
to sacral promontory
S/E : Sigmoid colon obstruction

5) Khanna's Posterior Sling Operation

• Sling is tied from lateral aspect of cervix
to anterior superior iliac spine

6) Virkud’s Sling Operation

• Left side Purandare + Right side Shirodkar

Family completed : Vaginal hysterectomy

+
Cystocele : Ant. Colporrhaphy WARD MAYO SURGERY
+
Rectocele : Post. Colpoperineorraphy

Enterocele : Moscowitz Surgery

(POD obliterated) MC calls culdoplasty
Hallbans repair

Vault Prolapse : Sacro colpopexy

Stress Urinary Incontinence 32:21

• Rise in Intra abdominal pressure → Passage of urine

• 85% Urethral hypermobility
• 15% - Sphincter defect

C/F : Involuntary passage of small amount of urine on straining, coughing

TREATMENT OF CHOICE:

Tension free trans of obturator tape > Transvaginal tape > Burch colposuspension
(Paraurethral tissue are anchored to
iliopectineal ligament)

Fistula 35:12

• Vesicouterine fistula → Cyclical hematuria / menouria

• Vesicovaginal fistula → Continuous passage of urine from vagina
+
NO normal micturition

• Urethrovaginal fistula → Passage of urine from vagina only during micturition

• Ureterovaginal fistula → Continuous passage of urine from vagina
+
(N) Micturition present

THREE SWAB TEST

Upper Swab wet by urine – Uretrovaginal fistula

Middle Swab blue color – Vesicovaginal fistula

Lower Swab blue color – Urethrovaginal fistula

VESICOVAGINAL FISTULA MC

• MC cause of UVF in India : Obstructed labour

• MC cause of VVF in Developed : Post hysterectomy
C/P : Continuous dribbling of urine from vagina

• Best investigation to se VVF : Cystoscopy

• Timing of repair if sed during Sx : Repair immediately
• Timing of repair if sed later : Repair after 6 weeks
• Radiation fistula : Repair after 6 months

Rx : 3 layer technique/Latzko technique

Complete perineal tear diagnosed :

• During Sx : repair immediately

• Later : repair after 3 months