PRACTICAL ASPECT

OF
GYNECOLOGIC CONDITIONS

Approach to common symptoms

Shina Oranratanaphan, MD
Dep of Obstetrics and Gynecology
Faculty of Medicine
Chulalongkorn University
APPROACH TO COMMON SYMPTOMS

• Vaginal discharge

• Pelvic pain

• Vaginal bleeding
 nnnolr.n.no/w.nrinnhirinuriinihilinensoonnnioinoon

VAGINAL DISCHARGE
• winionnnoiliwviwinlnaiwnihñ / oimrÉu e.
g.
ñw ,
Vonnoiwoo

• Physiologic VS pathologic discharge noiui cause iwioiiuwn Tx

inn/ñmwiou cycle
• Physiologic: Characteristic of physiologic leukorrhea

• Pathologic:

• STD: Trichomoniasis, Gonorrhea, etc

• Non STD: Candidiasis, Bacterial vaginosis

PHYSIOLOGIC DISCHARGE
normal nliiiiinohrñnuniivoi sebaceous glñ genitalia g. Shane 's gland gland
"
-
: e.
,
Bartholin 's
+ transudate voi epithelial cell uironioinnon
KIWI Unwrap
+

-
Jinn / iron :NÉow /Umw:O cycle e.
g.
non cycle ovulation nnnoifww.nuwho + Én

pH ≤ 4.5 -

:
'
Ñ lactobacillus iwrinnini

-
Frio / nib lwiuaiwlaiñw
-
now Ñoi speculum i. iuwlñnii posterior fornix

.
if nnnoÑnÉwuÑwuÑ"ouVnuñw / ñu / Ñnvn:NÉow e.
g.
ÑunÑw -

www.n ,
ÑÉwuÉoi -
uuoi

pathologic inoi -1×1

CANDIDIASIS
•
Ñnwinioñw / i. muiñoiluiloinoon or r.muirfoiuiitnkr.info + nnnotnohunfoidiwwwnnfwnoii~wwu.nl curd - liked discharge ,

.nu/niiou;7sivoidniinuriniiiinluioinnon at least i line

45% widnÉ ≥ 1 times

-
riiinñiwuiou .es -

got.
Candida albicans
glabrata / tropicalis ailonwñiioiwnnoi albicans
-

minority C. c.

. Rish factors e.
g. prolonged ATB ,
pregnancy ,
DM
,
on immunosuppressant
Pseudohyphae
 fiona's aides
,
outcome ñnoi nystatin oimiñiiilw I -3
days
TREATMENT VVC

• Uncomplicated uifwniinno not recurrent ,

liuwuniwwow )
• Clotrimazole (100 mg) 1 tab Vg supp x 6 d
• Clotrimazole (200 mg) 1 tab vg supp x 3 d
• Clotrimazole (500mg) 1 tab vg supp single dose
it lair: nonliouuiiu
• Fluconazole 150 mg oral single dose

• Complicated
• Recurrent VVC > a /
yr

• Fluconazole 150 mg 1 tab q 3 d x 3 times then 1 tab weekly for 6 months

to Tx got
no:
response
~
.

'
UÑIUU not 50-1
. i: recurrent
,
TRICHOMONAS VAGINITIS
nnodimnmntndul
anti riwlwioinvagi
union
nonorhi
nalis aioflagellated
imr.NU protozoa
•

STDs Trichomonas itrans mission rate to -1.1

•
t.dnidmr.no nÑwÑu anaerobic environment wviiwñu BV /ñ ooi

noir room STDs Éiwrioo

'
Ñw risk PPROM hi
 -
motile organism i
jerking movements

. iuw Wbc roo :

•
wuiiwñu clue cells lñ

it dimwit"ivo:

flagellated protozoa site . wk

jerking movement noiiunuriiinvnnnowi
-

: ñiliwiw TV no ilwiuw movements

i. Funk btw TV & wbc
•
lainoili Holt : nilñtrmo
TREATMENT TRICHOMONIASIS
response rate ≥ gs %
-

-
moi Tx partner is ) niu

• Metronidazole 2 g oral single dose SE 100 : : NIV

• Tinidazole 2 g oral single dose

Or
• Metronidazole 500mg oral bid x 7 d
BACTERIAL VAGINOSIS
•
winiomnvio ÑnÉwiuÑw Ñw / r.mu in"oi

.
ninon normal flora / lactobacillus anni pH NÉow anaerobe ruin e.
g. Gardnerella vaginalis Mycoplasma
,
hominis
lainnvoiiuriñiannnrniw nilñnnrioainñi

. iÉw risk ihwnpninidv.PRO MIPPROM chorioamnionitis , , postpartum metritis , vaginal stump infx iuris hysterectomy ,

:/ñnÉu fishy odors

•
Dx Ansel criteria 13/41
by fishy odor unit 51 / mens or Whitt test turn NoHo

ÑiminÉouwwiÑi noon i while /

gray homogeneous discharge )

pH 4.5 1nF /✓ 4.7-5.71

>

clue cells lot of epithelial cells

>
few / no wbc
,

www.vi: : debris mm :
TREATMENT BV
•

response rate
75 -
sat .
.

high recurrent rate

.
Tainui Tx partner is ) : Kili STDs

• Recommended regimen
• Metronidazole 500mg oral bid x 7 d
• Metronidazole gel 0.75% 5 g vg once daily for 5 d
• Alternative regimen
• Tinidazole 2 g orally for 2 d
• Tinidazole 1 g oral x 5 d
• Clindamycin 300mg oral bid x 7 d or
clindamycin cream it
.

sg Vg hs ✗ 1- d
it mi / nu metro titi
si
.
voi
or
clindamycin ovule
loony Vg suppo
hs 3d ✗
✓

www.ninidunoi rnw.n icxriow-lhenli aiwi niniwindo

CERVICITIS

• Neisseria Gonorrhea , Chlamydia trachomatis

• Prurlent discharge from cervix: Mucopus
nvilxluiiinownpnnaiuw.wivnnendoierrix.mu
copies
ÑÑuo✓wuÑoi
.WS Wbc >
so cells / HPF + niw intracellular b- ve diplococci IN .
gonorrheal
linin bait into C. trachomatis
GONORRHEA / CHLAMYDIA
ñii Ñ"i into
• moi Tx +
Tx partner is

• Gonorrhea: Ceftriaxone 250 mg IM single dose + Azithromycin 1 g oral single dose

• Alternative
• Cefixime 400mg oral single dose + Azithromycin 1 g oral single dose
• Chlamydia: Azithromycin 1 g orally single dose or Doxycycline 100 mg orally twice a day
fro 7 days days -

14

• Alternative
• Erythromycin base 500 mg oral 4 times a day for 7 days
• Levofloxacin 500 mg oral once daily for 7 days
• Ofloxacin 300 mg oral twice a day for 7 days
PID •

-
winionnvio
infxd.in 'm
+ Ii / pelvic pain
cervix e.
g.
endone Iritis
-

, salpingitis

• Neisseria gonorrhea, Chlamydia trachomatis is -117s )

• Minimum criteria: noili additional criteria min

spec Moin't invasive procedure / IX HWI

• cervical motion tenderness

• uterine tenderness
• adnexal tenderness

. Practical DX PID by minimum + additional criteria

 Ñn Tx

PID TREATMENT
•
Wv OPD case

.
Ñu STDs moi Tx partner in Ñoo

• Recommended IM/ Oral regimens I OPD case ,

• Cefoxitin 2 g IM + Probenecid 1 g oral + Doxycycline 100 mg oral bid x 14 days ± metro 15001 1×1 for 14 D

• Ceftriaxone 250 mg IM single dose + Doxycycline 100mg oral bid for 14 days with or
without metronidazole 500 mg oral bid for 14 days
river/ ailñ iidniihwnn.nl compliance hi / ñ
• Recommended parenteral IIPD cases it lift ,
severe NN , ,
-10A , poor ,
an FN

• Cefotetan 2 g IV q 12 hr + Dozxycycline 100 mg oral or IV q 12 hr

• Cefoxitin 2 g IV q 6 hr + Dozxycycline 100 mg oral or IV q 12 hr
• Clindamicin 900 mg IV q 8 r + Gentamicin loading 2 mg/kg then 1.5 mg/kg q 8 hr
•
it ñiii NÉou IV ntw oral ,
advise STDs prevention
 ✓ onnoiwooiirowaiivoiroinoi ,

PELVIC PAIN

Pelvis

1)DX 1 .
GI e.
g. appendix diverticulum
,

1. Vro e.
g.
ureter bladder
,

3.
Gyne e.g. uterus tube ovary
, ,
RIQ Supra pubic
gas pain ,

c- complication
 PELVIC PAIN PID noiinuaistwviow

Hx localize lesion / ñ Ñnmw IODIFAFT +

Hx GYNE / 51 / . contraception
VonÑu , Huling hollow virus organ e. bowel ureter uterus
g.
•

, ,

Vonñwñ twisted cyst / rupture

'

• Acute VS Chronic
ovarian
etiology
-

+ Txniñw
not in chronic pelvic pain
• Acute: von onset lñiniiw oiiwuiiwñv autonomic
,
reflex response e.
g.
NN
, sweating ,
uwiÉn
tinnriiwuwuninlmwlñ iwi early Dx + Tx V15 in / nñ / ñ

• Genital tract or non genital tract

• non genital tract: Acute appendicitis, diverticulitis
• Gyne : PID, ovarian cyst with complication, ectopic
pregnancy
• Pregnancy or not pregnancy ectopic / abortion
normal / complicated ,
noididu
✓ onriwwuiñunensluwi pregnancy
• Associated with menstruation?: Dysmenorrhea .
Amenorrhea

• Associated with other symptoms : Fever, Vaginal discharge?

• May have autonomic response
 PELVIC PAIN
• Ddx
• Ectopic pregnancy pelvic pain + amenorrhea
-
it rupture Vs change

• Ovarian cyst with complication: Leakage, rupture, twisted,

infection
• PID pelvic pain + fever + leukorrhea

• Acute appendicitis lit symptom migratory

,
pain

• Acute diverticulitis
• cystitis
 PELVIC PAIN
• Dysmenorrhea
• Primary Ñniiolunuoiywio ,
Vonniñilunrin cycle
:
,
Pio : WNI fi symptomatic Tx

Runnin / riwñiiiniiiidinuoiy cnn.im prostanoid ,

ñiiiiwiolñ NSAIDs NSAIDs
• mens an

UP i :b inhibit ovulation an pain ñ

/

• Secondary
•

.
Vi nuioilatiiiw
:

Ñn .im/nrivoioiuo:luo.iitinnw e.
g.
endometriosis ,
adenonyosis
•
✓ in 1-1 Wh Iou Mens WI + ✓ oniuuwn Mens

•
NSAIDs oiilainiliñiiii

progressive pain winiiiluniiy cycle

-

.
Tx Mw cause
 PELVIC PAIN
• Chronic Pelvic pain
• Definition of chronic pelvic pain : 6 months •
uiiniiuon onset laiin
-
iunowfindr.inihriunoiwiwvnwnu
hi / ñ / mom
• Multidisciplinary approach -

win'm cause

• Organic :Ñn indu :mwñ"oÑwÉou Innis

onvihnlofaiochronic
. i

_
iountwwi
.

got .
pelvic ipain
,

iun.i.wniivoilrnninriiwv.iposts
,

op
/ iñnrindulwiloinoi e.
g.
PID
,
endometriosis

• Gyne: Endometriosis, Adhesion ,

Pelvic congestion syndrome
iii.ruiuñoroi Kinnan iili
vein +

Vonnoiwoiluñildysnem ñinriuniinnli
• Non gyne: Myofascial pain, urology, GI -
-
uwnnens

e.
g.
IBD appendicitis hernia

• Non organic: Psychosomatic

, ,

-
lower GI ñu UNE di nerve iu pain iiwñw uuriwiilouo : von
organ
laiin

e. recurrent cystourethritii urethral syndrome interstitial cystitis

g. ,
,
 Wu - 1/3 % OPD GYNE

ABNORMAL VAGINAL BLEEDING

-
incidence to so
-
I voidnfiuiiin.w.us!
-
nfwoimr not DX Moin cause i.is/rniioniie.g endometrial
.
cancer / hyperplasia
 '

I 14 Is D
-
invidious'ñw i.io D)

WHAT’S NORMAL -

.
D

A
4.5

5- so
-
s D

ml
Lilian .fi#on.uwioiniiu-iniluiviliwn
: union
TERMINOLOGY

n: Viun: Viou
/ noir: amount lñlñ
RECOMMENDATION TERMINOLOGY
ชือเรียก คําจํากัดความ

Irregular menstrual bleeding ระยะระหว่างรอบแปรปรวนมากกว่า 17-20 วัน

Absent menstrual bleeding ( amenorrhea) ขาดประจําเดือนนานกว่า 90 วัน

Frequent menstrual bleeding ประจําเดือนมาบ่อยกว่า 4 ครังในเวลา 90 วัน

Prolonged menstrual bleeding ประจําเดือนมานานกว่า 8 วัน

Shortened menstrual bleeding ประจําเดือนมาน้อยกว่า 2 วัน

Heavy Menstrual bleeding ปริมาณประจําเดือนมากกว่า 80 มิลลิลิตร

Light menstrual bleeding ปริมาณประจําเดือนน้อยกว่า 5 มิลลิลิตร

OTHER PATTERN OF BLEEDING
Bleeding ñilaiñiuoroiñunens

• Irregular non menstrual bleeding

• Intermenstrual bleeding Ñiov mens ✓ nri + nionoonwnilnñi : uiiiiov hens

• Postcoital bleeding bleed unit SI

• Bleeding outside reproductive age

• Postmenopausal bleeding
 VAGINAL BLEEDING
Approach
DDX it / end tri bleeding
• Pregnancy VS non pregnancy

• Menopause VS Reproductive age

• Ovulatory VS non-ovulatory
PALM ñiitniiwthilñ
organic cause COEIN in
organic cause

causes intern enstrual bleeding

•
Dx by Usb /
hysterosiope

VAGINAL BLEEDING
globular shaped
-
uterus ± Hx dysmenorrhea
-
mens /
man win
-

: uterusluriiii

/ hyperplasia

incidence of IA iiiñv irish factors

age
-
•

e.
g. unopposed E
,
obesity ,

chronic an ovulation in Plo

-
it rñonoonuriiaoyo endometrial sampling / Bx
MYOMA wnpnri in.wmnmyone-lriun.nu/ri4o-oot
iwiiion
.

uiinuwinionriiniwlñ /
'

asymptomatic iÉi out / mens

oonwinwndnri.PE compressive symptoms
• Now win
,

enlarged nodular
wu uterus ,
surface
•
Dx by V10
 ITP
e.
g. VWD ,

nilvinenswiwnlñ ainwvlwnwoiuuoitiiaiaionirñiiiri mens winking

nun wvlñ
,

lot
noirs endometrial tissue
-
.

winiii
.
.

ao
or
age
>

wuluiui.ir/iulnniuwn mens
Wola / hyperplasias
.ÑnÑw spotting fairtrade
,
air
:p
interval hitman

i disorder of endometrial hemostasis DX by exclusion

niinihñvosruynnionvoi endometrium Ñniñninnuninñovoivss / aiñ / rindv
'

iiilainnv cause riinñoii )

e.
g.
lñui DMPA /
progestin for endometriosis ooiÉwÑn Hxoi

Treatment depends on the cause of bleeding

 -
oui Ew i
survey n' on esp us change
TREATMENT OF ACUTE AUB
• Aim
• To control the current bleeding
• To prevent recurrent AUB
• Medical : initial treatment
I E /P )

• Hormonal management : CEE, COC, MPA

• Non hormonal management: Tranexanamic acid
• Surgical: fail medication or contraindicated for medical treatment
• Dilatation and curettage iouuyniñ Initiation
"

on + DX

• Endometrial ablation
• Uterine arteries embolization
• Hysterectomy