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INDEX

S.NO TOPIC P.NO

1. DISORDERS OF OVARY 2

2. POLYCYSTIC OVARIAN SYNDROME 5

3. OVARIAN CANCER 15

4. ENDOMETRIOSIS 17

5. ADENOMYOSIS 31

6. OVARIAN TUMOURS 35

7. THERAPEUTICS 48

8. MIASM 57

9. REPERTORY 58

10. MULTIPLE CHOICE QUESTIONS 63

11. BIBLIOGRAPHY 69

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 DISORDERS OF OVARY
Ovarian enlargements, cystic or solid, may occur at any age. Functional and inflammatory
enlargements of the ovary develop almost exclusively during the childbearing years.

They may be asymptomatic or produce local discomfort, menstrual disturbances, infertility, or in

rare cases cause acute symptoms due to complications like haemorrhage, rupture or torsion.

The ovary is complex in its embryology, histology, steroidogenesis, and has the potential to
develop malignancy. Therefore, ovarian neoplasms exhibit a wide variation in structure and
biological behaviour. Unlike the cervix and uterus, the ovaries are not clinically accessible, and
therefore, easy screening methods for detecting ovarian neoplasms are not available.

The ovary, after the uterus, is the second most common site for development of gynaecological
malignancy, and the prognosis remains poor.

Non-Neoplastic Enlargements of the Ovary

Such an ovarian enlargement may be the result of ovarian congestion due
to adnexal inflammatory states, ovarian endometriosis causing a chocolate cyst or persistence
and enlargement of physiological structures in the ovary like the Graafian follicle or corpus
luteum.

● Follicular Cysts
Follicular cysts are not uncommon. They may be single or multiple, may be bilateral and vary in
size from small blebs to cysts of large size but generally do not exceed 5.0 cm in diameter. They
are the result of failure of absorption of the fluid in an incompletely developed follicle or
anovulation.

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They are usually asymptomatic unless haemorrhage, rupture or torsion supervenes, in which case
symptoms and signs of an acute abdomen develop. Large and multiple cysts may cause pelvic
pain, dyspareunia and irregular bleeding. The enlarged ovary may be recognizable clinically or
documented on sonography. Ovarian neoplasms, inflammatory adnexal enlargement and
endometriosis must be considered in the differential diagnosis.

Most follicular cysts disappear spontaneously within a few weeks to months. When symptoms
like amenorrhoea are prolonged, stimulation of postovulatory change by administering oral
medroxyprogesterone 10 mg three times a day over a period of 5–7 days will generally bring on
menstruation. Primolut N 5 mg tid for 3 days also induces menstruation.

Clomiphene citrate 50 mg given orally for five consecutive days helps to induce ovulation and
brings about menstruation, or pregnancy.

Oral combined pills administered for 3 months also resolve the cyst in most cases. If any cyst
persists for longer than 3 months, or size increases to .7 cm, the possibility of a neoplastic cyst
must be kept in mind, and the patient investigated.

● Follicular Haematomas

Small follicular haematomas are common. To the naked eye, the ovary
contains haemorrhagic cysts. Old cysts appear to contain tarry material and are likely to be
mistaken for endometriosis.

Many of these are asymptomatic and of no clinical significance except for the rare case, when
the cyst bursts into the peritoneal cavity causing acute abdomen, and is mistaken for an ectopic
pregnancy.

● Lutein Cysts of the Ovary

Two types of lutein cysts are recognized:

Granulosa lutein cysts found within the corpus luteum.

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 Theca lutein cysts associated with trophoblastic disease and chorionic gonadotropin
therapy.

Corpus Luteum (Granulosa Lutein) Cysts

Corpus luteum cysts are functional, non-neoplastic enlargements of the

ovary. Persistent corpus luteum cysts may cause local pain, tenderness or delayed menstruation.
These cysts are often palpable clinically.

Unless complications like torsion or rupture lead to an acute abdomen requiring surgical
treatment, most cysts will resolve in due course of time. Hence observation is recommended
whenever this condition is suspected, because it resembles unruptured ectopic pregnancy.
Sonography and serum quantitative estimations of b-hCG help to resolve the diagnosis.
Ultrasound reveals spider-web-like structure with or without a clot.

Doppler shows rich vascularization with high blood flow velocity.

● Theca Lutein Cysts

These cysts can sometimes enlarge to several centimetres in diameter. They are usually bilateral
and filled with straw-coloured fluid.

Theca lutein cysts are often found in association with hydatidiform moles, choriocarcinoma and
gonadotropin (hCG) or clomiphene therapy.

The cysts spontaneously regress after elimination of the mole, therapeutic curettage, treatment of
choriocarcinoma or discontinuation of gonadotropin therapy. Functional cysts are distinguished
from neoplastic cysts by the fact that they never grow more than 7 cm in size, are unilocular with
clear fluid, and regress after some time. The hyperstimulation syndrome by clomiphene therapy
has been described in the chapter on hormonal therapy.

● Multiple Functional Cysts

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Multiple functional cysts are caused by the following: n FSH secreting pituitary adenoma n
Ovarian hyperstimulation syndrome (OHSS) n Polycystic ovarian syndrome (PCOS) In pituitary
adenoma, ovarian cysts measure more than 1 cm; FSH and oestrogen levels are raised, but LH
level is low.

Other signs of hyperstimulation such as haemoconcentration and coagulation profile are not
affected.

Ovarian hyperstimulation syndrome is caused mainly by human chorionic gonadotropin hormone;

the follicular size is more than 3 cm. PCOS is characterized by multiple small cysts less than 1
cm; LH is raised and LH/FSH ratio is 2. Amenorrhoea, oligomenorrhoea and infertility are the
clinical features. Pituitary adenoma may requires transphenoidal excision of the adenoma, but no
surgery is required for the ovarian cysts.

Polycystic Ovarian Syndrome (PCOS) or Disease (PCOD) :

Polycystic ovarian disease is a heterogeneous, multisystem endocrinopathy in

women of reproductive age with the ovarian expression of various metabolic disturbances and a
wide spectrum of clinical features such as obesity, menstrual abnormalities and
hyperandrogenism.

This disease was discovered by and named as Stein–Leventhal syndrome in 1935.

To diagnose PCOS, adrenal and androgen secretory ovarian tumour should be excluded.Women
with PCOS are at increased risk of glucose intolerance and some authorities recommend
screening for type 2 diabetes and other cardiovascular risk factors associated with the metabolic
syndrome.

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Incidence

Current incidence of PCOS (5–6%) is fast increasing lately due to change in

lifestyle and stress. It is also becoming a common problem amongst adolescents, developing
soon after puberty.

Amongst infertile women, about 20% infertility is attributed to anovulation caused by PCOS.

Some of the women who develop cardiovascular disease, hypertension, endometrial cancer and
type 2 diabetes later in life appear to have suffered from PCOS in earlier years.

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Aetiology and Pathogenesis
PCOS has been attributed to several causes including change in
lifestyle, diet and stress. Initially, the ovaries were thought to be the primary source which set the
changes in the endocrine pattern.

Genetic and familial environment factors (autosomal dominant inherited factors) were later
added as aetiological factors in the development of PCOS. The environment factor may function
in the utero or in early adolescent life, manifesting clinically a few years later as PCOS. CYP21
gene mutation has been discovered in this connection.

Familial occurrence has been reported. X-linked dominant mode of inheritance is also involved.

Another view held for occurrence of PCOS is enhanced serine phosphorylation unification
activity in the ovary (hyperandrogen) and reduced insulin reception activity peripherally (insulin
resistance).

Obesity is related to PCOS. The adipose tissue (fat) is considered an endocrine and
immunomodulatory organ; it secretes leptin, adiponectin and cytokines which interfere with
insulin signalling pathways in the liver and muscle resulting in insulin resistance, and
hyperinsulinaemia.

Increased birth weight in obese and PCOS mothers can also cause PCOS in adolescent
daughters.

Raised LH secretion by insulin can cause infertility or miscarriage through improper oocyte
maturation. Obesity is characterized as the condition when body mass index .30 kg/m2 and waist
line .88 cm prevails.

Waist/hip ratio .0.85.

Endogenous b endorphin also stimulates insulin release and may contribute to insulin resistance.

Hyperandrogenism and resulting anovulation was initially thought to arise primarily in the
ovaries.

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It is now proved that insulin resistance with resultant hyperinsulinaemia initiates PCOS in 50–
70% cases, though hypothalamic–pituitary–ovarian axis and adrenal glands are also involved to
some extent.

Insulin induces LH to cause thecal hyperplasia and secrete androgens, testosterone and epi-
androstenedione which are converted to oestrogen in the granulose cells.

Epi-androstenedione is converted in the peripheral fat to oestrone. This leads to rise in the
oestrogen and inhibin level. These in turn cause high LH surge.

While oestrone level increases, oestradiol level remains normal with the result that the
oestrone/oestradiol ratio rises.

Hyperandrogenism lowers the level of hepatic sex hormone binding globulin (SHBG), so that the
level of free testosterone rises leading to hirsutism.

Polycystic ovarian syndrome may set in early adolescent life, but clinically manifest in the
reproductive age with long-term implications of diabetes, hypertension, hyperlipidaemia and
cardiovascular disease; this cluster of disorders is known as the ‘X syndrome’.

Endocrinological changes are as follows:

1. Oestrone/E2 level rises.

2. LH level is raised over 10 IU/mL. FSH level remains normal, but FSH/LH ratio falls.

3. SHBG level falls due to hyperandrogenism.

4. Testosterone and epi-androstenedione levels rise.

5. Fasting blood glucose/fasting insulin < 4.5 suggests insulin resistance.

6. Triglyceride level >150 mg/dL-hyperlipidaemia HDL <50 mg/dL.

Testosterone >2 ng/mL, free T >2.2 pg/mL (Normal level 0.2–0.8 ng/mL)

Normal androstenedione level is 1.3–1.5 ng/mL

DHEA >700 ng/mL suggests adrenal tumour.

7. Prolactin is mildly raised in 15% cases.

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8. Fasting insulin is more than 10 mIU/L in PCOS in 50–70%cases.

9. Thyroid function tests may be abnormal (hypothyroidism).

10. 17-a-hydroxyprogesterone in the follicular phase >300 ng/dL suggests adrenal hyperplasia
due to 21-hydroxylase deficiency.

11. Urinary cortisol <50 µg/24h.

Pathology
Macroscopically, both ovaries are enlarged, though one PCOS ovary is also diagnostic. The
ovary shows a thick capsule of tunica albuginea.

The ovarian surface may be lobulated but the peritoneal surface free of adhesions. Multiple cysts
(12 or more) of 2–9 mm size are located peripherally along the surface of the ovary giving it a
‘necklace’ appearance on ultrasound. These are persistent atretic follicles.

Theca cell hyperplasia and stromal hyperplasia account for the increase in the size of the ovary
which amounts to more than 10 cm3 in volume.

Clinical Features

The pathogenesis appears to be initiated in utero or early adolescent period. Early adrenarche in
the form of early pubertal hair and early menarche is observed in a few girls.

Menstruation for a couple of years may be normal, but clinical features of PCOS develop early
with oligomenorrhoea (87%) or with a short period of amenorrhoea (26%) followed by
prolonged or heavy periods ( a common complaint in a majority of cases).

Dysmenorrhoea is absent.

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In the reproductive years, infertility accounts for about 20% cases. This is due to anovulatory
cycles.

During pregnancy, if the woman conceives, carbohydrate intolerance, diabetes and hypertension
may develop. Pregnancy loss occurs in 20–30%.

Hyperandrogenism appears in the form of acne (30%) and hirsutism. Facial hair appears over the
upper lip, chin, breasts and thighs. Baldness is sometimes noted, but virilism does not develop.

History of lifestyle, diet and smoking and exogenous hormone administration should be inquired
into. Family history of diabetes and hypertension should be asked.

Excessive exercise, history of tuberculosis and thyroid are important in menstrual disorder.

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Examination

Look for

1. Obesity, especially waistline. Waist over hip ratio .0.85 is abnormal; 50% women are
obese.
2. Body mass index between 25 and 30—overweight; and above 30—obesity.
3. Thyroid enlargement.
4. Hirsutism and acne.

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 5. Hyperinsulinaemia which may manifest as acanthosis nigra (5%) over the nape of the
neck, axilla and below the breasts; 75% obese women reveal hyperinsulinaemia.
6. Blood pressure in obese women.

Pelvic findings are normal, and it is not common to palpate the enlarged ovaries.

For the diagnosis of PCOS, the Rotterdam criteria (2003) suggests that at least two out of three
criteria should be present. These criteria are:

● Oligo/amenorrhoea, anovulation, infertility

● Hirsutism–acne

● Ultrasound findings

Differential Diagnosis

Though the diagnosis is easy in most cases, congenital or adult adrenal

hyperplasia, Cushing’s disease and ovarian masculinizing tumours should be considered in
extremely obese women with virilism.

With irregular cycles in young girls, hormonal assays will identify hypothalamic– pituitary–
ovarian dysfunction. Thyroid function tests may be called for in a few cases.

Investigations

Ultrasound is diagnostic of PCOS.

● It confirms the enlarged ovaries, their size and increased stroma. Ovarian volume will be
more than 10 mm3.

● It shows 12 or more small follicles each of 2–9 mm in size placed peripherally.

● It rules out ovarian tumour.

● It shows endometrial hyperplasia if present

In case of doubt, abdominal scan will reveal adrenal hyperplasia or tumour. Ultrasound
should preferably be performed in the early follicular phase. Increased blood flow is

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 sometimes revealed on Doppler ultrasound. Ultrasound is also used to watch the response
of medication and to decide when to stop the drug therapy. Sometimes, only one ovary is
involved. These ovarian changes are not applicable if the woman is on combined oral
pills, as these pills change the ovarian morphology.

● Hormonal study mentioned earlier is not performed routinely, but specific hormonal
studies are undertaken in a woman as and when required. All hormonal studies are not
needed as a routine.

● Thyroid function tests in obese woman.

● Laparoscopy is reserved for therapeutic purpose, now that the diagnosis can be confirmed
on ultrasound findings. Laparoscopy reveals enlarged bilateral ovarian cysts.

Treatment

The purpose of treatment is

● to cure a woman with menstrual disorders

● to treat hirsutism

● to treat infertility

● to prevent long-term effects of X syndrome in later life. The treatment therefore is

catered to the requirement of the woman.

● Weight loss. Weight loss of more than 5% of previous weight alone is beneficial in mild
hirsutism; it restores the hormonal milieu considerably. Weight loss increases the

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 secretion of the sex hormone binding globulin, reduces insulin level and testosterone
level.

● Lifestyle. Cigarette smoking should be abandoned. It lowers E2 level and raises DHEA
and androgen level.

● Hormones to control menstruation are: n Oral combined pills (OC) n OC and

cyproterone acetate; OC and spironolactone n Ketoconazole 200 mg daily reduces
testosterone secretion.

Surgery
Surgery is reserved for those in whom

● Medical therapy fails

● Hyperstimulation occurs

● Infertile women

● Previous pregnancy losses

Surgery comprises laparoscopic drilling or puncture of not more than four cysts in each ovary
either by laser or by unipolar electrocautery .

Surgery restores endocrine milieu and improves fertility for a year or so.

Thereafter, pelvic adhesions caused by surgery may again reduce fertility rate. Hydrofloatation
reduces adhesion formation.

Management
This should be directed at the presenting complaint, but all PCOS patients who are
overweight should be encouraged to lose weight, as this can improve several symptoms,
including menstrual irregularity, and reduces the risk of type 2 diabetes

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Prevention
With the knowledge that PCOS has long-term adverse effects (threefold) on
the health of the woman, such as diabetes, hypertension, cardiovascular disease and
hyperlipidaemia, endometrial cancer, it is now suggested that PCOS should be adequately treated
at the earliest.

This woman should be observed for these ailments in later life. Obesity in adolescents needs to
be avoided and corrected.

Lifestyle changes should be recommended.

OVARIAN CANCER

Ovarian cancer is the most common gynaecological tumour in Western countries. Most ovarian
cancers are epithelial in origin (90%), and up to 7% of women

Ovarian cancer have a positive family history. Patients often present late in ovarian cancer with
vague abdominal discomfort, low back pain, bloating, altered bowel habit and weight loss.

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Occasionaly, peritoneal deposits are palpable as an omental cake and nodules in the umbilicus
(Sister Mary Joseph nodules).

Pathogenesis

● Genetic and environmental factors play a role.

● Risk of ovarian cancer is increased in patients with BRCA1 or BRCA2 mutations,

and Lynch type II families (a subtype of hereditary non-polyposis colon cancer
(HNPCC)) have ovarian, endometrial, colorectal and gastric tumours due to
mutations of mismatch repair enzymes.

● Advanced age, nulliparity, ovarian stimulation and Caucasian descent all increase
the risk of Ovarian cancer, whilst suppressed ovulation appears to protect, so
pregnancy, prolonged breastfeeding and the contraceptive pill have all been
shown to reduce the risk of ovarian cancer.

Investigations

Initial workup for patients with suspected ovarian malignancy includes

imaging in the form of ultrasound scan and CT.

Serum levels of the tumour marker CA-125 are oftern measured.

Surgery plays a key roleiagnosis, staging and treatment of ovarian cancer and in early cases,
palpation of viscera, intraoperative washing and biopsies are generally performed to define
disease extent.

Management

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 In early disease, surgery followed by adjuvant chemotherapy with carboplatin,
or carboplatin plus paclitaxel is the treatment of choice.

Surgery should include removal of the tumour along with total hysterectomy, bilateral salpingo-
oophorectomy, and omentectomy.

ENDOMETRIOSIS

Endometriosis is one of the most mysterious and fascinating benign gynaecological disorders. By
definition, endometriosis is the occurrence of ectopic benign endometrial tissues outside the
cavity of the uterus.

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 The incidence is about 10%, but awareness of more cases is increasing on account of
diagnostic laparoscopy. Amongst infertile women, incidence is 20% and is 15% in women with
chronic pelvic pain (CPP). The incidence is very high amongst Japanese women.
Characteristics of endometriosis

● The ectopic endometrial tissue responds to ovarian hormones.

● While proliferative endometrium is always seen, secretory endometrium depends upon

the presence of progesterone receptors in the tissues.

● Blood oozing during menstruation in ectopic endometrium causes local adhesions in the
pelvis.

● Malignancy is extremely rare, though endometrial tissue is highly proliferative

Aetiology

● Endometriosis is a proliferative hormonal dependent disease of the childbearing period. It

is extremely rare before menarche and disappears after menopause.

● Its incidence appears to be on the increase, partly due to improvement in diagnostic

techniques and partly due to changing social patterns like late marriage and limitation of
family size.

● It tends to occur more amongst the affluent class, and is frequently associated with
infertility. Genetic susceptibility and familial tendency is seen in 15% cases.

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Sites of Endometriosis

Endometriosis is found widely dispersed throughout the lower pelvis, and below the level of the
umbilicus.

The common sites are the ovaries, the pouch of Douglas including the uterosacral ligaments,
peritoneum overlying the bladder, sigmoid colon, back of the uterus, ovarian fossa, intestinal
coils and appendix.

Endometriosis is seen in the umbilicus following an operation, in laparotomy scars, in tubal

stumps following sterilization operation, in the amputated stump of the cervix, and in the scars of
the vulva and perineum

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Scar endometriosis following lower segment caesarean section is seen in only 0.2%, but is high
following classical caesarean section.

Pathology

There are three categories of endometriosis.

● Pelvic endometriosis may be localized or diffused and scattered over the pelvic
peritoneum, pouch of Douglas and utero-sacral ligaments.

● Ovarian endometriosis or chocolate cyst.

● Rectovaginal endometriosis.

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Pelvic Endometriosis
Early lesions appear papular and red vesicles are filled with
haemorrhagic fluid with surrounding flame-like lesions.
With age, these vesicles change colour and endometriotic areas appear as dark red, bluish or
black cystic areas adherent to the site where they are lodged. Scarring around the endometriosis
gives it a puckered look.
Lately, atypical lesions such as nonpigmented areas or yellowish-white thick plaques have been
noticed, which are healed lesions.
Peritoneal cavity contains yellowish-brown fluid in the cul-de-sac, and this contains
prostaglandin responsible for pain.
Powder burnt areas are the inactive and old lesions seen scattered over the pelvic peritoneum.
Sometimes, healed areas of endometriosis appear as small peritoneal defects (windows) or white
patches.

Chocolate Cysts
Chocolate cysts of the ovaries represent the most important manifestation
of endometriosis. To the naked eye, the chocolate cyst shows obvious thickening of the
tunica albuginea, and vascular red adhesions are well marked on the undersurface of the
ovary.

The inner surface of the cyst wall is vascular and contains areas of dark brown tissue. The
chocolate cyst lies between the ovary and the lateral pelvic wall.

Histology fails to reveal endometrial tissue in most chocolate cysts. The lining epithelium is
usually columnar with a tendency to form papillae.

Beneath the epithelium, a zone of tissue containing large cells with brown cytoplasm,
polyhedral in shape and resembling lutein cells is nearly always seen.

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 These pseudoxanthoma cells are probably large macrophages or scavenger cells, and their
brown colouration is due to ingested blood pigments such as haemosiderin.

The chocolate cyst develops as an invagination into the ovarian cortex.

Circular peritoneal defects over the broad ligament and uterosacral ligaments reveal
endometriotic tissue by biopsy in 50% cases, and they are healed areas of endometriosis.

The levels of tumour necrosis factor and matrix metalloproteinase inhibitors are raised in
pelvic endometriosis.

Clinical Features

Endometriosis affects women in the reproductive age, around 30 years. It may occur in an
adolescent if obstruction in the lower genital tract causes cryptomenorrhoea and retrograde
spill of menstrual fluid.

A rare case of endometriosis has been reported in a postmenopausal woman on hormone

replacement therapy (HRT).

Symptoms The symptoms vary according to the site, depth of lesion and do not always
correlate well with the extent of disease.

The classic symptom complex includes dysmenorrhoea, dyspareunia, menorrhagia and

infertility. About 30% of the patients are asymptomatic.
Overlapping of symptoms are common.

The following are the common symptoms.

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 Dysmenorrhoea

This is the most common symptom. Seventy per cent pain begins before the onset of
menstruation, builds up continuously until the flow begins, and thereafter, it gradually
declines.

The character of pain can be very variable, from a dull ache to grinding or crushing pain,
colicky pain or a bearing-down pain.

Backache is a common accompaniment. Sometimes, there may be radiating pain along the
sciatic nerve.

With passage of time, the intensity and duration of pain increases and dysmenorrhoea may
persist for a few days after menstruation.

Pain of endometriosis is chiefly related to the location and not the extent of the lesion.

Deeper lesions cause more pain than superficial ones.

The peritoneal fluid contains prostaglandin which is supposed to cause dysmenorrhoea and
abdominal pain.

Abdominal Pain

Lower abdominal pain of varying intensity may appear at any time, but is usually
common around menstruation. It is a dull ache culminating in dysmenorrhoea. Occasionally, the

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pain suddenly becomes very severe, presenting as an acute abdomen necessitating immediate
surgery. At laprotomy, a ruptured chocolate cyst is observed.

Dyspareunia

Endometriotic involvement of the cul-de-sac and the uterosacral ligaments may produce
adhesions and fixation of the uterus and nodular thickening of the uterosacral ligaments.
Movements of the cervix elicit tenderness.
Dyspareunia and backache may be the result of this pathology.

These patients are often reluctant to attempt intercourse, and this adds to the magnitude of
infertility (25–50%).

Infertility Endometriosis affects fertility at all stages of the disease but in asymptomatic
women with mild disease, infertility is difficult to explain. While about one-fifth of all
women who are infertile tend to suffer from endometriosis, the incidence of infertility
amongst women suffering from endometriosis ranges between 30% and 40%. Endometriosis
possibly interferes with tubal motility and function.

It may inhibit ovulation, ovum pick-up by the fimbria and because of dyspareunia there is
reduced frequency of sexual intercourse.

Other causes of infertility are luteinized unruptured follicular (LUF) syndrome, increased
prolactin and corpus luteal phase defect, nonovulation and tubal blockage.

Prostaglandin affects the tubal motility and also causes corpus luteolysis. The activated
macrophages in the peritoneal fluid engulf the sperms or immobilize them.

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Menstrual Symptoms

Menorrhagia (20%) is common with adenomyosis and irregular bleeding may occur with
cervical and vaginal lesions.

Polymenorrhoea is noted with ovarian involvement (10–30%).

Chronic Pelvic Pain (CPP)

Endometriosis is one of the important causes of CPP. Brownish-yellow peritoneal

fluid containing prostaglandin E2 is responsible for this pain.
Nerve entrapment in endometriosis tissue may also be responsible for pain.

Other Symptoms

Urological symptoms like increase in frequency, dysuria and in rare cases,

haematuria during menstruation may result from bladder or ureteral involvement.

Obstruction of the ureter directly or as a result of kinking by adhesions leads to

hydronephrosis and renal infection.

Bowel symptoms are often the result of direct involvement of the sigmoid colon and rectum
causing painful defaecation, diarrhoea and melaena around menstruation.

Occasionally, pelvic endometriotic adnexal masses can cause obstructive symptoms of

constipation and present with a painful abdominal mass or as an acute abdomen simulating
peritonitis, appendicitis or an ectopic pregnancy.

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 Scar endometriosis causes cyclical pain and enlargement, and pulmonary lesion causes
cyclical haemoptysis.

Differential Diagnosis

● Because of varied clinical features, endometriosis poses a diagnostic challenge at times.

Chronic pelvic inflammatory disease (PID) closely mimics endometriosis in its symptoms
and signs. Both the conditions produce pelvic pain, congestive dysmenorrhoea,
menorrhagia and sterility. Endometriosis may, if there is leakage of blood contents,
produce leucocytosis, raised erythrocyte sedimentation rate (ESR) and moderate fever.
Both also have similar physical signs. Laparoscopic visualization of the pelvis will reveal
the true pathology.

● Uterine myomas, unless degenerate, are painless and the uterus is not fixed. Ultrasound
and laparoscopic visualization will differentiate one condition from the other.

● Ovarian malignant tumour with metastatic deposits in the pouch of Douglas can be
mistaken for endometriosis. The history, pain, the age of the patient and other symptoms
suggestive of endometriosis are against the diagnosis of cancer, but the physical signs,
apart from tenderness, are very similar to those of an ovarian neoplasm.

● Rectosigmoid involvement will cause rectal symptoms which resemble the symptoms of
rectal carcinoma. It may be impossible to make an accurate diagnosis until sigmoidoscopy
and biopsy are performed.

● If the chocolate cyst ruptures, all possibilities of an acute abdominal catastrophe must be
considered, including a ruptured tubal gestation, though the most frequent error is to
operate for acute appendicitis.

● Chronic pelvic congestion syndrome due to other causes must be excluded by ultrasound,
CT, MRI and laparoscopy.

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 Investigations

Laparoscopic Findings: These have already been described earlier.

Laparoscopy should be employed not merely for diagnostic purposes; the endoscopist
should be able to proceed with minimal invasive surgery (see below) in the presence of
this pathology.
Laparoscopy is the gold standard in the diagnosis of endometriosis. The diagnosis should
be validated by peritoneal and tissue biopsy, because corpus luteal haematoma can
resemble a chocolate cyst.

Role of laparoscopy
● To detect and diagnose pelvic endometriosis.

● Locate the site of endometriosis and staging.

● To take biopsy.

● To surgically treat endometriosis by ablation, removal.

CA-125, glycoprotein and cell surface antigen, is raised to more than 35 U/mL in 80%
cases of endometriosis and the level is directly proportional to the extent of the disease.
The level is not specific, because it is also raised in abdominal tuberculosis, PID,
malignant epithelial ovarian tumour, chronic liver disease and in 2% normal women,
especially during menstruation. While CA-125 estimation may not be helpful in the initial
diagnosis, once the diagnosis is established, raised level of CA-125 indicates either
persistence or recurrence of the disease in the follow-up.

Ultrasound and MRI

Transvaginal ultrasound reveals an echo-free cyst, low level
echoes or clumps of high-density level echoes representing clots.

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The cyst wall is thick and irregular, and multiple cysts in different phases of evolution may be
observed. Ultrasound is 83% sensitive and 98% specific as small nodules may not be picked up
by ultrasound.

CT and magnetic resonance imaging give identical picture as in ultrasound and are not more
useful in the diagnosis of endometriosis.

● Colour Doppler flow shows increased vascularity but does not confirm the diagnosis—
vascularity is diffuse; in a fibroid, blood vessels are seen in the periphery.

● Cystoscopy will identify involvement of the bladder.

● Sigmoidoscopy is required if the woman develops bowel symptoms. A biopsy is required

if malignancy is suspected.

● Antiendometrial antibodies are identified in the serum, peritoneal fluid and

endometriotic fluid as well as in normal endometrial tissue. However, as yet these are not
measured to be of screening value and used as a tissue marker. They may also not be
sensitive and specific.

● Tumour necrosis factor is raised proportionate to the severity of the disease.

Prophylaxis

● Low-dose oral contraceptive pills reduce the menstrual flow and protect against
endometriosis. Three monthly oral pills are convenient to take and effective.

● Tubal patency tests should be avoided in the immediate premenstrual phase to avoid spill.

● Operations on the genital tract should be scheduled in the postmenstrual period.

● Classical caesarean section and hysterotomy operation which cause scar endometriosis
are now rarely performed.

Management

Minimal asymptomatic cases should be observed over 6–8 months. Infertility should
be investigated and treated as necessary .All symptomatic women need treatment. The treatment

28
depends upon the age of the patient, need for preserving reproductive functions, severity of the
symptoms, extent of the disease, response to medical treatment, relief obtained with any previous
conservative surgery and the attitude of the patient towards her problem.

The objective of the treatment should be to eradicate the lesion and avoid recurrence of the
disease process, alleviate symptoms, facilitate childbearing and enable the patient to lead a
comfortable life. Therefore, the treatment should be individualized.

The treatment comprises medical surgical and a combination of both.

Drug Treatment

1. Combined oral contraceptives

2. Mirena IUCD

3. Progestogens

4. Androgens

5. GnRH analogues

6. Letrozole

7. RU-486

Surgery
Recurrence following conservative surgery is 10% at the end of 1 year and 25% at the end of 3
years. Adhesions form in 10%, more with cauterization than laser. These women may require
second surgery which may be technically difficult. Therefore, some prefer laparotomy over
laparoscopy when repeat surgery is required. Indications for surgery:

● Advanced stage of disease detected

● Large lesion—can be dealt with

29
 ● Medical therapy fails or is intolerable

● Recurrence occurs

● In elderly parous women

Laparotomy

Laparotomy is also required in advanced stages and in larger lesions if medical

therapy fails or hormones cannot be tolerated and for recurrence.

● Dissection and excision of a chocolate cyst.

● Salpingo-oophorectomy.

● Abdominal hysterectomy and bilateral salpingooophorectomy. Surgery can be difficult

due to adhesions.
Mirena IUCD is an alternative to a repeat surgery.
A premenopausal woman may need HRT after the radical surgery; tibolone is safer than
E2 P therapy. Scar endometriosis requires excision or danazol.
Hormone replacement therapy following bilateral ovarian removal in young women may
be prescribed under strict monitoring, as the risk of recurrence remains. Calcium and
vitamin D is added to HRT.
As mentioned before, tibolone 2.5 mg daily is better than E2 and progestogen.
Metastatic endometriosis is dealt with using hormone therapy.

Combined Therapy
Combined therapy is indicated in the following conditions.

● Preoperative GnRH monthly for 3 months reduces the size and extent of the
lesions, softens the adhesions and makes the subsequent surgery easier and more
complete.

● Postoperative hormonal therapy may be required if the surgery has been

incomplete, and some residual lesion is left behind due to technical difficulty. It
also reduces the recurrence rate.

30
31
 ADENOMYOSIS

Adenomyosis, also labelled uterine endometriosis, is a relatively common condition in which

islands of endometrium are found in the wall of the uterus. It is observed frequently in elderly
women.

More than one-third of the hysterectomy specimens from women aged 40 years and above reveal
the presence of adenomyosis, irrespective of the indications for hysterectomy. The disease often
coexists with uterine fibromyomas, pelvic endometriosis (15%) and endometrial carcinoma.

Grossly, the uterus appears symmetrically enlarged to not more than 14 weeks size. The cut
section may show only a localized nodular enlargement. Most of the time, the affected area

32
reveals a peculiar, diffuse, striated and noncapsulated involvement of the myometrium, mostly
the posterior wall, with tiny dark haemorrhagic areas interspersed in between.

Laparoscopy reveals a uniformly enlarged uterus.

Histological examination reveals islands of endometrial glands surrounded by stroma, in the

midst of myometrial tissue at least two low-power fields beyond the endomyometrial junction,
more than 2.5 mm beneath the basal endometrium.

These women are usually parous, around the age of 40 years. Some are asymptomatic, others
present with menorrhagia and progressively increasing dysmenorrhoea.

Pelvic discomfort, backache and dyspareunia are the other symptoms of adenomyosis.

Clinical examination reveals a symmetrical enlargement of the uterus if the adenomyosis is

diffuse and the uterus is tender.

The uterine enlargement rarely exceeds that of a 3-month pregnancy and is often mistaken for a
myoma.

If a patient gives a history of menorrhagia with accompanying dysmenorrhoea, one should

always consider the possibility of adenomyosis.

If the adenomyosis is localized, the enlargement is asymmetrical and the resemblance to a

myoma is more close.

A myoma of this size is rarely painful.

Therefore, a painful, symmetrical enlargement of the uterus should suggest the correct diagnosis.

MRI is superior to ultrasound showing hypo- or anechoic area in the uterine wall.

Ultrasound shows illdefined hypoechoic areas, heterogeneous echoes in the myometrium,

asymmetrical uterine enlargement and subendometrial halo thickening .

It also shows endometrial infiltration into the myometrium.

33
Treatment
A diagnostic hysteroscopy combined with a curettage is the initial step in the management of
adenomyosis because of menorrhagia. Since most women are elderly and past the age of
childbearing, total hysterectomy is the treatment.

In younger women, in whom a localized adenomyosis is found confined to one part of the uterus,
a localized excision is sometimes feasible, and this conservative resection is reasonable if the
patient is particularly anxious to have a child.

34
The possibility of scar rupture should be borne in mind. Nonsteroidal anti-inflammatory drugs
(NSAIDs) and hormonal therapy are employed with some success in women reluctant to undergo
hysterectomy, but the overall results are not satisfactory.

Drugs used are danazol, GnRH and Mirena IUCD for menorrhagia and pain.

Transcervical resection of endometrium (TCRE) is effective for about 2 years. Unlike fibroid,
uterine artery embolization has no effective role in adenomyosis.

Mirena has been increasingly used in adenomyosis. Lately, danazol IUCD

is under trial (Danazol containing 300–400 mg IUCD).

MRI guided ultrasonic focused surgery and resection is under trial, and is
desirable in young women.

35
 OVARIAN TUMOURS

Ovarian tumour is not a single entity, but a complex wide spectrum of neoplasms involving a
variety of histological tissues ranging from epithelial tissues, connective tissues, specialized
hormone-secreting cells to germinal and embryonal cells.

The most common are epithelial tumours forming 80% of all tumours. Eighty per cent are
benign tumours and 20% malignant. Of all the malignant tumours, 90% are epithelial in origin,
80% are primary in the ovary and 20% secondary from breasts, gastrointestinal tract and colon.

Benign tumours can become secondarily malignant. Mucinous cyst becomes malignant in 5%
but papillary cyst adenoma becomes malignant in 50% if left untreated.

Varieties of cystic/neoplastic enlargements of the ovaries

1. Functional cysts
• Follicular cysts
• Lutein cysts
• Multiple functional cysts

36
 • Corpus luteal cyst (PCOS)
2. Inflammatory
• Salpingo-oophoritis
• Puerperal, abortal, IUCD related
3. Metaplastic
• Endometrioma
4. Neoplastic benign and malignant
• Premenarchal years: 10% are malignant—mostly dysgerminoma teratoma
• Reproductive period—15% malignant
• Premenopausal—50% malignant

37
Pathology
In an attempt to standardize the nomenclature used in describing the diverse varieties of tumours,
the World Health Organization (WHO) devised a classification listing nine major groups for
benign and malignant tumours .

Epithelial ovarian neoplasms arise from the mesoepithelial cells on the ovarian surface.
Epithelial cancers constitute about 80% of all ovarian cancers.

The most common histologic type is the papillary serous cystadenomas and carcinomas
accounting for almost 50% of all epithelial tumours.

Mucinous cysts account for 12–15%, clear cell and endometrioid combined about 10%, and the
unspecified types 25–27% of the cases.

The degree of cellular differentiation of the epithelial ovarian neoplasm expressed as histologic
grade has an important prognostic significance as well as in identifying malignancy.

The criteria of grading used include mitotic count, stratification, cellular pleomorphism, nuclear
atypism and proportion of solid areas within the tumour. Grade ‘0’ tumours, also known as
borderline malignancies or tumours of low malignant potential (LMP), may demonstrate
papillary tufting, stratification, epithelial atypia, exfoliation of cellular clusters, minimal mitotic
activity, but no stromal invasion. The 5-year survival of patients with Stage I Grade ‘0’ tumours
is more than 90% compared to 54% survival for patients with Stage I Grade 3 serous
cystadenocarcinomas.

WHO classification of ovarian tumours (major groups)

I. Common epithelial tumours:

• Serous tumours
• Mucinous tumours
• Endometrioid tumours
• Clear cell (mesonephroid tumours)
• Brenner tumours

38
 • Mixed epithelial tumours
• Undifferentiated carcinoma
• Unclassified epithelial tumours
II. Sex cord (gonadal stromal) tumours:
• Granulosa stromal cell tumours, theca cell tumours
• Androblastomas: Sertoli–Leydig cell tumours
• Gynandroblastomas
• Unclassified
III. Lipid (lipoid) cell tumours
IV. Germ cell tumours:
• Dysgerminoma
• Endodermal sinus tumour
• Embryonal carcinoma
• Polyembryoma
• Choriocarcinoma
• Teratoma
• Mixed forms
V. Gonadoblastoma:
• Pure
• Mixed with dysgerminoma or other germ cell tumours
VI. Soft tissue tumours not specific to ovary
VII. Unclassified tumours
VIII. Secondary (metastatic) tumours
IX. Tumour-like condition

Ovarian Tumours Associated with Pregnancy

The ovarian tumour discovered during pregnancy is an enlarged corpus

luteal cyst, a benign as well as a malignant tumour.

An asymptomatic tumour is discovered during routine ultrasound scanning in early pregnancy.

Symptomatic tumour however presents with abdominal pain in pregnancy.

39
Corpus luteal cyst regresses after the 12th week and can therefore be observed.

The benign tumour should be removed in the second trimester between the 14th and 16th week.

Earlier surgery may increase the risk of abortion, whereas laparotomy in the third trimester
increases the surgical difficulty because of the growing uterus; preterm labour is also a
possibility.

The tumour discovered late in pregnancy should be removed in early puerperium to avoid torsion
and infection.

The malignant ovarian tumour requires laparotomy at the earliest, irrespective of the duration of
pregnancy.

Ovarian Cyst in a Menopausal Woman

A simple unilocular cyst measuring less than 5 cm can be observed with repeat ultrasound and
CA-125 every tahir99 - UnitedVRG 452 Shaw’s Textbook of Gynaecology 3 months.

Many resolve in 6 months. A persistent cyst calls for its removal laparoscopically or by
laparotomy.

Aspiration of the cyst is contraindicated because of low yield of malignant cells (false-negative)
and possibility of spread of malignancy if the cyst proves malignant histologically.

Many perform bilateral oophorectomy and hysterectomy in perimenopausal women

Ovarian Remnant Syndrome

Ovarian remnant syndrome follows hysterectomy in 1.4% cases. It is caused by ovarian
adhesions to the vaginal vault, and causes cyclical abdominal pain and deep dyspareunia. It
requires oophorectomy.

The retained ovary may also develop malignancy in 1% cases. Apart from these, it is also
observed that many ovaries atrophy prematurely (within 4 years) following hysterectomy, if the
ovarian vessels get kinked and obliterated during hysterectomy.

40
The conservation of ovaries at hysterectomy for benign tumour therefore remains a debatable
issue at present. Recent belief is to remove the ovaries at the time of hysterectomy and give
hormone replacement therapy thereafter.

Ovarian Tumours in Adolescents

Ovarian tumours account for 4–5% of all genital tumours, of which 25% are primary malignant
tumours.

Before the age of 20 years, 60% are germ cell tumours and 65% of these are malignant.

41
Since epithelial tumours are related to ovulation (combined oral contraceptives therefore protect
against ovarian cancers in 40–50%) and ovulation occurs only after puberty, epithelial tumours
are extremely rare (0.5%) during adolescent period.

Dysgerminoma is the commonest tumour and causes amenorrhoea. Clinically, ‘Grade 0’

epithelial tumour may occasionally be encountered.

Conservative surgery followed by chemotherapy is effective and has replaced the older treatment
of hysterectomy with bilateral salpingo-oophorectomy and radiotherapy in young girls.

Adnexal Mass

The ovary and the fallopian tube form the adnexa along with a rare tumour in the broad ligament.
It is at times difficult clinically to identify the site of adnexal mass. Ultrasound, MRI and at times
laparoscopy may be required to diagnose the condition.

Adnexal Mass in Premenarchial Age

● Mainly an ovarian tumour, i.e. germ cell tumour, dysgerminoma, teratoma,

granulose cell tumour; 25% of them are malignant tumours.

● Tubercular pelvic mass.

● In rare cases, a pelvic kidney.

During Reproductive Age

● Functional ovarian cysts.

● Pelvic inflammatory disease

● Ectopic pregnancy

● Endometrioma.

● Broad ligament tumour.

● Tubercular mass.

● Ovarian tumour, mostly benign.

● Pedunculated uterine fibroid.

42
 Post Menopausal

● Malignant ovarian tumour 50%.

● Benign ovarian tumour.

● Pedunculated uterine fibroid.

● Colonic tumour

Correct diagnosis by clinical history examination, ultrasound, CT, MRI and if

required laparoscopy is required, and the disorder treated by appropriate therapy.

Diagnosis

Tests and procedures used to diagnose ovarian cancer include:

43
● Pelvic exam. During a pelvic exam, your doctor inserts gloved fingers into your vagina and
simultaneously presses a hand on your abdomen in order to feel (palpate) your pelvic
organs. The doctor also visually examines your external genitalia, vagina and cervix.

● Imaging tests. Tests, such as ultrasound or CT scans of your abdomen and pelvis, may
help determine the size, shape and structure of your ovaries.

● Blood tests. Blood tests might include organ function tests that can help determine your
overall health.

44
 Your doctor might also test your blood for tumor markers that indicate ovarian cancer. For
example, a cancer antigen (CA) 125 test can detect a protein that's often found on the
surface of ovarian cancer cells. These tests can't tell your doctor whether you have cancer,
but they may provide clues about your diagnosis and prognosis.

● Surgery. Sometimes your doctor can't be certain of your diagnosis until you undergo
surgery to remove an ovary and have it tested for signs of cancer.

● Genetic testing. Your doctor may recommend testing a sample of your blood to look for
gene changes that increase the risk of ovarian cancer. Knowing you have an inherited

45
 change in your DNA helps your doctor make decisions about your treatment plan. You may
wish to share the information with your blood relatives, such as your siblings and your
children, since they also may have a risk of having those same gene changes.

Once it's confirmed that you have ovarian cancer, your doctor will use information from your
tests and procedures to assign your cancer a stage. The stages of ovarian cancer range from 1 to 4,
which are often indicated with Roman numerals I to IV. The lowest stage indicates that the
cancer is confined to the ovaries. By stage 4, the cancer has spread to distant areas of the body.

Treatment

Treatment of ovarian cancer usually involves a combination of surgery and chemotherapy. Other
treatments may be used in certain situations.

Surgery

Operations to remove ovarian cancer include:

● Surgery to remove one ovary. For early-stage cancer that hasn't spread beyond one ovary,
surgery may involve removing the affected ovary and its fallopian tube. This procedure
may preserve your ability to have children.

● Surgery to remove both ovaries. If cancer is present in both your ovaries, but there are no
signs of additional cancer, your surgeon may remove both ovaries and both fallopian tubes.
This procedure leaves your uterus intact, so you may still be able to become pregnant using
your own frozen embryos or eggs or with eggs from a donor.

● Surgery to remove both ovaries and the uterus. If your cancer is more extensive or if
you don't wish to preserve your ability to have children, your surgeon will remove the
ovaries, the fallopian tubes, the uterus, nearby lymph nodes and a fold of fatty abdominal
tissue (omentum).

46
 ● Surgery for advanced cancer. If your cancer is advanced, your doctor may recommend
surgery to remove as much of the cancer as possible.

● Sometimes chemotherapy is given before or after surgery in this situation.

Chemotherapy

Chemotherapy is a drug treatment that uses chemicals to kill fast-growing cells in the body,
including cancer cells. Chemotherapy drugs can be injected into a vein or taken by mouth.

Chemotherapy is often used after surgery to kill any cancer cells that might remain. It can also be
used before surgery.

In certain situations, chemotherapy drugs may be heated and infused into the abdomen during
surgery (hyperthermic intraperitoneal chemotherapy).

The drugs are left in place for a certain amount of time before they're drained. Then the
operation is completed.

Targeted therapy

Targeted drug treatments focus on specific weaknesses present within cancer cells. By attacking
these weaknesses, targeted drug treatments can cause cancer cells to die.

If you're considering targeted therapy for ovarian cancer, your doctor may test your cancer cells
to determine which targeted therapy is most likely to have an effect on your cancer.

Hormone therapy

Hormone therapy uses drugs to block the effects of the hormone estrogen on ovarian cancer cells.
Some ovarian cancer cells use estrogen to help them grow, so blocking estrogen may help
control the cancer.

47
Hormone therapy might be a treatment option for some types of slow-growing ovarian cancers. It
may also be an option if the cancer comes back after initial treatments.

Immunotherapy

Immunotherapy uses the immune system to fight cancer. The body's disease-fighting immune
system may not attack cancer cells because they produce proteins that help them hide from the
immune system cells. Immunotherapy works by interfering with that process.

Immunotherapy might be an option for treating ovarian cancer in certain situations.

Supportive (palliative) care

Palliative care is specialized medical care that focuses on providing relief from pain and other
symptoms of a serious illness. Palliative care specialists work with you, your family and your
other doctors to provide an extra layer of support that complements your ongoing care.

Palliative care can be used while undergoing other aggressive treatments, such as surgery and
chemotherapy.

When palliative care is used along with all of the other appropriate treatments, people with
cancer may feel better and live longer.

Palliative care is provided by a team of doctors, nurses and other specially trained professionals.
Palliative care teams aim to improve the quality of life for people with cancer and their families.
This form of care is offered alongside curative or other treatments you may be receiving.

Prevention

There's no sure way to prevent ovarian cancer. But there may be ways to reduce your risk:

48
 ● Consider taking birth control pills. Ask your doctor whether birth control pills (oral
contraceptives) may be right for you. Taking birth control pills reduces the risk of ovarian
cancer. But these medications do have risks, so discuss whether the benefits outweigh those
risks based on your situation.

● Discuss your risk factors with your doctor. If you have a family history of breast and
ovarian cancers, bring this up with your doctor. Your doctor can determine what this may
mean for your own risk of cancer. You may be referred to a genetic counselor who can help
you decide whether genetic testing may be right for you. If you're found to have a gene
change that increases your risk of ovarian cancer, you may consider surgery to remove your
ovaries to prevent cancer.

● Family history of ovarian or breast cancer

● Condition linked with a high risk of ovarian cancer, such as Lynch syndrome or Peutz-
Jeghers syndrome
● BRCA1 or BRCA2 mutation
● Previous breast, colorectal or endometrial cancer diagnosis

THERAPEUTICS
Lilienthal :

OVARIES, Diseases of.

Principal remedies :

49
1 . apis , canth ., con . , staph ., thuj. ;

2 .asaf., aur., bry. , carb. an . , chin ., cimicif., hamam ., lach . , lyc., plat., pallad ., ran . bulb .,
sec. , sep. , zinc.;

3 . acon . , ambr. , ammon. mur., ant. crud ., ars . , bell. , carb. veg. , chel., coloc ., graph ., bep. ,
ign . , merc. , mez ., nitr. ac., n . vom ., pod. , sulph ., uistil . , zinc. val.

Apis mel

Soft encysted ovarian tumor, perceptible as a slight pro tuberance at first, and then movable ;
stinging pain, sometimes lancinating ;

thirstlessness and scanty urine ; dropsy, local or in connection with abundant anasarca ; skin
white and transparent; bowels costive, with large, difficult, hard stool.

Ovaritis, with stinging pains ; aggravation after coitus ; enlargement of the right ovary, and pain
in the left pectoral region, with cough from mutual sympathy between ovaries and lungs ;
especially for right ovary

Bryonia

Soreness of right ovary, like a sore spot, causing irritation and dragging pains which extend
down into the thighs while at rest, worse from touch ;

stinging pain or stitches in the ovary on taking a deep inspiration cannot bear to have the parts
touched ; shooting pains extending towards the hip ; ovaritis with rheumatic affections.

Cantharides

Cysto -ovarium ; much tenderness and burning in ovarian region ; dysuria, cutting burning in
passing only a drop or two, which is often bloody, or strangury complete ;

stitches in ovarian region , arresting breathing, or violent pinching pain , with bearing down
towards genitals

50
Cimicifuga

Ovaritis, with irritable uterus ; hysterical symptoms and rheumatism ; suppressed, painful, or
profuse menstruation ;

distress and dulness of head , trembling sinking of the stomach , frequent calls to urinate

Conium

İnduration and enlargement with lancinating pains ; in duration , suppuration, with nausea,
vomiting, eructation of wind and expectoration of phlegm ;

burning, sore, aching pains ; affections of ovaries with amenorrhæa; atrophy with sterility

Graphites

The left indurated ovary swells up and becomes very hard ; violent pains on touch , on
inspiration, or hawking, when the most violent stitches shoot in it , with profuse general sweat
and continued loss of sleep ;

tumor in right and left iliac fossa, hard , round, slightly movable, of the size of an orange, not
painful to pressure ; swelling and hardness of ovaries after menses ;

inflammation worse from cold or from getting feet wet ; tearing, grinding, twisting pains in the
right ovary, as if it would burst, followed by discharge of bloody pus, before or during menses ;
morning sickness during menses ; constipation ; blotches on skin .

Lachesis

Induration and enlargement ( iodum ), worse from moral emotions or great exertions ( right ).
Pains, boring or burning, in creasing more and more, until relieved by a discharge of blood from
the vagina (right). Shooting pains extending from the left to the right ovarian region (lilium ).

Neuralgic pains ( left ). Stitcbing, pressing, tensive pain with swelling of the left ovary.
Suppuration, after pus has been formed , it will promote its discharge. Pain in the right ovary

51
extending towards the uterus. Pain in the right ovarian region of long standing, extending to the
genital organs , or upwards to the liver and chest.

Palladium

Induration and swelling of the right ovary , with soreness and shooting pains from the navel to
the pelvis.

Heaviness and weight in the pelvis, worse from exertion or while standing, better when lying on
the left side Drawing down and forward in the right ovary, relieved by rubbing. Swelling and
tenderness to touch of the right ovary with bearing-down pain ; pain in the right ovary,
aggravated from mental agitation, from being in society , from music, conversation , or motion ;
great urgency to urinate, with scanty emission ;

sallow complexion , blue half circles under eyes ; eructations which do not relieve ; acid
eructations, with spasmodic pains in chest, back, and abdomen ; derangement of stomach ; heavy
weight in pelvis, relieved by lying on left side.

Plumbum

Patient wants to stretch upper and lower limbs during ovarian pains ;

feeling as if there was not room enough in the pelvis : atrophy and sterility .

Staphysagria

Sharp shooting pain in ovary, which is very sensitive to pressure ; painful sensitiveness of sexual
organs, especially when the mind has been dwelling too much on sexual subjects ;

pains extending down into the crural region and thighs

Thuja

52
Inflammation, with pain , in the left ovary, extending through the left iliac region into the groin
and sometimes into the left leg, frequently worse from walking or riding, so that she has to lie
down (during menses );

burning pain in the ovary ; ovarian affections and pains are worse during menses ; affections
connected with gonorrhea or syphilis. Cysto -ovarium .

Ustilago

Burning pain ; pain in the ovaries shooting down the legs, intermittent, with swelling, worse in
the left ; severe ovarian and uterine irritation , with severe pain in the back ;

ovarian irritation with amenorrhæa ; pain in the right ovary with metrorrhagia ; neuralgic pains

Minton’s uterine therapeutics:

OVARIAN REGION

Burning in : Bell., canth. Cramps in : Coloc.

as though the parts were squeezed in a vise : Coloc.

Heaviness in : Apis. Pains in, boring : Zinc.

burning : Ars., tell., canth., plat., zinc.

cutting: Apis., lil. tig., sabad.

as from knives : Sabad.

dull, left: Brom.

right: Iod.

extending to the thighs : Apis., ars., try., cact., cham.,

53
OVARIES

Congestion of : Apis.

Cramps in, bending her double : Coloc.

Distress in : Ust.

Diseases of, going from right to left : Lye.

Indurated : Apis, aur., con., iocl., lach., pall, plat.

Inflammation of : Aeon., apis, ars., bell., bry., canth., chin., con.,

cub., graph., iod., lach., lye, mere, phos. ac, plat., phyt., staph.,

thuja, ust.

left side : Apis, graph., lach., thuja.

right side : Bell.

from exposure to cold dry air : Aeon.

debilitating influences : Phos. ac.

fright : Aeon.

mechanical injuries : Arm, ham.

sexual excesses : Chin., phos. ac

with rheumatic complaints : Act. rac, phyt.

Pains in : Aeon., apis, ars., bell., brom., bry., cact., canth., coloc, iod., lach., HI. tig., pod., rhod.,
sabad., staph., sulph.

54
as if the parts were squeezed in a vise : Coloc.

OVARY.— LEFT.

Cramps in, bending her double : Coloc.

Burning in : Lil. tig.

Inflammation of : Apis, lach., lil. tig., thuja.

Induration of : Lach.

Numb aching in : Pod.

Pains in : Arg. n., brom., coloc, lach., lil. tig., phos., ust.

, as if the parts were squeezed in a vise : Coloc.

, boring : Coloc.

, burning: Lil. tig.

, constant : Brom.

-, cutting : Lil. tig.

-, drawing : Lil. tig.

-, dull : Brom.

-, extending to thighs : Phos.

-, from, to back : iEs. hip.

-, grasping : Lil. tig.

-, intermittent : Ust.

55
-, neuralgic : Lach.

-, pressive : Lach.

-, spasmodic : Coloc, ust.

-, squeezing: Coloc.

-, stitching : Lach.

-, stinging : Lil. tig.

-, tensive : Lach.

Sore and tender : Ust.

Swelling of: Graph., lach., lil. tig.

OVARY.— RIGHT

Diseases of, with dropsy : Apis.

Dropsy of : Apis.

Enlargement of : Apis, tell., ust.

Inflammation of : Bell.

Induration of : Iod., pall.

Pains in : Apis, Ml., try., iod., pall.

Pains in, as from a sore spot : Bry.

wedge between right ovary and uterus : Iod.

crampy: Cub.

56
drawing : Bell., pall.

extending to left pectoral region : Apis.

thighs : Bry.

uterus : Ham., iod.

stitching: Ars., bell.

throbbing: Bell,

MIASM
PSORA

● Amenorrhoea

● Impotency

57
 ● Sterility

● Lack of sexual desire

● Vaginal and uterine polypi

● Longs for peculiar things

SYCOSIS

● Ectopic pregnancy

● Endometriosis

● Salphingitis

● Ovaritis

● Ovarian tumours

● A mottled appearance of the mucous membrane of the endometrium

● The uterus may be retroverted or retroflexed, with problems often occurring right after
puberty.

● Polycystic disease of the ovaries

SYPHILIS

● Recurrent abortions and still birth

● A perverted sexual appetite and perverted desires

● Ulcerative and degenerative varieties of tumours

● Cervical and vulval erosion and ulceration

● Offensive menses.

58
 ● Acrid, putrid and offensive leucorrhoea.

TUBERCULAR

● Uterine and vaginal polyps with profuse bleeding

● DUB (dysfunctional uterine bleeding) characterised by profuse haemorrhage.

● sunken eyes and an anaemic appearance

● Uterus retroverted or retroflexed as in sycosis, but in the tubercular miasm the condition
is characterised by profuse uterine bleeding.

● Climacteric flush (sycotubercular).

● Metastatic and haemorrhagic variety of cancers.

59
 REPERTORY

REPERTORY OF THE HOMOEOPATHIC MATERIA MEDICA:

Genetalia-Female:

NUMBNESS
Ovaries: Apis, podo.
beginning in right, ribs and extending to hip and over thigh

PAIN
Ovaries: Acon., æsc., am-m., anan., Apis,
agn-m., arg-n., arn., ars., ars-i., atro., aur.,
Bell., brom., bry., bufo, cact., calc., carnth., carb-ac., cench., cham., cimic., cocc., col., Coloc.,
cop., con., crot-h., gels., graph.. guaj., ham., helon., hydrc., ign., iod., kalibr.,
kali-p., kreos., lac-ac., lac-c., lac-d., Lach., il-t., Lyc.y lyss., Mag-p, md.,
merc., murx., naja, onos., pall., phos., phyt., plat., plb., Podo, uls., 1an-b., rhod.,
sabad., sars., seC., SeneC., sep., stann., staph., sulph., syph., tarent., ter., ther.,
thuj., urt-u., usk., vesp., vib., xan., wye.,

right: Apis, arg-n., ars., ars-i., Bell, bry., calc., cub., graph., iod., lil-t., Lyc., Podo, sars., syph.

lying on right side amel.: Apis.

to left: Graph., Lye., xan.

to uterus: Iod., podo

60
lying on painful side left: AEsc., abrot., Arg-m., brom., carb-ac., amel.: Bry.
Cimic., coloc., graph., ham., kali-br.,
kali-p., Lach., lac-., lil-t., lyss., med.,
merc., naja, pho5., plat., tarent., ther.,
thay., Ust., Vesp., wye., zun.

lying on left side agg.: Thuj.

amel: Kali-p.
back amel.: Kali-p.
extendihng to abdomen: Ham., lil-t.
to heart: Tarent.
on right side amel.: Apis,
on left side amel.: Pall.

Menses,
before: Apis, bell., Cench., colae graph., lac-c., Lach-, podo., thuj., ust vib., zinc.
during: Apis, arg-m., bell., bry., cench cocc., con., gels., iod., kali-p., lac Lach., Iyc., lil-t.,
pall., pkos., plat podo., ther., thuy., ust., xan.
amel.: Lac-., lach., mosch., ust.,, zinc,
right: Apis, lac-c., Lach., li1-t, naja,
syph., ust.
small of back: sc., merc., plat.,
podo., syph.
uterus: Naja, ust.
after: Lach., pall.
mental exertion: Calc.
night: Kali-p., merc., podo., yph.
alternating sides: Lacc.
pain in eye, with: Sulph.
animated conversation: Pall

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Motion
agg.: Ars., Bell, Bry, cemc.
lac-c., pall., ther.
amel: Iod.
moving feet amel.: Ars.
music and excitement: Pall.
bending backward amel.: Lac-c.
double amel.: Coloc., kali-p.
paroxysmal: Ham.
breathing agg.: Bry., lac-c.
pregnancy, during: Kali-p., podo., xan.
changes in the weather, from: Ran-b.,
rhod., rhus-t., thuj.
pressure amel.: Pall., podo., zinc.
pulsating: Cop., onos.
raising ams: Apis, sulph.

POCKET MANUAL OF HOMOEOPATHIC MATERIA MEDICA

& REPERTORY:

OVARIES-Abscess:
Cinch.; Hep.; Lach.; Mere.; Phos. ac.; Pyr.; Si. Atrophy-Iod.; Oophor.; Orchit.

Complaints attending, or following, ovariotomy-

Ars.; Bell.; Bry.; Cinch.; Coff.; Col.; äyper.; Ipec.; Lyc.; Naja; Nux v.; Oophor.; Orchit.; Stuph.

Congestion-Acon.; Æsc.; Aloe; Am. br.; Apis; Arg. n.; Bell.; Bry.; Canth.; Cin.; Col.; Con.;
Gels.; Ham.; Iod.; Lil. t.; Merc.; Naja: Nat. chlor.; Sep.; Tar. h.; Ustil.; Vib. 0p.
CYSTS, DROPSY-

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Apis; Apoc.; Arn.; Ars.; Aur. iod.; Aur. m. n.; Bell.; Bov.; Bry.; Cinch.; Col.; Con.; Ferr. iod.;
Graph.; Iod.; Kali br.; Lach.; Lil. t.; Lye.; Med.; Oophor.; Rhod.; Sab.; Tereb.; Zine.
Induration-
Aur.; Aur. m. n.; Carbo an.; Con.; Graph.; Iod.; Lach. Pall., Plat.; Ustil.

Infammatdon (ovaritis)-Acute:
Acon.; An. br.; Apis; Bel.; Bry.; Cact.; Canth.; Cim.; Col.; Con.; Lil.; Merc. c.; Mere.; Phos. ac.;
Plat.; Piuls.; Sab.; Thuja; Viscum. Acate, with
Ferr. p.; Guaiac.; Ham.; Iod.; Lach.;

peritoneal involvement-
Acon.; Apis: Ars.; Bell.; Bry.i Canth.; Chin. s.; Cinch.; Col.; Hep.; Merc. e., Sil. Tatammation,
chronie, with induration-Con.; Graph.; lod.; Lach.; Pall.; Plat.; Sabai; Sep.; Thuja.

Pain, in left ovary-

Am. br.; Apis; Apium gr.; Arg. m.; Caps.; Carb. ae.;
Cim.; Col.; Erig.; Eup. purp.; Frax. am.; Graph.; Iod.; Lach.; Lil.
Med.; Murex; Naja; Ov. g. pell.; Phos.; Picr. ac.; Thaspium; Thea;
Thuja; Ustil.; Vespa; Wyeth.; Xath.; Zinc.

Pain, in right ovary-

Absinth.; Apis; Ars.; Bell.; Branca; Bry.; Col.;
Eupion; Fagop.; Graph.; Iod.; Lach.; Lil. t.; Lyc.; Pall.; Phyt.; Pod.;
Ustil.

BOENNINGHAUSEN'S CHARACTERISTICS
MATERIA MEDICA & REPERTORY:
Ovaries :-
Acon., Agar., Agn., Ambr., Ant-c., APIS (r.), Arn., Ars., Asaf., Aur., BELL., Calc., CANTH.,
Carb-an., Carb-v., Caust., Chel., Chin., Clem., Coloc. (l.), Con., Dros., Dulc., Graph., Hyos., Ign.,

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Kali-c., Kali-n., LACH., Laur., LIL-T., Lyc., MERC., Mez., Nat-c., Nit-ac., Nux-v., Pall., PLAT.,
Plb., Puls., Ran-b., Ran-s., Ruta, Sabin., Sars., Sec., Sep., STAPH., Sulph., THUJ., Zinc.

Right :- APIS, LYC., Staph.

Left :- Lil-t., Puls., Thuj.

Alternating sides :- Cimic., Lac-c., Onos.

Cramps :- Cocc., Ign., Lil-t., Lyc., Mag-m., Mag-p., Naja, Phos., Plat., Staph.

Cutting :-
Ovaries right :- Apis, Bell.

Drawing :-
Ovaries right :- Apis.

Inflammation :-
Ovaries :- Acon., Ambr., Ant-c., Ars., Bell., Canth., Chin., Con., Dulc., LACH., MERC., Plat.,
Sabin., Staph.

Numbness :-
Ovaries :- Apis, Podo.

Soreness, painful :-
Ovaries :- Bell., Bry.

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 MULTIPLE CHOICE QUESTIONS

1. In polycystic ovary syndrome, estrogen levels are elevated, increasing the risk of
which of the following?

A. Metabolic syndrome
B. Endometrial cancer
C. Hirsutism
D. Hypertension

ANS:B

2. When assessing a patient’s serum hormone levels, what would be consistent with
PCOS?

A. Decreased testosterone and decreased estrogen

B. Increased testosterone and LH, decreased FSH
C. Decreased testosterone and decreased prolactin
D. Decreased LH and Increased FSH

ANS:B

3. All of the following are germ cell tumours except?

A. Mesonephroid tumors
B. Teratoma
C. Dysgerminoma

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D. Endodermal sinus tumour

ANS:A

4. All are true regarding medical treatment of endometriosis except?

A. Oral progestins cause decidualization of endometrial tissue

B. Injectable progestagen is used once in 3 months in the management of pain of endometriosis
C. Levonorgestrel releasing intrauterine system reduces dysmenorrhoea in endometriosis
D. Gestrinone is given orally 2.5 – 5 mg per day to induce endometrial atrophy

ANS:D

5. Which of the following is not the function of the ovary?

A. Release the female gamete for fertilization

B. Produce female sex hormones
C. Provide a hostile environment for the development of the embryo
D .Protection and development of the egg

ANS:C

6. Outermost layer of ovary is made up of ________

A. simple cuboidal cells

B. stereocilia
C. stroma
D. cilia

ANS:A

66
 7. ______________ is one of the most common symptoms of endometriosis.

A. Bloating
B. Infertility
C. Pelvic muscle spasms
D. Diarrhea

ANS:B

8. Which of the following types of cysts most commonly ruptures?

A. Endometriomas
B. Corpus luteum cysts
C. Dermoid cysts
D. Cystadenomas

ANS:B

9. Most cases of adenomyosis affect women aged:

A. 15-19 years
B. 20-30 years
C. 31-39 years
D. 40-50 years

ANS:D

10. Acanthosis nigricans (areas of thickened, darkened skin), a symptom of polycystic

ovary syndrome, is caused by which of the following?
A. Increased serum estrogen levels

67
 B. .Increased serum progesterone levels
C. Insulin resistance
D. Obesity

ANS:C

11. The most common symptom associated with adenomyosis is :

A. Infertility
B. Menorrhagia
C. Haematometra
D. Dyspareunia

ANS:B

12. Which patient has the highest risk for endometriosis?

A. 45 year old nuclear physicist that has been overexposed to radiation.

B. 35 year old woman with abdominal cramps that suffer from endometriosis.
C. 13 year old girl whose mother has struggled with endometriosis.
D. A 65 year old woman with a total hysterectomy

ANS:C

13. How does a follicular cyst form?

A. When a follicle does not break down after ovulation.

B. When a follicle develops before ovulation.
C. When a follicle develops during ovulation.
D. When ovulation fails to occur.

ANS:D

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 14. Common symptoms of ovarian cancer include:

A.Pelvic or abdominal pain

B.Lack of appetite
C.Bloating
D.All of the above

ANS:D

15. Which risk factor is not associated with an increased risk for ovarian cancer?

A. Increased age
B. Family history
C. Use of oral contraceptives
D. Use of HRT

ANS:C

16. The cysts in Polycystic Ovarian syndrome are formed by:

A. Failure of atretic follicles to undergo apoptosis

B. Oocyte proliferation
C. Multiple corpus lutea
D. Cystic degeneration of ovarian cortex

ANS:A

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 17. Dehydroepiandrosterone sulphate (DHEAS) is quantitatively the most abundant
circulating sex steroid in women. Which of the following statements characterizes its
secretion?
A. It increases during puberty and early adulthood.
B. It decreases significantly as a result of the menopause transition.
C. It reaches its highest levels in old age.
D. It is controlled by FSH.

ANS:B

18. Nerve supply of ovary is through

A. Sacral fibers
B. Pudendal nerve
C. Branches of renal and aortic plexus
D. none of the above

ANS:C

19. Right ovarian artery arises from

A. Uterine artery
B. Aorta
C. Renal artery
D. Common iliac artery

ANS:B

20. Where does ovarian cancer occur?

A. On tissue within the ovary
B. On the surface of the ovary

70
 C. In egg-forming germ cells within the ovary
D. Any of the above

ANS:D

71
 BIBLIOGRAPHY

1. HOWKINS & BOURNE SHAW'S TEXTBOOK OF GYNAECOLOGY -16TH

EDITION BY VG PADUBIDRI & SN DAFTARY
2. DC DUTTA'S TEXTBOOK OF GYNECOLOGY-7TH EDITION
3. DAVIDSON’S PRINCIPLES & PRACICE OF MEDICINE -22ND EDITION
4. HOMEOPATHIC THERAPEUTICS BY SAMUEL LILIENTHAL
5. UTERINE THERAPEUTICS BY MINTON
6. POCKET MANUAL OF HOMOEOPATHIC MATERIA MEDICA & REPERTORY-
9TH EDITION
7. REPERTORY OF THE HOMOEOPATHIC MATERIA MEDICA BY J.T.KENT-9TH
EDTION
8. MIASMATIC PRESCRIEBING BY DR.SUBRATA KUMAR BANERJEA
9. WWW.IMPEYOBGYN.COM
10. WWW.MEDINDIA.NET
11. WWW.OCRAHOPE.ORG

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