UNIT 8: GYNECOLOGICAL PROBLEM AND THEIR MANAGEMENT

Disease of genital tract: infection, prolapse, injuries

Genital tract infections, also known as reproductive tract infections can lead to
extreme pain, discomfort, and unwanted consequences in women.

Categories of genital tract infection

• Lower Genital Tract Infections: This includes any infection of the lower

reproductive tract including the vagina, vulva and cervix.

• Upper Genital Tract Infections: This includes any infection of the upper

reproductive tract which includes the fallopian tubes, uterus and ovaries.

Types of Genital Tract Infection

• Sexually Transmitted Diseases: As the name suggests, these diseases are

contracted through unprotected sexual intercourse. The most common STDs
include gonorrhoea, chlamydia, chancroid and HIV or human immunodeficiency
virus.

• Endogenous Infections: These issues are caused by the overgrowth of certain

organisms that are commonly found in the genital tract of healthy women. This
includes conditions like vulvovaginal candidiasis, bacterial vaginosis etc.

• Iatrogenic Infections: These infections are caused by medical procedures that

have been performed improperly. The most common causes of these infections
are poor delivery or childbirth and unsafe abortion.

• Any reproductive tract infection in women is treatable, provided it is diagnosed

early.

• Complications related to the infection are most prevalent in the upper genital tract
which can lead to issues with conception, pregnancy, etc.

Symptoms
• The most common symptoms of any genital tract infection in women are as
follows:

• Itching and redness in the vaginal region

• Vaginal spotting or bleeding

• Difficulty during urination

• Burning sensation during urination

• Painful intercourse

• Change in the amount of vaginal discharge

• Change in the colour of vaginal discharge

• Heavy bleeding during periods

• Inconsistency in periods

• Pain in the lower abdomen

• If you notice any of the symptoms mentioned above, make sure you visit your
gynaecologist immediately for a test.

Diagnosis

• The first step of diagnosing any female reproductive tract infections is to

understand the symptoms and causes. Your doctor may ask you a few questions
like:

• What are the symptoms you are experiencing?

• For how long have you noticed these symptoms?

• Do you experience any pain during intercourse?

• Have you engaged in unprotected sex?

• Are you currently undergoing any fertility treatment?

• Have you had these symptoms in the past?

 • Once you answer these questions, the doctor will perform a physical
examination. This is followed by different tests such as:

• Pap Smear

• Hysteroscopy

• Laparoscopy

• Pelvic Ultrasound

treatments for Genital Tract Infection

Based on the source of the infection, the reproductive tract infection

treatment procedure varies. The most common treatment options are as follows:

• Topical creams: For any vaginal or lower genital tract infection at the surface
level, topical creams are provided to ease the symptoms.

• Antibiotics: In case of bacterial or other microbial genital tract infection causes,

antibiotics are prescribed to reduce the infection and the growth of the microbial
population.

• Laparoscopic surgery: This is a minimally invasive procedure that is used to

manage complications in the infection of the fallopian tube, pelvic inflammatory
disease etc.

Post-Operative Care and Prevention

• Preventive measures for genital tract infections are as follows:

• Ensure the cleanliness and hygiene of the genitals.

• Avoid unprotected sex

• Have an active lifestyle

• A healthy diet is a must to prevent infections

• Avoid the use of any abrasive soaps to clean the genital areas.

• Stay hydrated
 HYSTERECTOMY

 
Hysterectomy
 It is the surgical removal of the uterus, it may also involve removal of the
cervix, ovaries, fallopian tubes and other surrounding structures.
 It is a common operation carried out to treat conditions of the female reproductive
system.
 Hysterectomy is a major surgical procedure that
 has risks and benefits, and
 affects a woman's hormonal balance and overall health for the rest of her
life.
 normally recommended as a last option to remedy certain uterine conditions.

 Indications Of Hysterectomy:
 Fibroids
 Adenomyosis
 Endometriosis
 Dysfunctional Uterine Bleeding
 Cervical Cancer
 Rupture or Injury to Uterus
 Uterine Prolapse
 Uterine Cancer
 Ovarian Cancer
Types Of Hysterectomy:
 Total Hysterectomy
 Partial Hysterectomy
 Radical Hysterectomy

1. Total hysterectomy:
 It is the surgical removal of the uterus and the cervix, which is the lower
"neck" of the uterus that opens into the vagina.
 A Total Hysterectomy is necessary when the cervix needs to be removed.
 For example: In case of Cervical cancer.

2. Partial hysterectomy:
In Partial Hysterectomy (also known as Supracervical or subtotal hysterectomy),
the uterus is removed, but cervix is not removed.

3. Radical hysterectomy:
 It is the removal of uterus, cervix, ovaries, structures that support the
uterus, and sometimes the lymph nodes.
 A radical hysterectomy may be done to treat endometriosis or cancer of the
uterus, ovaries, or cervix.
Total hysterectomy with bilateral salpingo- oophorectomy:
 A total hysterectomy with bilateral salpingo- oophorectomy is a hysterectomy
that involves removal of:
o Fallopian tubes (salpingectomy) and
o Ovaries (oophorectomy)
 Ovaries should be removed if there's a significant risk of ovarian cancer.
 EG: Total hysterectomy, subtotal hysterectomy, hysterectomy plus bilateral
salphingo-oopherectomy

Types According to Route:

1. Vaginal
2. Abdominal
3. Laproscopic

Vaginal Hysterectomy
 During a vaginal hysterectomy, the uterus and cervix are removed through an
incision made in the top of vagina.
 Surgical instruments are inserted into the vagina to detach the uterus from
ligaments.
 A vaginal hysterectomy can be done:
 To remove small uterine fibroids.
 When the uterus is of normal size.
 A vaginal hysterectomy is usually preferred over an abdominal hysterectomy,
because it is less invasive and the recovery time also tends to be quicker.

Abdominal hysterectomy
 During an abdominal hysterectomy, an incision will be made in the
abdomen. It will either be horizontally or vertically.
 An abdominal hysterectomy may be recommended when:
 Uterus is very large.
 Uterine fibroids are larger than 20 cm (across or located around blood
vessels).
 Cancer of the uterus, ovaries, or cervix.
 An ovarian growth (mass).
 Endometriosis.
Laparoscopic hysterectomy
Nowadays, a laparoscopic hysterectomy is the preferred treatment method for
removing the organs and surrounding tissues of the reproductive system.
A. Laparoscopically assisted vaginal hysterectomy (LAVH)
B. Laparoscopic supracervical hysterectomy (LSH)
C. Total laparoscopic hysterectomy (TLH)
A. Laparoscopically-assisted Vaginal Hysterectomy (LAVH)
 During the procedure, lighted tube and scope (laparoscope) and surgical
instruments inserted through a vaginal incision and one or more small abdominal
incisions.
 The ovaries and other organs may removed.
 The uterus is removed through the vagina.
 It is done when:
 Uterine fibroids are small to moderate in size.
 Uterus is slightly larger than normal.
 Endometriosis.
B. Supracervical Hysterectomy (LSH)
 Laparoscopic supracervical hysterectomy is done by inserting a laparoscope and
surgical instruments through several small abdominal incisions.
 The uterus is removed in small pieces through one of the incisions and the cervix
is left intact.
 This is also known as subtotal or partial hysterectomy .
 This type of procedure usually causes minimal blood loss and pain. LSH can be
done:
o To remove uterine fibroids of any size.
o To remove a uterus of any size.
C. Total Laparoscopic Hysterectomy (TLH) 
 The total laparoscopic hysterectomy is done by inserting a laparoscope and
surgical instruments through several small incisions in the abdomen.
 The uterus and the cervix are removed in small pieces through one of the
incisions.
 TLH can be done when:
o To remove uterine fibroids, which are small to moderate in size.
o There is no chance of uterine or ovarian cancer.
Complications Of Hysterectomy
  Sepsis
 Shock
 Trauma to adjacent organs: Ureters / Bladder or Bowel
 Urine Retention
 Cystitis
 Vaginal wall Prolapse
 Hemorrhage
 Weakening of Pelvic muscles
 Osteoporosis
 Chances of CVS increases

MENSTURAL IRREGULARITIES
 Menstruation is the visible manifestation of cyclic physiologic uterine bleeding
due to shedding of the endometrium following invisible interplay of hormones
mainly through hypo thalamo - pituitary- ovarian axis.
 The development and maturation of a follicle, ovulation and formation of
corpus luteum and its degeneration constitute an ovarian cycle. All these events
occur within 4 weeks. The ovarian cycle consists of:
 Recruitment of groups of follicles.
 Selection of dominant follicle and its maturation.
 Ovulation
 Corpus luteum formation
 Demise of corpus luteum.
 MENSTRUAL IRREGULARITIES
Menstrual irregularities are common abnormalities of a woman’s menstrual cycle.
Menstrual irregularities include a variety of conditions in which menstruation is irregular,
heavy, painful, or does not occur at all.
Common types of menstrual irregularities include:
 Amenorrhea [ primary /secondary ]
 Dysmenorrhea
  Dysfunctional uterine bleeding.
 Oligomenorrhea
 Polymenorrhea
 Spotting
 Menorrhagia
 Metorrhagia
AMENORRHOEA
 Amenorrhoea means absence of menstruation.
 It is not a symptom and not a disease.
 5 basic factors involved in the onset and continuation of normal menstruation.
These are: 1. Normal female chromosomal pattern(46XX).
2. Co- ordinate hypothalamo-pituitary ovarian axis.
3. Anatomical presence and patency of the outflow tract.
4. Responsive endometrium.
5. Active support of thyroid and adrenal
 CLINICAL TYPES
Physiological amenorrhea
 Primary (before puberty)
 Secondary -during pregnancy,-during lactation,-following menopause.
Pathological amenorrhea
 Concealed (cryptomenorrhoea)
 Congenital
 acquired
 real (true)
 primary
 secondary
PRIMARY AMENORRHOEA
A young girl who has not yet menstruated by her 16 years of age is giving primary
amenorrhoea rather than delayed menarche. The normal upper age limit for menarche
is 15 years.
CAUSES:
 Hypogonadotrophic hypogonadism
 Hypergonadotrophic hypogonadism
 Abnormal chromosomal pattern
 Developmental defect of genital tract
 Metabolic disorders
 Systemic illness[ Malnutrition, anemia,Weight loss ,Tuberculosis ]
 Unresponsive endometrium
SPECIAL INVESTIGATIONS OF PRIMARY AMENORRHOEA
Mullerian agenesis USG,Laproscopy, Karyotype
Unresponsive endometrium : Progesterone challenge test,HSG/ Hysteroscopy,
Hormonal studies
Tubercular : X ray- chest, Mantaoux test, Endometrial biopsy
Hypogonadotrophic gonadism: Progesterone challenge test,Serum gonadotrophins,
Serum oestradiol
Primary ovarian failure :Ovarian biopsy
Tumor: Laproscopy Serum gonadotrophins  Karyotype
Thyroid dysfunction (hypo)  Serum TSH  T3, T4
Diabetes:  RBS
MANAGEMENT OF PRIMARY AMENORRHOA
In primary amenorrhea:
 correct the underlying cause
 estrogen replacement therapy
 if pituitary tumor: treatment with surgical resection, radiation and drug therapy
 surgery to correct abnormalities of genital tract

SECONDRY AMENORRHOEA
Absence of menses for 3 cycles or 6 months in women who have previously
menstruated regularly. Causes:
 Breast feeding
 Emotional stress
 Mal nutrition, tuberculosis
 Pregnancy
 PCOS Premature ovarian failure
 Pituitary, ovarian, or adrenal tumour
 Depression
 Hyper thyroid or hypothyroid
 Diabetes
 Hyper prolactinemia
 Rapid wt gain or loss related to amenorrhoea
 Kallmann syndrome
 post pill amenorrhoea
 Chemotherapy or radiotherapy
 Aneroxia nervosa
 Hypothalamic dysfunction- stress, exercise, rapid wt. gain or loss.
 Kidney failure
 Tranquilizers or antidepressant , anti hypertensives
 Post partum pituitary necrosis
 Early menopause
MANAGEMENT
Detailed history:
 Mode of onset- whether sudden or gradual preceded by hypomenorrhoea or
oligomenorrhoea. Sudden changes in envt., emotional, stress, psychogenic
shock, eating disorders etc
 Sudden loss or gain weight
 Intake of psychotrophic or anti hypertensive drugs .
 Intake of oral pills or its recent withdrawl. h/o recent chemo or radiotherapy
 Appearance of abnormal manifestations either by coinciding or preceeding
the amenorrhoea. Acne, hirsutism or change in voice.
  Inappropriate lactation galactorrhoea.( abnormal secretion of milk unrelated
to pregnancy and lactation.
 Headache and visual disturbances.
 Hot flushes and vaginal dryness
 Obstetric history- overzealous curettage leading to synechiae.
 Cessarrian section may be extended to hysterectomy of which the patient may
be unaware.
 Severe PPH, shock, infection.
 Postpartum or postabortal uterine curettage
 Prolonged lactation
 Medical history of TB., Diabetes, chronic nephritis, hypothyroid.
General examination:
 Nutritional status
 Extreme emaciation or marked obesity
 Presence of acne, hirsutism
 Discharge of milk from breasts
Abdominal examination
 Presence of striae associated with obesity may be related to Cushing syndrome.
 A mass in lower abdomen.
Pelvic examination
 Enlargement of clitoris.
 Adnexal mass suggestive of tubercular tuboovarian mass or ovarian tumour.
Tests that can be done are:
 Progesterone challenging test
 Oestrogen- progesterone challenge test
 Serum gonadotrophins
 Gn RH dynamic test.
 CT
 MRI
 X-RAY
MANAGEMENT FOR SECONDARY AMMENORRHOEA
1. NO ABNORMALITY DETECTED
 If patient is not anxious, no treatment is required. Provide assurance.
 If she is anxious provide oral contraceptive pills to be continued for
atleast 3 cycles.
 With low endogenous oestrogen : ethinyl oestradiol 0.02 mg or
conjugated equine oestragen 1.25 mg daily is to be taken for 25 days.
Medroxyprogesterone acetate 10 mg daily is added from day 16-25.
The WOMEN is anxious for fertility.
Husbands semen analysis in primary infertility and the tubal factor of the women are to
be evaluated prior to induction of ovulation using clomiphene 

2. CASES WITH DETECTABLE CAUSE

 Anxiety and stress- may be corrected by reassurance, psychotherapy.
 Improve health status
3. POLYCYSTIC OVARIAN SYNDROME (PCOS)
 First correct the biochemical parameters such as : Hyperandrogenemia,
Hyperprolactenemia ,Hyperinsulinemia ,Insulin resistance High serum
oestradiol,Low FSH, Low serum progesterone androgenic follicular
microenvironment,Weight reduction
If fertility not desired
 Management of hyperandrogenemia
 Combined oral contraceptive pills
 Antiandrogens such as cyproterone acetate, flutamide may be given.
 Metformin may be given as an oral insulin sensitizing agent.
 Endometrial biopsy can be done in case of endometrial hyperplasia.
 If premature ovarian failure- HRT can be given )
 Thyroxine ---- of hypothyroid state.
 SURGERY
Laproscopic ovarian drilling (LOD)
 Bariatric surgery in case of PCOS who are morbidly obese
DYSMENORRHOEA
 painful menses or cramping during menstruation of sufficient magnitude
so as to incapacitate day to day activities.
 Typically dysmenorrhoea begins upto 48 hours before the onset of
menses and resolves within 2 to 4 days of onset or by the end of
menses
TYPES OF DYSMENORRHOEA
 Primary dysmenorrhoea (spasmodic)
 Secondary dysmenorrhoea (congestive)
PRIMARY DYSMENORRHOEA ( spasmodic)
It is painful menses with a uterine cause, but without pelvic pathology and usually
occurs within 1-3 years of menarche.
Cause:
 Painful uterine contractions stimulated by prostaglandin produced by the
endometrium during menses
Symptoms
 Sharp, intermittent suprapubic pain radiating to the back or thigh.
 Headache, fatigue, backache, flushing, dizziness and syncope.
 Adolescents typically experience the problem only after menstrual cycles become
ovulatory.
 Women often experience reduction in dysmenorrhoea after pregnancy.
THERAPEUTIC INTERVENTIONS
 Nonsteriodal anti inflammatory drugs (NSAID) started 1-3 days prior to the
onset of menstrual flow (to decrease prostaglandin production).
 Oral contraceptives, to decrease endometrial proliferation and therefore
production of prostaglandin. Surgery:
 Transcutaneous electrical nerve stimulation (TENS)
 Laproscopic uterine nerve ablation(LUNA).
 Dilatation of cervical canal.
  Presacral neurotomy (LPSN).

SECONDARY DYSMENORRHOA (congestive) :Secondary dysmenorrhoea is painful

menses resulting from a pathologic process.
Cause:
 pressure from outside the uterus
 tissue ischemia
 cervical stenosis
 congenital abnormality (imperfotate hymen)
 endometriosis
 ovarian cysts
 pelvic inflammatory disease (PID)
 uterine fibroid tumous.
 IUCD in utero and pelvic congestion.
 Obstruction due to mullerian malformation.
clinical features:
 The pain is dull, situated in the back and in front without any radiation.
 It usually appears 3-5 days prior to the period and relieves with the start of
bleeding.
 The onset and duration depends on the pathology producing the pain.
 There is no systemic discomfort unlike primary dysmenorrhoea.
 Other symptoms may be breast tenderness and change in bowel habits.

Diagnostic evaluation:
 Laproscopy
 Hysteroscopy/laparotomy
TREATMENT
 The treatment aims at the cause rather than the symptom. The type of treatment
depends on the severity, age and parity of the patient.
 OVARIAN DYSMENORRHOEA (RIGHT OVARIAN VEIN SYNDROME) Right
ovarian vein crosses the ureter at right angle. During premenstrual period, due to
pelvic congestion or increased blood flow, there may be marked engorgement in the
vein –pressure on ureter- stasis- infection- pyelonephritis- pain.
 MITTELSCHMERZ’S SYNDROME (ovular pain)
 Ovular pain is not an infrequent complaint.
 It appears in the mid menstrual period.
 The pain usually situated in the hypogastric or in either iliac fossa.
 The pain is usually located at one side and does not change from side to
side according to which ovary is ovulating.
 Nausea or vomiting is conspicuously absent.
 It rarely lasts for 12 hours.
 It may be associated with slight vaginal bleeding or excessive mucoid
vaginal discharge.
Cause:
 The exact cause is unknown.
 Increased tension of graffian follicle just prior to rupture
 Peritoneal irritation by the follicular fluid following ovulation
 Contraction of the tubes and uterus.
Treatment:
 Provide assurance
 analgesics
 in obstetrics cases, the cure is absolute by making the cycle anovular with
contraceptive pills.
PELVIC CONGESTION SYNDROME There is disturbance in the autonomic nervous
system which may lead to gross vascular congestion with pelvic varicosities. The
patient may be congestive type of dysmenorrhoea without any demonstrable pelvic
pathology.
Symptoms:
 Backache
  Pelvic pain on long standing, dyspareunia
 Menorrhagia or epimenorrhoea
 Uterus may be bulky and boggy.
 Diagnosis:
Pelvic venography
Doppler scan
CT/ MRI
Angiography
 ABNORMAL UTERINE BLEEDING
 Menorrhagia
 Polymenorrhoea
 Metrorrhagia
 Oligomenorrhoea
 Hypomenorrhoea
 Dysfunctional uterine bleeding
 MENORRHAGIA
Menorrhagia is defined as the cyclic bleeding at normal intervals; the bleeding is
either excessive in amount (> 80ml) or duration (>7 days) or both. The term
menotaxis is often used to denote prolonged bleeding.
CAUSES:
Menorrhagia is a symptom of some underlying pathology-organic or functional
 Cause:
Organic Functional
Pelvic: Disturbed hypothalamo-pituitary
Fibroid uterus ovarian- endometrial axsis.
Adenomosis
Pelvic endometriosis
IUCD in utero
Chronic tubo- ovarian mass
Tubercular endometriotis (early
 cases) Retroverted uterus – due to
congestion Granulose cell tumour of
the ovary.
Systemic
Endocrinal
Hematological
Emotional upset
Others causes DUB,Fibroid,
adenomyosis

Diagnosis
 Long duration of flow.
 Passage of big clots
 Use of increased number of thick sanitary pads
 Pallor and low level of hemoglobin
TREATMENT: The definitive treatment is appropriate to the cause for menorrhagia.
POLYMENORRHOEA (epimenorrhoea)
 Polymenorrhoea is defined as cyclic bleeding where the cycle is reduced to an
arbitrary limit of less than 21 days and remains constant at that frequency.
 If the frequent cycle is associated with excessive and or prolonged bleeding, it is
called epimenorrhoea.
 Causes:
 Dysfunctional uterine.
 It is seen predominantly during adolescence, preceding menopause and
following delivery and abortion.
 Hyperstimulation of the ovary by the pituitary hormones may be a responsible
factor.
 Ovarian hyperemia- as in PID or ovarian endometritis.

Treatment:
  Persistent dysfunctional type is treated by hormone as in dysfunctional uterine
bleeding.

 METRORRHAGIA
 Metorrhagia is defined as irregular acyclic bleeding from the uterus.
 Amount of bleeding is variable.
 While metorrhagia strictly concerns uterine bleeding but in clinical practice,
the bleeding from any part of the genital tract is included under the healing.
 The irregular bleeding in the form of contact bleeding or intermittent
bleeding is an otherwise normal cycle is also indicated in metorrhagia.
MENOMETORRGIA:
Is the term applied when the bleeding is so irregular and excessive that the menses
cannot be identified at all.
Causes of acyclic bleeding:
 DUB- usually during adolescence following childbirth and abortion and preceding
menopause.
 Submucosal fibroid
 Uterine polyp
 Carcinoma cervix and endometrial carcinoma.
Causes of contact bleeding:
 Ca cervix
 Mucous polyp of cervix
 Vascular ectopy of the cervix specially during pregnancy, pill use cervix.
 Infections- chlamydial or tubercular cervicitis.
 Cervical endometritis.
Causes of intermenstrual bleeding
 contact bleeding
 Urethral carnucle
 Ovular bleeding
 Breakthrough bleeding in pill use
  IUCD in utero
 Decubitis ulcer
Treatment:
 Treatment is directed to the underlying pathology. Malignancy is to be excluded
prior to any definitive treatment.
OLIGOMENORRHOEA
Menstrual bleeding occurring more than 35 days apart and which remains constant at
that frequency is called oligomenorrhoea.

Causes:
 Age related- during adolescence and preceding menopause.
 Weight related- obesity
 Stress and exercise related
 Endocrine disorders- PCOS
 Androgen producing tumours- ovarion, adrenal
 Tubercular endometritis

HYPOMENORRHOEA
When the menstrual bleeding is unduly scanty and lasts for less than 2 days, it is called
hypomenorrhoea.
Causes:
Local ( uterine synchiae or endometrial tuberculosis)
Endocrinal ( use of oral contraceptives, thyroid dysfunction and premenopausal periods)

DYSFUNCTIONAL UTERINE BLEEDING (DUB)

 DUB is defined as a state of abnormal uterine bleeding without any clinically
detectable organic, systemic and iatrogenic cause. (pelvic pathology eg- tumour,
inflammation or pregnancy is excluded.)
  Currently DUB is defined as a state of abnormal uterine bleeding following
anovulation due to dysfunction of hypothalamo- pituitary- ovarian axis.
(endocrine origin).
 Heavy menstrual bleeding (HMB) is defined as a bleeding that interferes with
woman’s physical, emotional, social and maternal quality of life.
 PATHOPHYSIOLOGY
The physiological mechanism of haemostasis in normal menstruation are:
 Platelet adhesion formation
 Formation of platelet plug with fibrin to seal the bleeding vessels.
 Locasied vaso constriction.
 Regeneration of vaso constriction.
 Regeneration of endometrium.
 Biochemical mechanisms involved are: inc. endometrial ratio of PGF2 alpha/
PGE2.
 PGF2alpha causes vasoconstriction and reduces bleeding.
 Progesterone increases the level of PGF2 alpha from arachidonic acid.
 Levels of endothelin which is a powerful vasoconstrictor is also increased.
 In anovulatory DUB there is decreased synthesis of PGF2 alpha and the ratio
of PGF2 alpha/ PGE2 is low.
The abnormal bleeding may be associated with or without ovulation and
accordingly gouped into:
 Ovular bleeding: Polymenorrhoea/ polymenorrhagia/Oligomenorrhoea/Functional
menorrhagia
 Anovular bleeding includes: Menorrhagia /Cystic glandular hyperplasia.

INVESTIGATION
 Blood investigations including T3, T4, TSH  USG & color Doppler
 TVS
 Saline infusion sonography (SIS)
 Hysteroscopy
  Endometrial sampling
 Laproscopy
 Diagnostic uterine curettage (D & C)

 COMMON CAUSE OF ABNORMAL VAGINAL BLEEDING

Organic: Non menstrual bleeding Hematological and endocrine:
Uterine fibroid Foreign body Urethral Platelet deficiency
Endometriosis carnucles Genital malignancy Leukemia
Adenomyosis Postcoital Intermenstrual ITP
Endometrial polyps Abortion Breakthrough Von willebrand disease
IUCD bleeding Thyroid dysfunction
Adnexal pathology

 MEDICAL MANAGEMENT
HORMONES:
With the introduction of hormones , potent oral active progestins, they became the
mainstay in the management of DUB in all age groups and practically replaced the
isolated use of oestrogens and androgens. Eg medroxyprogesterone acetate,
norethisterone acetate etc.
Progestins : involves prostaglandin synthetase inhibitors (PSI) eg; fenamates
( mefenamic acid)
The preparation are used:
 Cyclic therapy
 Continuous therapy.
To stop bleeding and regulate the cycle:  Norethisterone preparations (5mg tab )
are used thrice daily till bleeding stops which it usually does by 3-7 days.
a. cyclic therapy: 
5th- 25th day course:
In ovular bleeding----- any low dose combined oral pills are effective when given from
5-25th day of cycle for 3 consecutive cycles. It causes endometrial atrophy.normal
menstruation is expected to resume with restoration of normally functioning pituitary
ovarian endometrial axis.
In anovular bleeding--- cyclic progesterone preparation medroxyprogesterone acetate
(MPA)10 MG r norethisterone 5mg is used from 5th- 25th day of cycle for 3 cycles.
15-25th day course:
 In ovular bleeding where patient wants pregnancy or in cases of irregular
shedding or irregular ripening of the endometrium.dydrogesterone 1 tab
(10 mg) daily bd from 15-25th day may cure the state. It does not
suppress the ovulation.

 Anovulatory women have immaturity of H-P-O axis. They are ideal for the
use of short term cyclic therapy until the maturity of the positive feedback
system is established.
b. Continuous progestins:
Medroxyprogesterone acetate 10 mg tds daily is given and treatment is usually
continued for atleast 90 days. Inj DMPA i/m can be given
 Oestrogen
 Intrauterine progestogen
 Danazol
 Mifepristone (RU 486)
 GnRH agonists
NON HORMONAL MANAGEMENT
Anti fibrinolytic agents (tranexamic acid)
Prostaglandin synthetase inhibitors
NSAIDS
Desmopressin
SURGICAL MANAGEMENT
Uterine curettage
Endometrial ablation/ resection
Laser
Roller ball
 Thermal balloon
Microwave
novasure
resection
transcervical resection (TCRE)
uterine artery embolisation
hysterectomy
COMPLICATIONS
 Infections
 Uterine perforations (<1%)
 Fluid absorption may occur during hysteroscopic procedures.
 
DISEASE OF GENITAL TRACT

Genital infections

Genital prolapse

Genital injuries

Vaginitis : Infection of vagina,common gynecologic problem women of all age groups.

Symptoms Etiology Diagnosis

• Vaginal • Fungus • Measurement of the

discharge /most (Candidiasis) 25% vaginal pH
common
• Protozoan • KOH test
• Dyspareunia (Trichomoniasis)
• Examination of the vaginal
25%
• Dysuria secretion under the
• Bacterial infection microscope
• Odor
(Bacterial
• Vulvar burning vaginosis) 50% 

• Pruritus
Treatment of vaginitis

• Metronidazole (in tablet, cream, or

gel form) or Clindamycin (in cream
or gel form) to treat a bacterial
infection

• Antifungal creams
or suppositories to treat a yeast
infection.

• Metronidazole or tinidazole tablets

to treat trichomoniasis

• Estrogen creams or tablets to help

treat severe vaginal dryness and
irritation associated with atrophic
vaginitis

Prevention

• Avoid using scented period products, including tampons, pads, and liners.

• Avoid douching, vaginal deodorants, and any scented sprays or perfumes on or

in the vagina.

• Bathe in plain water only, since bubble bath and scented body washes can affect
vaginal pH.

• Wear cotton underwear, or underwear with a cotton crotch, to help improve

airflow and prevent vaginal irritation and inflammation. Change underwear at
least once each day, or after exercising.
• Stick to tights, leggings, pantyhose, and workout bottoms that have a cotton
crotch.

• Change out of swimsuits and damp workout gear as soon as possible to help
prevent excess moisture.

• Switch to an unscented detergent, or one designed for sensitive skin, and skip
the perfumed fabric softener.

• Using condoms during sex can also help lower the chances of developing a
vaginal infection, even though vaginal infections aren’t considered STIs.

Cervicitis : Cervicitis is an irritation or infection of the cervix, Cervicitis can be either

acute, meaning symptoms start suddenly and are severe, or chronic, lasting over a
period of months or longer. 

Causes Symptoms

Cervicitis is most often • Purulent discharge

caused by an infection that
• Pelvic pain
is caught during sexual
activity. • Bleeding between
periods or after
Sexually transmitted
sexual intercourse
infections (STIs) that can
cause cervicitis include . • Urinary problems

• Chlamydia • Complications

• Gonorrhea • Severe pain

• Herpes virus • Blood clots

• Human • Bleeding

papilloma • Fistula
virus
• Vaginal discharge
Prevention

Cervical cancer risks can be prevented by:

• Getting vaccinated against HPV ( Human papilloma virus ) from age 9 to 26.
Vaccine is effective if administered before they turn sexually active .

• Regular pap smear tests to detect the cancerous conditions of the cervix after 35
years

• Safe sexual practices such as using condoms

• Avoid smoking

 Endometritis  Endometritis is inflammation of the inner lining of the uterus

(endometrium).

Causes

The exact cause of endometriosis is not known. The commonly associated causes are:

• Retrograde menstruation: Normally, the menstrual blood flows from uterus

through cervix and vagina. In retrograde menstruation, menstrual blood flows
back through the fallopian tubes and into the pelvic cavity

• Hormonal imbalance in the body

• Surgical scars: from surgeries such as a Caesarean (C-section) or hysterectomy

• Immune system problems

• Genetics

Symptoms

• fever

• lower abdominal pain, and abnormal vaginal bleeding or discharge.

• It is the most common cause of infection after childbirth.

 • It is also part of spectrum of diseases that make up pelvic inflammatory disease.

Diagnosis

• Blood testing: A complete blood count, or CBC, can be used to monitor for
possible infection or assess inflammatory conditions.

• Cervical cultures :The doctor may take a swab from the cervix to look for
chlamydia, gonorrhea, or other bacteria.

• Wet mount Discharge from the cervix may be collected and looked at under a
microscope. This can help to identify other causes of an infection or
inflammation.

• Endometrial biopsy : This is a brief procedure performed in the doctor’s office,

where the cervix is dilated to allow a small instrument into the uterus. The
instrument takes a small sample of the endometrial lining, which is then sent to
the lab for analysis.

• Laparoscopy or hysteroscopy: These surgical procedures allow the doctor to look

directly at the uterus.

Treatment

• Antibiotics :- If the infection is very severe, a person may need intravenous

antibiotics in the hospital.

• Further tests:- Cervical cultures or an endometrial biopsy to ensure that the

infection is completely gone after finishing the course of antibiotics. If not, a
different antibiotic may be needed.

• Removing tissue:- If there is any tissue left in the uterus after childbirth or a
miscarriage, the surgeon may need to remove it.

• Treating any abscesses:- If an abscess forms in the abdomen from the infection,
surgery or a needle aspiration will be needed to remove the infected fluid or pus.

• If the infection is sexually transmitted, a woman’s sexual partner may need to be

treated also.
Complications

• Endometritis, if it is left untreated, may cause the following complications:

• infertility

• pelvic peritonitis (general pelvic infection)

• abscess in the pelvis or uterus

• septicemia (bacteria in the bloodstream)

• septic shock

Outlook

• The outlook for a woman with endometritis is very good, especially if she is
treated with antibiotics.

• collection of pus in the uterine cavity is called pyometra .

• occlusion of the cervical.

• enough sources of pus formation inside the uterine cavity .

• presence of low grade infection .

CAUSE

• Obstetrical

• endocervical carcinoma

• Infected hematometra

• Tubercular endometritis

Symptoms

• Purulent discharge per vaginam

• Abdomenal pain

• Fever
 • Bodyache

• Treatment

• Pyometra is drained by simple dilatation of the cervix.

• Hysterectomy

Salpingitis

• Salpingitis is a type of pelvic inflammatory disease (PID).

• PID refers to an infection of the reproductive organs.

• It develops when harmful bacteria enter the reproductive tract.

• Salpingitis and other forms of PID usually result from sexually transmitted
infections (STIs) that involve bacteria, such as chlamydia or gonorrhea.

• Salpingitis causes inflammation of the fallopian tubes. Inflammation can spread

easily from one tube to the other, so both tubes may become affected.

Causes

• have had an STI

• have unprotected sex

• have multiple sexual partners

• have one partner who has multiple sexual partners

Symptoms

• foul-smelling vaginal discharge

• yellow vaginal discharge

• pain during ovulation, menstruation, or sex

• spotting between periods

• dull lower back pain

 • abdominal pain

• Nausea

• vomiting

• fever

• frequent urination

• Oral or intravenous antibiotics

• Clear the bacterial infection. The sexual partners will also require antibiotics.

• Encourage them to get tested for STIs.

• Laparoscopic surgery

Oophoritis

• Oophoritis is an inflammation of the ovaries.

• It is often seen in combination with salpingitis.

• It may develop in response to infection.

Symptoms

• pain in the lower abdomen and pelvis

• menstrual bleeding that’s heavier than usual

• bleeding between menstrual cycles

• pain or bleeding during intercourse

• heavy vaginal discharge, which may have a foul odor

• burning sensations or pain during urination

• difficulty urinating

Causes

• The partner is having STDs

 • Insertion IUD without following sterilization and also lack of personal hygiene
cause the possibilities infectious agent’s entrance.

• Douching also promotes the infection of the uterus and gradually spread to
the fallopian tubes and ovaries.

• Infections of the cervix also lead to tubo-ovarian abscess formation.

Treatment

• Antibiotics

• Drain infected abscesses.

• Surgery may also be used to remove blockages or pelvic adhesions

• Hormone replacement therapy

• Analgesic

Parametritis

•  Parametritis, is an inflammation of the parametrium.

• It is considered a form of pelvic inflammatory disease.

• It is a type of a Puerperal infection or postpartum infection, which is an infection

that occurs when bacteria infect the uterus and surrounding areas after a woman
gives birth.

• It's also known as a postpartum infection.

Causes

• Abortions

• Inflammation of neighboring organs (rectum, appendix, etc.).

• The causative agents in this case penetrate the peritoneal tissue, usually by a
lymphogenous route.

SYMPTOM
 • Pain in the lower abdomen, radiating to the sacrum and waist.

• Parametritis always accompanied by fever, sometimes with chills.

• Depending on localization and distribution process disturbed activity of adjacent

organs.

• Redness, increased blood and lymphatic vessels, edema

Treatment

• In the acute stage of the disease used antibiotics and sulfa drugs.

• Antibiotic according to the result of pus culture and sensitivity results.

• Sulfa drugs should be combined with antibiotics.

• Need peace, strict bed rest, ice on his stomach, care bowel enema, light saline
laxatives), pain - narcotic and antispasmodic.

PELVIC ABSCESS

• A tender mass filled with pus caused due to infection. The abscesses can
develop in any part of the body. They are usually red, warm and painful.

• Most common causes are bacterial infection.

• Warmth or redness in the area, fever, and chills are the common symptoms.

• Treatment depends on the type of abscess.

• Surgery may be necessary, and the type of surgery depends on the location of
the abscess.

• A smooth swelling under the skin that may feel hard or firm

• Pain and tenderness in the affected area

• Warmth and redness in the affected area

• A visible build-up of white or yellow pus under the skin in the affected area

• A high body temperature (fever)

 Signs and symptoms of an internal abscess are:

• Discomfort in the area of the abscess

• Fever

• Increased sweating

• Feeling sick

• Vomiting

• Chills

• Pain or swelling in the tummy (abdomen)

• Loss of appetite and weight Loss

• Extreme tiredness (fatigue)

MANAGEMENT

Treatment depends on the type of abscess.

Surgery may be necessary, and the type of surgery depends on the location of the
abscess.

• Medication :-

• Antibiotics: For bacterial infections.

• Flucloxacillin · Clindamycin · Cephalosporins

• Medical procedures: Drainage