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GENITAL INFECTIONS

BASIC MECHANISM OF VAGINAL DEFENCE

• ACIDIC VAGINAL SECRETIONS are due to

o Estrogen
o Lactobacillus (normal vaginal flora) – aka DODERLEIN BACILLUS
• Due to action of estrogen, vaginal epithelial cells contain glycogen, and lactobacillus
uses this glycogen and release LACTIC ACID → this makes the secretions acidic.
• Normal pH of vagina
o In reproductive age group → 3.5 – 4.5 (acidic)
o Prepubertal age group → 6 – 8
o At the time of menses →6 – 8
o After menopause → 6 – 8
o Newborn female → 4 – 5 (slightly acidic bcz of effects of maternal
estrogens in the circulation)

Ques – when is the vaginal defence lost in the child? OR

when does the DORDELEIN’s bacilli disappear in a newborn ?
Ans → 10 - 14 days after birth

V A G I NI T I S

o Bacterial vaginosis
o Candidiais
o Trichomoniasis

BACTERIAL VAGINOSIS

• It is not an infection (just alteration of the flora)

• IT IS NOT A STD (SEXUALLY TRANSMITTED DISEASE)
• Alteration in the micro flora → lactobacillus (gram positive) is replaced with other
gram negative rods , most importantly = GARDENELLA VAGINALIS
• Other gram negative rods are = mycoplasma , ureaplamsa
• So now acidic pH cannot be maintained → pH becomes alkaline = > 4.5

PREDISPOSING FACTORS

• Anything that causes repeated alkalinisation of vagina

o Repeated Intercourse
o Repeated Douching

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CLINICAL FEATURES

• Milky white or grey vaginal discharge

• Very foul smelling
• Discharge sticks to the vaginal walls
• NO pruritis
• NO dysuria
• pH of the discharge = >4.5

INVESTIGATIONS

• IOC ➔Wet smear / Saline microscopy

o CLUE CELLS ARE SEEN (they are vaginal epithelial cells which are studded
with gram negative rods → gave them the appearance of fuzzy borders )
• PAP stain
o Here also, CLUE cells are seen.
• WHIFF TEST
o Take the discharge and add 10% KOH →very foul ammonia like odour occur
• THERE ARE NO LEUCOCYTES IN THE DISCHARGE (bcz it is not an infection)

AMSEL’S CRITERIA (if 3/4

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positive → diagnosis is BV)

• Foul smelling grey white discharge

• pH >4.5
• clue cells are +nt
• whiff test +ve

GOLD STANDARD FOR BV:- GRAM STAINING

NUGENT SCORING

o on gram staining, we count the number of gram –ve rods V/S the number of
gram +ve rods
o if the score is 7 -10 ➔ then the diagnosis is surely BACTERIAL
VAGINOSIS.

TREATMENT

• DOC – metronidazole 500mg BD for 7 days

• Other drug – clindamycin orally
• Vaginal pessaries, tablets , gels of same drug are also available
• DOC FOR BV IN PREGNANCY – metronidazole (vaginal route)

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BACTERIAL VAGINOSIS IN PREGNANCY

• Linked with –
o Preterm labor
o Preterm rupture of membrane
o Chorioamnionitis
o Endometritis
• Treat BV in pregnancy only if symptomatic.
• Do not treat if asymptomatic.
• So there is no routine screening for BV in pregnancy.
• DOC FOR BV IN PREGNANCY – metronidazole (vaginal route)

CANDIDIASIS

• MC species – C.albicans
• Predisposing factors
o Immunocompromised
o Pregnancy (MC VAGINTIS IN PREGNANCY = VAGINAL CANDIDIASIS)
o Antibiotic use
o Diabetes mellitus
• MC VAGINTIS IN PREGNANCY = VAGINAL CANDIDIASIS (bcz candida can survive
and flourish in acidic medium)
• Vaginal pH in candidiasis = <4.5 (acidic)
• This is the only vaginitis that occur in acidic environment.

CLINICAL FEATURES

• Curdy white discharge aka COTTAGE CHEESE DISCHARGE.

• Intense pruritis
• SPLASH dysuria – caused by intense itching and scratching of the vulva by the
female →causes excoriations → so whenever she passes urine, it touches excoriated
vulva→ causes pain.

INVESTIGATIONS

• IOC – saline microscopy/ wet smear

o Fungal pseudo-hyphae seen

• GOLD STANDARD IX - CULTURE

TREATMENT

• Oral fluconazole = 150 mg single dose

• Other options – vaginal tablets or pessaries of clotrimazole /miconazole

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• IN PREGNANCY – VAGINAL TABLETS OF CLOTRIMAZOLE ARE PREFFERED

RECURRENT CANDIDIASIS

• >= 4 episodes of candidiasis in a year

• Rule out any predisposing factor
• T/t – longer duration of antifungals
o Oral fluconazole 150 mg every 3 days for 3 doses f/b weekly for 6 months.

CANDIDIASIS IS USUALLY NOT A STD (but it can be transmitted sexually)

TRICHOMONIAIS

• IT IS AN STD
• AGENT – T.vaginalis

CLINICAL FEATURES

• Frothy thin greenish discharge

• Intense pruritis
• Dysuria
• Vaginal pH - alkaline
• STRAWBERRY CERVIX – patchy vaginal /cervical erythema (red dots)

INVESTIGATIONS
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• Saline microscopy
o Flagellated organisms (tennis racket shape appearance )
o ALSO WBC’S ARE PRESENT IN THE DISCHARGE
• Pap smear staining
• GOLD STANDARD - CULTURE

TREATMENT

• DOC = Metronidazole
o 2 grams orally single dose OR
o 500mg BD for 7 days
• PARTNER TREATMENT IS ALSO REQUIRED IN THE TRICHOMONIAISIS (STD)

CERVICITIS

• Caused by the organisms which can lodge in the endocervix.

• 2 most important causes are – Chlamydia and Gonorrhea.
• MC cervicitis – CHLAMYDIA
• Chlamydia cervicitis is asymptomatic in 80% of cases.
• Gonorrhea cervicitis is asymptomatic in 50% of cases.
• Clinical features of cervicitis
o Discharge per vaginum

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o Dysuria (bcz both of these organisms can cause urethritis)

o Sometimes inflamed cervix can lead to postcoital bleeding.
• Per-speculum Examination
o Discharge coming out of the cervix – yellowish/purulent.
o ECTROPION / EROSION – endocervix is seen pouting out into the
ectocervix

• Next investigation to do is ➔
simple gram staining
o Vaginal epithelial cells seen colonized
by these gram –ve diplococci
➔ presumptive diagnosis is of gonococci.
o If gram stain doesn’t show any
bacteria ➔ make a presumptive diagnosis of Chlamydia.
• IOC for Chlamydia = NAAT (nucleic acid amplification test)
o Sample – endocervical swab / discharge , urine.
• IOC for Gonorrhea = gram staining
• GOLD STANDARD for Chlamydia ➔ culture in Mc Coy cell line.
• GOLD STANDARD for Gonorrhea ➔ culture in Thayer Martin medium

TREATMENT

• For Chlamydia →
o DOC is azithromycin 1gm orally single dose
o Doxycycline 100mg BD for 7 days
o Doxycycline is absolutely contraindicated in pregnancy
o So DOC in pregnancy ➔ AZITHROMYCIN
• For Gonorrhea
o DOC is injection ce ftriaxone 250mg i/m (preferable ) OR
o Tab cefixime 400mg orally single dose

PLUS (+)

o Azithromycin 1gm orally single dose (also take care of Chlamydia too)

Alternative treatment

o Azithromycin alone 2gram orally single dose

o Treatment for gonorrhea in pregnancy is also same.

SYNDROMIC APPROACH FOR VAGINAL DISCHARGE TREATMENT

• Whenever a female came with a complaint of vaginal discharge → simply began with
per-speculum examination → look for whether the discha rge is limited only to vagina
i.e. VAGINITIS or discharge is coming out of os i.e. CERVICITIS

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• For cervicitis ➔
o ceftriaxone/cefixime (for gonorrhea)
plus
o Azithromycin (for Chlam ydia).
• For vaginitis ➔
o Tab Fluconazole 150mg orally single dose (for candidiasis).
plus
o Secnidazole 2gm orally single dose (for BV and trichomoniasis)

PELVIC INFLAMMATORY DISEASE

• Infection of the upper genital tract which involves –

o Endometritis
o Slapingitis
o Oophoritis
o Pelvic peitonitis
• Ascending infection from the organisms which lodge in the endocervix.
• MC organism responsible for PID in reproductive age group ➔ Chlamydia >Gonorrhea
• MC organism responsible for PID in a virgin/young female ➔ Tuberculosis
• MC organism responsible for PID in a post -menopausal female ➔ E.Coli

CLINICAL FEATURES
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• Primary complain of chronic pelvic pain (lower abdominal pain) (not dysmenorrhea)
• Discharge per vaginum
• Fever
• Dysuria

PHYSICAL EXAMINATION

• On p/v examination
o tenderness of the upper genital tract +.
o Cervical motion tenderness present.
• On bimanual palpation
o Patient winces in pain.

PID IS MAINLY A CLINICAL DIAGNOSIS

• MINIMUM CRITERIA FOR DIAGNOSIS OF PID

o Cervical motion tenderness OR
o uterine tenderness OR
o adnexal tenderness.

ADDITIONAL TESTS /FEATURES FOR DIAGNOSIS –

• Fever
• Increase WBC count
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• Mucopurulent cervicitis
• Increase CRP
• +ve test for Chlamydia / gonorrhea.

GOLD STANDARD/DEFINITVE CRITERIA

1. Laproscopy – pus coming out of inflamed tubes

2. Endometritis seen on endometrial sampling.
3. USG showing tubo-ovarian abscess.

CONSEQUENCES OF PID

1. Chronic pelvic pain (occurs due to adhesions formed )

a. Tube gets damaged. Cilia are destroyed →Pyo-salpinx, hydro-salpinx,
agglutination of fimbriae → tubal blockage
b. Frozen pelvis (due to fibrosis/adhesions)
2. Infertility
a. Incidence of infertility increases with increasing numbers of PID episode
b. 1 episode = 12% chances
c. 2 episode = 35% chances
d. 3 episode = 75% chances
3. Adhesions on the undersurface of liver k/a FITZ-HUGH-CURTIS SYNDROME

TREATMENT

• OPD T/t
o injection ceftriaxone 250mg i/m single dose
Plus
o Doxycycline 100mg BD orally for 14 days
o +/- metronidazole 500mg BD for 7 days
o Also treat the partner
• IPD T/t
o Whom to be admitted
▪ Pregnant female with PID
▪ If she has severe symtoms
▪ Unable to take orally
▪ h/o peritonitis
o start with inj. Cefoxitin + inj. Doxycycline + inj. Metronidazole for 48 -72
hrs → then switch to oral drugs
o alternative = inj.clindamycin + inj.gentamicin

GENITAL TUBERCULOSIS

• It is always secondary
• MC primary comes from the = LUNGS > Lymph nodes
• From lungs, it comes via hematogenous route.

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• From lymph nodes of abdomen, it came via direct spread.
• Most common structure involved = fallopian tubes

GENITAL TRACT INVOLVEMENT

• Fallopian tubes are involved in around 80 -90% cases.

• There is a direct spread from tubes to the endometrium.
• Endometrium is involved in around 50 -60% cases.
• Ovaries are involved in around 15-25% cases.
• Cervix is involved in around 5-15% cases.
• Vagina is involved least.

PATHOLOGY

• Tube involvement = leads to infertility in long term.

• Endometrium involvement
o In acute cases → acute endometritis
o In chronic cases → adhesions and scarring (ASHERMAN SYNDROME)
• Ovaries involvement = tubo ovarian mass formed
• Cervix involvement = mimics cervical cancer

CLINICAL FEATURES

• MC presentation = infertility > pain > menstrual complaints

•
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What % of women with genital TB are infertile ➔ 75 %
• What % of infertility patients have genital TB ➔ 17 %
st
• What is 1 menstrual complaint ➔ menorrhagia
• MC menstrual complaint ➔ hypomenorrhea / amenorrhea

PHYSICAL FINDINGS

• Per vaginal examination ➔

o Most of the time it is normal.
o Rarely, we can find adnexal mass.

INVESTIGATIONS & DIAGNOSIS

• Findings on HSG suggestive of genital TB ➔

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Beaded tube (cobblestone appearance Pipe stem tube / horse pipe /

of the tube) – lead pipe appearance –

(Sperm head appearance or

golf club appearance) (Tobacco pouch appearance )

• For the final diagnosis of the genital TB

1. Endometrial sampling and sent it for
a. Histopathological examination – granulomas seen
b. AFB staining
c. BACTEC
2. Laparoscopy
a. Yellowish tubercles are seen – very much diagnostic
b. DRIED TREE BRANCH SIGN
c. HPE and culture done from biopsy of these tubercular deposits

❖ TREATMENT ➔ ATT

Treatment- ATT

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 FIBROID UTERUS
(Pathology, Types & Clinical Presentation)

Aka LEIOMYOMA – Benign tumor arising from the smooth muscle of the uterus

• MC tumor of female pelvis

• It is estrogen dependent so, it is mostly seen in the reproductive age group

• It Becomes symptomatic mostly at around 35 – 45 yrs of age.

• Since it is estrogen dependent, it regresses after menopause it is More common in

(Factors which increases the risk of fibroid)

• Nulliparous
• Obese women
• African American women
• +ve Family h is tory ( risk increase By 2.5 times)

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Factors decreasing the risk of fibroid –

• Parity
• Smoking (causes Breakdown of estrogen in the Body)
• OCP’ s do not increase the r is k of fibroid

GROSS APPEARANCE

• Whorled appearance on cut section.

• Pseudo- capsule +nt, formed By the surrounding compressed myometrium
• Vascularity comes from the outside center of the fibroid is least vascular part
• Any necrosis or degeneration if occur, will occur in center first.
• But any deposition ( ex- calcium) will occur on the outside first.

T Y P E S OF F I B R O I D
Remember Body of the uterus is mostly formed of smooth muscle, whereas cervix is mostly formed of
connective tissue (only 10% muscle). So, most of the fibroids arise from the Body of the uterus and cervical
fibroid can Be present but less common.

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Fibroids arising from the Body of uterus

intracavitory, sub mucous, intramural, sub serous, sub serous, pedunculated FIGO

CLASSIFICATION

All fibroids are intramural to Begin with

• Remember intramural is TYPE 4
• Touching mucosa = TYPE 3
• Touching SEROSA = TYPE 5
• Touching Both mucosa and serosa = TYPE 3-5
• Protrudes into cavity, But > 50% is still intramural = TYPE 2
• Protrudes into cavity, But ONLY < 50% is left intramural = TYPE 1
• Pedunculated intra cavitory ** = TYPE 0
• Protrudes on outside towards serosa, But > 50% is still intramural = TYPE 5
• Protrudes on the outside, But ONLY < 50% is left intramural = TYPE 6
• Pedunculated su bserous** = TYPE 7

TYPE 8 : OTHER TYPES FIBROID

Parasitic fibroid, cervical fibroid, Ligamentous fibroid (within sheets of broad ligament)

TRUE Vs FALSE Broad ligament fibroid

In false Broad ligament fibroid, ureter is pushed laterally
In true Broad ligament fibroid, ureter is medial CERVICAL FIBROID
Central cervical fibroid, DOME OF ST. PAUL APPEARANCE
These cervical fibroids can be normal Bleeding as well as pressure symptoms like urinary
frequency, retention of urine.

CLINICAL PRESENTATION
1. MC presentation = asymptomatic
2. MC symptom = abnormal uterine Bleeding (MC- cyclical menorrhagia)
a. Incidence of bleeding, sub mucous > intramural > sub serous
b. Intermenstrual Bleeding (normal cyclical Bleeding with episodes of Bleeding in Between) is
typically seen in - FIBROID POLYP.
c. Post- coital bleeding seen with - FIBROID POLYP.

Pressure symptoms
a. Huge sub serous fibroid can press rectum => CONSTIPATION
b. Huge sub serous fibroid or cervical fibroid, can press on the urethra - urethra stretched
over the fibroid - narrowing & kinking of the urethra and lead to retention of urine
c. Anterior cervical fibroid - can press urinary bladder directly, irritation of the bladder,
increase frequency of micturition

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 Infertility problems
a. Sub mucous fibroid contribute maximum to infertility
B. Sub serous fibroid do not cause infertility
c. Intramural fibroid +/-
PAIN
a. Fibroid By themselves usually do not cause pain
B. They can cause pain in following conditions –
i. Torsion occurs of a pedunculated sub serous or intracavitory fibroid
ii. Red degeneration
iii. Sarcomatous degeneration DEGENERATIONS IN FIBROID

Degenerations & Medical management

HYALINE DEGENERATION
a. MC degeneration
B. Whorled appearance of the f i Broid is lost
CYSTIC DEGENERATION
FATTY DEGENERATION
CALCAREOUS DEGENERATION
a. MC in sub serous type
B. Aka WOMB STONE
INFECTION
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a. MC in fibroid polyp coming out of the Os > su Bmucous

NECROSIS

SARCOMATOUS DEGENRATION
a. Malignant change
B. Very rare, only 0.2 - 0.5 % cases
c. When occurs, i t is mostly seen in postmenopausal women
d. If after menopause, fibroid increases in size = highly suspicious of sarcomatous change
e. Diagnosis of leiomyosarcoma
i. Made only on HPE
ii. > 10 mitotic f i gures/ 10 hpf

RED DEGENERATION (CARNEOUS DEGNERATION)

a. Mostly seen in pregnancy (when there i s rapid growth of uterus )

i. In the 2nd trimester most commonly.

B. Clinical features
i. Pain
ii. Mild fever
iii. Nausea / vomiting

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iv. Increase WBC count

c. It is an aseptic degeneration . There is no infection

d. So the treatment is only conservative
i. We have to admit the patient ( risk of preterm labor is there)
ii. Analgesics
iii. IV fluids / hydration
iv. Adequate rest.
v. No role of antibiotic s.

PREGNAN CY CO MPL ICA TIO NS OCCUR WITH FIBROID

1) Red degeneration
2) Abortion (with sub mucous fibroid)
3) IUGR
4) Preterm labor
5) Abruptio placenta
6) Mal presentation
7) At the time of labor
a. Abnormal labor
B. Mechanical restriction to descent of head
8) PPH
9) Post-partum endometritis

PHYSICAL EXAMINATION

• On P/ V examination
Uterus is enlarged – uniformly or irregularly

Firm to feel

INVESTIGATIONS

• IOC – USG ( TVS p r e f e r r e d )

o H e t e r o e c h o i c a r e a in t h e m y o m e t r i u m c l e a r l y d e m a r c a t e d .

• S A L IN E IN F U S IO N S O N O G R A P H Y ( SIS)
o Al s o k / a S O N O S A L P I N G O G R A P H Y ( S S G )
o B e t t e r f o r s uB m u c o u s a n d f i B r o i d p o l y p s

• HYSTEROSCOPY
o B e s t f o r s ubm u c o u s a n d fibr o i d p o l y p s
o it i s di a g n o s t ic a n d t h e r a p e u t i c a t t h e s a m e ti m e

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 TREATMENT
• Asymptomatic / incidentally diagnosed
• No treatment done
• Follow up after36 months

Symptomatic
• We have to treat
• DEFINITIVE TREATMENT surgery
• Depends on the age of the patient and her desire of future pregnancy

Myomectomy
• Only removes l e io myoma
• There i s a chance of recurrence around 30 %
• Fertility is preserved

Hysterectomy
• Fertility is not preserved
• No recurrence
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INDICATIONS of hysterectomy i n fibroid uterus are:
• Post- menopausal women with increase in size of fibroid
• Multiparous female > 40 yrs. of age, when severely symptomatic

MEDICAL TREATMENT
INDICATIONS
Premenopausal woman with only mild symptoms Pre- optreatment

DRUGS WHICH DECREASE BLEEDING

Tranexemic acid, Mefanemic acid, Low dose OCPs,

MIRENA (used only i f cavity is normal)

DRUGS WHICH SHRINK THE SIZE ( also decreases B leeding)

Mifepristone, Ulipristal acetate (SPRM), Danazole, Gestrinone, Aromatase inhibitors

Gn RH analogues
OTHER WAYS TO SHRINK THE SIZE OF FIBROID
Pre- op uterine artery embolization (done under fluoroscopic guidance)
Decreases the size By 40 - 50%.

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Surgical Management
MYOMECTOMY

There are various routes available

• Abdominal, Laparoscopic, Hysteroscopic,Vaginal

• If it is sub serous, intramural, or sub mucous type 2, we have to approach via abdominal or
laproscopically

In type 0 & type 1 hysteroscopic

• Hysteroscopically route has slightly increased risk of recurrence than abdominal or laparoscopy, But
still preferred.

Among abdominal or laparoscopic route, we have to consider

o Surgeons expertise
o Technical feasibility
o Instruments availability
o I f uterus very Big, then aBdominal route will be preferred

Advantages of laparoscopy

o Scar absent
o Pain is less
o Post op stay less
o Earlier ambulation

There is no difference in recurrence rate among abdominal Vs. laparoscopy.

Before myomectomy

o Pre-op correction of anemia is done.

o If> 40 yrs., rule out hyperplasia of endometrium.
o If infertile, rule out other causes of infertility (esp. Husband).
• MYOMA SCREW – helps in pulling out the myoma

WAYS TO DECREASE AMOUNT OF BLEEDING IN MYOMECTOMY

o Post the surgery in post menstrual phase / follicular phase

o Pre- op correction of anemia (minimum HB should be 10 gm/ dl)

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 Bonney’s myomectomy clamp

o Torniquets
o One is tied around the uterine artery
o Other is tied around the ovarian artery
o Intramyometrial injection of vasopressin

Controlled hypotensive anesthesia

o Pre- op uterine artery embolization

o Pre- op uses of GnRH analogues

NEWER METHODS OF TREATING FIBROID AfraTafreeh.com

Done only when family is completed and surgery cannot Be done

Uterine artery embolization

MRg FUS- MR guided Focussed Ultrasound

o MRI used for fibroid mapping

o Focused USG waves used to Burn the fibroid

ADENOMYOSIS

• Definition – condition in which endometrial glands and stroma are located deep within
the myometrium. And surrounding myom etrium undergoes hyperplasia and hypertrophy.
So there occurs diffuse enlargement of the uterus.
• Most important D/D of this is FIBROID UTERUS.

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THEORIES

• Mullerian rests in the myometrium

• Endometrium invaginates within the myometrium during the process of child birth
➔that’s why adenomyosis is more common in multiparous women.

CLINICAL FEATURES

• Heavy menstrual bleeding

• SEVERE CONGESTIVE DYSMENORRHEA (fibroid doesn’t cause pain)

GROSS SPECIMEN FINDINGS AND PHYSICAL FINDINGS –

• UTERUS
o Uniformly enlarged (in case of fibroid → irregularly enlarged)
o Globular
o Soft (fibroid have firm uterus)
o Tenderness +nt
o Enlargement is around 8 – 10 weeks’ size

INVESTIGATIONS

• USG findings suggestive of adenomyosis:

o Asymmetrical thickening of myometrium (posterior wall > anterior wall)
o Loss of Clear demarcation of endo -myometrial junction
o Intra-myometrial cysts (most specific finding among all the USG findings)
o Venetian blind appearance.
o Salt and pepper appearance.
• IOC for adenomyosis = MRI
o JUNCTIONAL ZONE –refers to the inner myometrium
o JZ THICKNESS > 12mm ➔ diagnosis is adenomyosis.
o JZ THICKNESS < 8mm ➔ adenomyosis is excluded.
o JZ THICKNESS 8 – 12mm ➔ diagnosis uncertain

❖ GOLD STANDARD ➔ definitive diagnosis of adenomyosis is made on HISTO -

PATHOLOGY OF HYSTERECTOMY SPECIMEN
o CRITERIA
▪ Endometrial gland and stroma should be located at least 2.5mm deep
to the JUNCTIONAL ZONE
OR
▪ At least 1 hpf deep to the JUNCTIONAL ZONE
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TREATMENT

• Definitive treatment is always HYSTERECTOMY;bcz these females do not respond to

medical management.
• If fertility is desirable (needed)➔ conservative treatment can be done
o MIRENA
o GnRH analogues
o Oral progestogens are usually ineffective.

ENDO M ET RI O SI S ( Pa th o p h ys io logy & Dia gno s is )

• DEFINITION – presence of functional endometrium (glands and stroma) outside the

uterus.
• MC location = ovary> pouch of Douglous> uterosacral ligament

THEORIES

1. SAMPSON’S THEORY OF RETROGRADE MENSTRUATION AND IMPLANTATION - IT

IS THE MOST ACCEPTED THEORY
2. THEORY OF COELOMIC METAPLASIA
3. HEMATOGENOUS THEORY –explain the occurrence of endometriosis in distant sites
lungs, nose etc.
4. IMMUNE MEDIATED THEORY
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5. THEORY OF DIRECT IMPLANTATION–explain the occurrence of endometriosis on
the cesarean scar site, episiotomy site.

PROBLEM WITH ENDOMETRIOSIS

• These endometrial deposits also grow under the action of the hormones and also bleed
cyclically , but there is no exit for the blood and the blood keep collecting in these
deposits →leads to PAIN.
• Many inflammatory mediators like PGs and cytokines are also released around these
deposits →leads to PAIN.
• Also the collected blood at these areas heals by fibrosis leads to scarring →also
contributes to PAIN.
• Also during intercourse, depo sits on uterosacral ligaments →also contributes to
PAIN(DYSPAREUNIA)

GENERAL POINTS –

• It is an estrogen dependent condition →regress after menopause.

• Mean age = 25 – 35 yrs.
• More common in nulliparous women.
• This condition also improves / regresses during pregnancy and lactation

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o Bcz there is increased amount of progesterone in pregnancy and progesterone

(causes decidualization of these deposits)
o During lactation ovaries are suppressed, so estrogen levels decrease.

GENETIC BASIS

• If 1st degree relatives have endometriosis –7 times increase risk

• KRAS gene mutation ➔ responsible for more aggressive endometriosis.

CLINICAL FEATURES

1. MC complaint ➔PAIN
o Congestive dysmenorrheal (pain starts few days before menses and last
throughout bleeding)
o Chronic pelvic pain
o Dyspareunia
o Low back pain
• Cause of pain –
o due to release of inflammatory
mediators from the deposits
o Deeply infiltrating deposits – irritate the nerves

❖ SEVERITY OF PAIN IS PROPORTIONAL TO DEPTH OF INVASION OF DEPOSITS.

2. INFERTILITY
a. Due to distorted anatomy.
b. Impaired folliculogenesis.
c. Toxicity to the sperms from inflammatory mediators.

❖ THERE IS NO ACTUAL BLOCKAGE OF TUBES FROM INSIDE.

3. ABDOMINAL / PELVIC MASS
a. This is due to formation of an endometrial ovarian cyst a/k/a
ENDOMETRIOMA.
b. This cyst has brown colour due to hemosiderin as its content, that’s why it is
a/k/a CHOCOLATE CYST
c. USG appearance of the endometrioma
i. GROUND GLASS APPEARANCE

INVESTIGATIONS

• IOCfor endometriosis ➔ LAPROSCOPY

o Purplish/bluish deposits → fresh deposits
o Powder burnt deposits → old deposits
o Scarring / adhesions seen
• CONFIRMATION➔ biopsy of the deposits and HPE done

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 ENDO M ET RI O SI S ( T rea tm ent )

TREATMENT

• T/t of PAIN
o Medical treatment

For mild cases = NSAIDs and combined OCPs

• OCPs work by suppressing ovaries and stop ovulation and follicular growth
• OCPs are given for continuously for 4 -6 months without stopping in between =
causes amenorrhea during this time = so no bleeding ➔ NO PAIN

For Moderate to severe pa in

• PROGESTOGENS – Stabilizes the effect of estrogens

• Orally medroxy progesterone acetate
• MIRENA (LNG containing IUD)
• DINOGEST (NEW**) – 2mg DAILY DOSE
• GnRH analogues – causes hypogonadal state
• Leuprolide(agonist) – given s.c.
• Cetrorelix (antagonist) – given s.c.
• New orally active compound recently approved – ELAGOLIX
• They cannot be used for more than 6 months bcz as estrogen becomes deficient, it
AfraTafreeh.com
leads to bone resorption = osteoporosis (estrogen promotes mineralization of bones)

Other drugs

• Aromatase inhibitors – letrozole (inhibit conversion of androgen to estrogen)

• Gestrinone –disadvantage is severe androgenic side effects
• Danazol –disadvantage is severe androgenic side effects

Surgical treatment of pain

▪ If medical treatment fails

▪ If present at certain sites → ex – bowel (don’t respond to medical T/t)
▪ Ovarian cysts

OPTIONS

• Laparoscopic route is preferred

• Fulguration of deposits done
• Adhesiolysis
• Cystectomy– done if cyst is > 4cm in size
• Drainage of cyst and fulguration – done if cyst is < 4cm in size
• Pre-sacral neurectomy
• Hysterectomy and salpingo-oophorectomy.

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 AfraTafreeh.com

• T/t of INFERTILITY
• Ovulation induction
• Ovulation induction + intra -uterine insemination
• In-vitro fertilization

Notes:

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