Gynaecology

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Anatomy

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Lymphatic drainage

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 Menstruation
• A) Normal menstrual cycle

• B) Abnormal menstrual cycle:

• i) Amenorrhoea
• ii) Dysfunctional Uterine Bleeding(DUB)

• C) Other problems related to Menstruation

• i)Dysmenorrhoea
• ii)PMS
• iii)Pelvic Congestion Syndrome
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Normal menstrual cycle

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7
• Normal menstrual cycle is 28 to 35 days
• Amount of normal blood loss is 50ml to
80ml/cycle.
• Method to check for ovulation is Day 21
progesterone assay. Normal values are > 20
nmol/L- 7 days before expected
menstruation. (Day 21 in a day 28 day cycle)

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 Amenorrhoea
• Amenorrhoea is the absence of menstruation,
either temporary or permanent.
• may occur as a normal physiological condition
• failure to start menstruation by the age of
16 years of age, or the absence of
primary secondary sexual characteristics by the age
of 14 years

• absence of menstruation for 6 months in a

previously regularly menstruating woman or
secondary for a time period of three cycles in a woman
with longer/irregular cycles.

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 Primary amenorrhoea
• Turner’s syndrome
• genotype- 45XO
• Inv- Karyotyping (best),
• high FSH & LH

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 2. TESTICULAR FEMINIZATION (Androgen
Insensitivity Syndrome)
• Genotype- 46XY
• Phenotype – Female
• Testes may be abdominally located in the
inguinal canals. Pubic and axillary hair are
absent. The labia minora tend to be juvenile
and the vagina is short and blind ending.
• Breast development occurs due to peripheral
aromatisation of testosterone to estrogen.

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 3. Congenital Adrenal Hyperplasia
• AR
• Def. of 21-hydroxylase (21-OH),
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 Imperforate hymen
• STRUCTURAL CAUSE- (of primary ameno)
• Genotype , Phenotype, Ext. Genitalia all normal.
• Age of presentation around 12-14 years of age.
Symptoms are due to imperforate hymen preventing
the menstrual blood to flow out. Therefore patient
will present with:
• Cyclical colicky abdominal pain, retention of urine,
palpable lump in lower abdomen, tense bluish
bulging membrane seen on separation of labia.
• INV- USG will show haematocolpus
• Rx- Cruciate incision of hymen .
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 Imperforate hymen
• Genotype, phenotype, ext. gentalia normal
• Presentation – age 12-14yrs
• Cyclical colicky abdominal pain, retention of
urine, palpable lump in lower abdomen, tense
bluish bulging membrane

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Inv- USG shows Hematocolpos Rx-Cruciate incision

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 Secondary amenorrhoea
• Pregnancy
physiological • Lactation
• Hormonal contraception

• PCOS

endocrinal
• Hyperprolactinemia
• Sheehan’s syndrome
• Cushing syndrome, hyper/hypothyroidism
• Premature menopause

miscellane •
•
•
Anorexia nervosa
Athletes
Stress
ous •
•
Post pill amenorrhoea
Asherman’s syndrome

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• Phenothiazines- proclorperazine,
metoclopramide, haloperidol, risperidone,
selective serotonin reuptake inhibitors,
estrogens, verapamil

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• Anorexia nervosa,Athletes, Stress- Hypothalamic pituitary ovarian axis affected.

• Anorexia nervosa- adolescent girl, BMI very low, h/o rigorous exercise, low food
intake. Parents are concerned, patient may/ may not have insight. Medical
admission needed for correction of electrolyte imbalance and diet programme.

• Post-pill amenorrhoea- when stopping OCP does not resume normal cycle, usually
settles in 3 months, otherwise investigate.

• Athlete amenorrhoea- may be due to low body weight. Triad of eating disorder,
amenorrhoea, osteoporosis, may predispose to stress fracture.

• Asherman’s syndrome: Iatrogenic. Aggressive/excessive curettage removes all

endometrial lining leading to development of adhesions between walls of the
uterus causing secondary ameno.
• INV- Hysteroscopy
• Rx- Hysteroscopic adhenolysis, followed by insertion of IUCD to prevent
recurrence, plus oestrogen for regeneration of endometrium.

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 Polycystic ovarian syndrome
Diagnosis- any 2 of the following:
• 1. polycystic ovaries (either 12 or more
follicles or increased ovarian volume [> 10
cm3 ])
• 2. oligo-ovulation or anovulation
• 3. clinical and/or biochemical signs of
hyperandrogenism
(with the exclusion of other aetiologies)
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• Other features
• Insulin resistance causing obesity, Type 2
diabetes
• high cholesterol levels
• Hyper androgenism causing acne, hair loss &
hirsutism
• Infertility

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 Investigations
1. Transvaginal scan- Polycystic ovaries seen in 70
%cases.
2. Altered FSH:LH ratio. Normally on day 3 of cycle FSH
is more than LH. In PCOS LH is >FSH (>2:1)
3. Elevated serum testosterone and Dehydro-epi-
androsterone sulphate(DHEA-S),testosterone
4. Serum Insulin levels (Raised) andGTT.
• (Investigations are suggestive but not diagnostic)

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Pearl string appearance
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 Management
• Weight reduction- restores ovulation &
menstruation
• Lowering of insulin resistance with Metformin
• Menstrual irregularity – COC and Weight loss
• For Hirsutism- Cyproterone acetate (anti
androgenic progestagin), COC, Topical
eflornithine cream for treating facial hirsutism
• For infertility- induction of ovulation with
Clomiphene citrate and FSH, finally ART.
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 Abnormal uterine bleeding

OLIGOMENORRHOEA- Irregular, POLYMENORRHOEA- Frequent

infrequent menstrual cycles.
periods with short interval.
Eg. puberty, perimenopause, PCOS.
Eg. luteal phase defect

MENORRHAGIA
Other causes:
Heavy menstrual bleeding Von Willibrand’s dz, haemophilias ,
Eg. fibroids, polyps,
Thyroiddysfunction,
endometrial hyperplasia, IUCDs , Post sterilization.
endometriosis
Eg. PID,Post abortal , post puerperal

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Menorrhagia or heavy menstrual bleeding

• Heavy menstrual bleeding (HMB) is defined as

excessive menstrual blood loss which
interferes with a woman's physical, social,
emotional and/or material quality of life. It
can occur alone or in combination with other
symptoms.

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 Investigation
• FBC
• Coagulation profile - if HMB since their periods
started and have a personal or family history
• Hysteroscopy- if symptoms such as persistent
intermenstrual bleeding or risk factors for endometrial
pathology
• Endometrial biopsy - for women who are at high risk of
endometrial pathology, to exclude endometrial cancer or
atypical hyperplasia
• Pelvic Ultrasound – for identifying structural abnormalities.

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 Management
1. LNG-IUS
2. Non-hormonal:
• tranexamic acid
• NSAIDs (non-steroidal anti-inflammatory drugs) eg. Mefenamic
acid
3. Hormonal:
• combined hormonal contraception
• cyclical oral progestogens.
4. Surgical options:
• endometrial ablation
• hysterectomy.

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PLAB FAV:
• Mefenemic acid for teenagegirl with
HMB (also fordysmenorrhea) Tranexamic acid
for single episode of HMB

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 Dysmenorrhoea
Primary Secondary
absence of any identifiable underlying with underlying pelvic pathology such as
pelvic pathology endometriosis, PID
fibroids, or endometrial polyps

Onset shortly after menarche appears after several years of painless

periods
Other gynecological symptoms areabsent. Gynaecological symptoms Present eg.
 headache, diarrhoea, nausea, and dyspareunia , vaginal discharge etc.
vomiting may be present.

Pelvic abnormality on physical

No abnormal findings on examination examination
Rx- NSAIDS first line- Ibuprofen, naproxen, Refer to a gynecologist for further
and mefenamic acid, COCPs, LNGIUS investigation after offering pain relief

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 Pre menstrual syndrome
•  symptoms between days 14 – 28 of menstrual
cycle (luteal phase) and they are severe enough
to impact on daily activity. The symptoms
should ease as soon as menstruation begins.
• Effective Symptoms- Anger , irritability,anxiety,
depression
• Somatic Symptoms-Breast tenderness,
headache, abdominal bloating

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 management
• Dx- symptom diary over 2 cycles
• 1st line- CBT, Vitamin B6 and lifestyle changes
• 1st line pharmaceutical rx- continuous
Drospirenone containing COCPs, SSRIs
• Transdermal oestrogen patch, GnRH
analogues

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 Pelvic Congestion Syndrome
Constant dull aching pain which is worse at the end of the day and after long periods of standing.

Varicose veins in lower abdomen 32

 Management
• Inv- 1st and best line- Doppler USG
• Venogram, CT scan, or an MRI or diagnostic laparoscopy
• Treatment:
1. Pain relief with NSAIDS. 
2. Suppression of ovarian function with COCP
3. Alternative therapies such as acupuncture and physical
therapy.
4. Surgical option: Stopping blood flow to the varicose
veins using noninvasive surgical techniques of pelvic
veins embolization.(80% success rate)
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 Menopause
• when menstruation ceases permanently due to the
loss of ovarian follicular activity. It occurs with the
final menstrual period and is usually diagnosed
clinically after 12 months of amenorrhea .
• Dx- clinical- Hot flushes , Sleep disturbance, mood
changes, depression, urinary and vaginal symptoms,
including vaginal discomfort and dryness,
dyspareunia, and recurrent urinary tract infections,
due to atrophic changes , osteopenia and
osteoporosis .
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 Management
• lifestyle changes such as regular exercise, avoiding
triggers for hot flushes (caffeine, nicotine and alcohol),
ensuring good sleep and hygiene.
• Ca supplement +/- Vit D
• HRT- if vasomotor symptoms present
• a trial of paroxetine, fluoxetine, citalopram, venlafaxine,
clonidine or gabapentin for hot flushes. (non-hormonal)
• vaginal oestrogen creams for vaginal dryness
• CBT for low mood ,anxiety

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 Risks of combined HRT
Mnemonic ABCDE LMP
• Allergy
• Breast Cancer
• Cigarette smoking
• DVT
• Epilepsy
• Liver problems
• Migraine
• Pills- Drug interaction
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 Risks of OESTROGEN ONLY HRT
• Endometrial and ovarian cancer. Oestrogen only HRT does
not appear to significantly increase the risk of breast cancer.
• Smokers over 35 years of age
• Uncontrolled hypertension, uncontrolled diabetes mellitus,
• Gallbladder disease requiring hospital admission
• Stroke, history of thromboembolic events. If the patient has
strong family history of thromboembolic events, test for
Factor V Leiden, Protein C, and Protein S to ensure the low
risk of developing thromboembolic events while on the
oestrogen replacement

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 Premature Menopause
• Cessation of ovarian function below 40 years
of age
• Dx-Serum FSH >40 mIU/mL or >20 IU/L on two
occasions 4 to 6 weeks apart
• Rx-HRT, IVF after egg donation, Counseling
• Aetiology- mostly idiopathic

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 Osteoporosis
• Osteoporosis is a systemic skeletal disorder that is
characterised by low bone mass with a consequent
increase in bone fragility and susceptibility to
fracture

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 Osteoporosis
Bone mineral density T-scores and osteoporosis conditions

  T-score

Normal
not less than –1 SD

Osteopenia
between –1 SD and –2.5 SD

Osteoporosis
–2.5 SD or less

Established osteoporosis
below –2.5 SD, with one or more
associated fragility fractures

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General risk factors Lifestyle factors Secondary causes of osteoporosis
The more risk factors that are present, the greater the risk.

Age current smoking Estrogen deficiency: Medical conditions

Sex alcohol intake of 3 untreated rheumatoid

or more units daily premature arthritis
menopause hyperthyroidism

low body mass sedentary lifestyle malabsorption

index (≤19 kg/m2) or conditions syndromes
associated with chronic liver disease
prolonged
immobility

previous fragility chronic obstructive

fracture, pulmonary disease,
particularly of the organ
hip, wrist and spine transplantation.

parental history of
hip fracture
current
glucocorticoid
treatment
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 Management
•  Fracture Risk Assessment (FRAX) tool
•  based on risk factor assessment and BMD
measurement is offered selectively in high-risk
individuals.
Dual energy X-ray absorptiometry (DEXA) is the
gold standard for diagnosis

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 Indications for measurement of BMD

• Estrogen deficiency (especially after

surgical or premature menopause).
• People with a fragility fracture,
vertebral deformity,
osteopenia noted on X-ray.
• People at risk of secondary
osteoporosis.
• Intermediate risk with FRAX tool.

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 Treatment for osteoperosis

• All women should receive advice on calcium

intake, lifestyle and exercise.

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 Lifestyle interventions

• A good dietary intake of calcium and vitamin D

• Exercise
• Moderate levels of activity
• Smoking cessation
• Avoidance of excessive alcohol

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 Drug treatment for osteoporosis
• First-line treatment is with alendronate (NICE Guidance 2011)
• Risedronate is used as an alternative if the woman is unable to tolerate
alendronate.
• Strontium ranelate is to be used only in severe osteoporosis as an
alternative (intolerance or unresponsive) to the above in view of cardiac
side effects.
• Raloxifene is not recommended for primary prevention of fractures in
women with osteoporosis.
• Denosumab is recommended for women who are unable to comply with,
have an intolerance of, or a contraindication to bisphosphonates.
• Calcium and vitamin D supplements
• HRT is recommended only if the woman suffers from vasomotor
symptoms also

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 Cancers

Cervical cancer Endometrial Ovarian cancer

cancer

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 Cervical cancer
• Second commonest cancer in women after breast cancer.
• CERVICAL SCREENING: NICE GUIDELINES
•  Cervical screening aims to detect early abnormalities of the cervix
(intraepithelial neoplasia), which, if untreated, could lead to cancer of the
cervix.
• Cervical screening is not a test for cancer.
• All cervical screening in the UK is done using liquid-based cytology.
• Age 25–49 years: screening every 3years.
• Age 50–64 years: screening every 5years.
• Women 65 years of age or older - out of the programme, but should have
screening if symptomatic or if last 3 pap smears were not normal.
• Urgent referral to a gynaecologist (within 2 weeks)If there are symptoms of
cervical cancer or if there are atypical endometrial cells

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 Pathology of the cervix – histology
• Cervical intraepithelial neoplasia
• CIN is a histological diagnosis. CIN1–3 represents a continuum of change
that correlates with worsening dyskaryosis (mild, moderate or severe).
Stage Description

Changes most apparent in basal

CIN1
third of epithelium ± HPV change

Changes affecting basal two-thirds

CIN2 of epithelium, more marked
nuclear atypia

More severe changes affecting the

CIN3
entire epithelium
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 CIN treatment
• CIN2 and CIN3 should be treated
Technique Definition/comment

Excisional

Removal of the transformational

Large loop excision of the transformational
zone using an electrodiathermy loop
zone – local anaesthetic

Removal of the transformational

Laser cone zone using the laser as a 'knife' –
local anaesthesia

Requires general anaesthesia and

allows a deep specimen to be taken
Knife cone biopsy
– can be necessary in cases of
glandular CIN (CGIN)

May be suitable if other Cervix after a LLETZ procedure for

Hysterectomy gynaecological problems co-exist or
if local excision has failed excision of CIN

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 Prevention - HPV Vaccine
• In the UK, HPV vaccination (Cervarix®) was introduced into the National
Immunisation Programme in September 2008. In September 2012,
Gardasil® replaced Cervarix® in the UK HPV immunisation programme.
• Available vaccines:

• Gardasil® – quadrivalent (6, 11, 16 and 18)

• Cervarix® – bivalent (16 and 18)

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 NICE guidelines
  Normal smear-
repeat 3 /5 yearly as per
age.

Treat infection, Colposcopy if

Inflammatory changes or inflammation
inflammation- then repeat smear persists in 3
after 6months. consecutive smears.

Colposcopy if three
Cytology sample is consecutive cervical
inadequate- Repeat smear cytology samples are
reported as
inadequate. Request HPV
testing. If result If positive for HPV
Borderline- negative go back send
forcolposcopy.
to regular
screening

Repeat smear in 4-
Mild Dyskaryosis- 6months

Moderate or severe Colposcopy Within

dyskaryosis after one test 4weeks
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 cervical sample shows URGENT Within 4 weeks if
possible invasive cancer colposcopy (within borderline glandular
or glandular neoplasia 2 weeks) change after one test

Repeat smear in 4 Colposcopy after 2

Mild atypia
months abnormal smears

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 Cervical cancer
• Cervical cancer is caused by persistent infection with human
papillomavirus (HPV). The strains responsible are HPV 16 and 18. (6, 8
and 11 cause warts)
• RISK FACTORS forHPV-
• Multiple sex partners
• High parity
• Smoking
• Drug abuse, lower socioeconomicgroups
• First coitus before 18 and
first baby before20.
• Immunosuppression, HIV
• Not using condoms.
• Prolonged pill use (co-factor)

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 Clinical symptoms
Women with early invasive disease may be
asymptomatic
In clinically apparent disease the following
symptoms may be present:
• postcoital or intermenstrual bleeding
• persistent vaginal discharge, which may be
bloodstained
• postmenopausal bleeding.

Colposcopic appearance of atypical blood

vessel patterns in a microinvasive carcinoma of
the cervix 55
 Investigations
• INV- FBC, LFT, X-ray chest, CT , MRI for staging.

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 STAGING OF CARCINOMA
• Stage 1- Micro invasion but still in cervix
•  Rx - If wishes to conceive-LLETZ,Cone BX. If family complete-Simple
Hyst.
 
• Stage 2- Outside ut. with LN involvement +_ upper 2/3 rd of vagina and
parametrium.
• Rx Radical Hysterectomy,with removal of LN

• Stage 3-involvement of lower 1/3rd of vagina and pelvic wall

• Stage 4 - all of stage 3 plus bladder and rectum
• Stage 4 b-distant metastasis (lungs, liver)
• Rx – Palliative

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 ENDOMETRIAL CANCER
• Risk factors-
• ERT- Un-opposed estrogen therapy in post
menopausal woman with intact uterus Early
menarche, Late menopause- i.e longer exposure to
estrogen.
• Combination of DM, HT, Increased BMI
• PCOS
• Tamoxifen for breast cancer
• Genetic- hereditary non-polyposis CA colon
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• SYMPTOMS: Post menopausal bleeding PV.
INV-
• TVS (endo metrial thickness of >5mm is
suspicious)
• Endo metrial biopsy sampling(Pippelle’s)
• Hysteroscopy ( to rule out other causes for
bleeding like polyps)

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 STAGING

• Stage I—within uterus

• Stage II—Cervix involved
• Stage III-Adnexa involved
• Stage IV –
• A-bowel bladder involved.
• B-Distant metastasis.

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 Treatment
• Stage I and II -Total abd. Hyst with BSO and
radiotherapy.
• Stage III and IV-Radiotherapy , palliative care.
• High dose MDPA (medroxy progesterone
acetate) is also used as part of treatment.

• Progesterone is used to treat frail old

women.
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 Ovarian tumors
• Ovarian tumours can be divided into –
1. Functional cyst – Follicular and lutealcyst
2. Benign tumors – account for majority – Dermoid
cyst, Serous cystadenoma and mucinous
cystadenoma
3. Other tumours – Fibroma,Thecoma

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• Treatment - <5CM – do not require follow up
would regress, likely physiological
• 5cm – 7cm – Yearly ultrasound and follow up
• >7cm – should be considered for intervention

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 Ovarian cancer
• Drawback: No screening prog.
 
• Risk factors- Age>5o years Nulliparity
• Long term use of ovulation induction medications High BMI
• Genetic- Presence of BRCA 1 and 2 gene mutations (family history
important)
 
• Symptoms-
• Usually vague, non specific in nature. Constant dull ache in lower abdomen
Bloating of abdomen
• Loss of appetite,unexplained wt. Loss., altered bowel habits,
• Pressure symptoms in pelvis and bladder (frequency, urgency) and
abdomen(ascitis) 

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 Management
• Investigations
• 1stUSG=Solid and Cystic mass in pelvis will be seen.
• 2nd -Tumor marker- CA 125>35 IU.
• Confirmatory Investigation is histopathology report after laparotomy and removal of
complete ovary
 
• STAGING
• Stage I One or both ovaries involved
• Stage II Beyond ovaries but still in pelvis
• Stage III beyond ovaries beyond pelvis
• Stage IV Distant metastasis-lungs, liver.
 
• Treatment-
• Stage I—TAH +BSO+LN removal
• Stages II, III and IV-Neoadjuvant chemotherapy then TAH +BSO.

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 Benign coditions
• Cervix
• Nabothian cyst Normal phenomena.
• Seen in reproductive age group.
• Treatment none.
• Cervical polyps benign tumours causing
increased discharge and post coital bleeding
• Cervicitis follicular, mucopurulent discharge
Causes: Infection with Chlamydia, GC, herpes
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• Cervical Ectropion central columnar epi. extends
out through ext. os. (scenario: young woman on
OCP). Commonest cause of post-coital bleeding.
• Causes: hormonal influence as in puberty,
pregnancy, patient on OCP S/S: contact bleeding
• INV: pap smear

• Rx: cryotherapy, diathermy, laser – only if

troublesome
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• VULVA
• Pruritis Vulvae itch due to general pruritis or skin disease or
local disease or infection S/local infl. +/- discharge
• Lichen Sclerosis white shiny flat itchy thickened areas on the
vulva. Mostly seen in post menopausal patients. Cause
unknown.
• S/S Skin appears cigarette paper like. Severe vulval pruritis INV
biopsy to confirm diagnosis
• Complications: erosions, ulcerations

• Treatment: topical steroids, refer to dermatologist

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•Leukoplakia àwhite thickened and
hypertrophied patches on the vulval skin
•INV: Biopsy, Rx: Steroids, Complications: pre-
cancerous condition, close follow up required.

•Vulval ulcers -> Syphilis: painless unless infected

•Herpes Simplex type 2: common in young
women, multiple, extremely painful

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 Leiomyoma (fibroids)
Benign smooth muscle tumours of the uterus
• Etiology:
• Race: more common in Afro-carribeans (PLAB
FAV)
• Estrogen dependent, therefore increases in
pregnancy, OCP. Atrophies post menopausally

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• Types: subserosal, submural, submucosal,
pedunculated
• Complications: red degeneration in
pregnancy,
• sarcomatous changes after
menopause (rare 0.1% risk),
• white degeneration due to calcium
deposition known as womb stones
(commonly seen on USG).
•  hyaline/cystic degeneration
pathological process.
• Torsion of pedunculated fibroids
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 Fibroid symptoms
• gynaecological - AUB, HMB, pelvic pain,
dyspareunia, pelvic/abdominal mass
• anaemia due to HMB
• obstetric - infertility, miscarriage, abdominal
pain, malpresentation
• compression of organ systems - abdominal
pressure-like effects on gastrointestinal and
urological tract and nerve entrapment like
symptoms.
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 Investigation
• The ideal first-line investigation is pelvic
ultrasound (transvaginal and transabdominal)
•  MRI is useful when planning surgery or as a
baseline prior to uterine artery embolisation
(UAE).

73
Hierarchy of treatment
Treatment hierarchy Seeking contraception Wishing to conceive
First step Management
COCs
Oral progestogens
Injected progestogens Tranexamic acid
Mirena LNG-IUS NSAIDs
Short (<6 month) course of
GnRHa
Second step
Hysteroscopic myomectomy
+/- Endometrial Hysteroscopic myomectomy
resection/ablation Laparoscopic myomectomy
+/- Mirena LNG-IUS
Second step (minimally
invasive uterus-conserving
treatments) Uterine artery embolisation
Magnetic resonance-guided focused ultrasonography
Transvaginal Doppler guided uterine artery occlusion
Bipolar radiofrequency ablation 

Third step Hysterectomy +/- bilateral

Abdominal myomectomy
salpingo-oophorectomy

74
INFECTIONS OF THE FEMALE GENITAL TRACT

 Pelvic inflammatory disease- PID

• Scenario for PLAB-young female with xple sex
partners
• Causative organisms:- Chlamydia (98%),GC,
streptococci.Less commonly TB, post
appendicitis.

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 History
Localised symptoms
• abnormal bleeding – intermenstrual bleeding, post-coital
bleeding or menorrhagia.
• lower abdominal pain
• purulent vaginal or cervical discharge.
• deep dyspareunia.
Systemic symptoms
• fever
• anorexia
• malaise.
76
 Examination findings
• mucopurulent cervicitis
• cervical inflammation or bleeding
• cervical excitation (positive cervical motion test)
• adnexal tenderness, usually bilateral
• possible adnexal mass
• abdominal distension
• lower abdominal tenderness
• rebound tenderness/guarding
• pyrexia, tachycardia, hypotension
Chlamydia cervicitis77
 Investigation
• Pregnancy test
• Endocervical swabs for Chlamydia trachomatis: Chlamydia is diagnosed using nucleic acid
amplification test (NAAT). Alternatively, NAAT can be done on first-catch urine sample or vaginal
swabs .

• Endocervical swab for gonorrhoea

• Raised white blood count count, erythrocyte sedimentation rate and C-reactive protein .

• Electrolytes, liver function and coagulation are only indicated in cases of systemic bacteraemia.
• A midstream specimen of urine should be checked to rule-out urinary tract infection as a
differential diagnosis.

• The absence of endocervical or vaginal pus cells on microscopy or wet-mounted vaginal smear
has a good negative predictive value (95%) for the diagnosis of PID, but their presence is non-
specific .

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 Transvaginal ultrasound
• for ruling out other pathology such as ovarian cysts,
ovarian torsion and detecting hydrosalpinges.
• In the diagnosis of tubo-ovarian abscess

Transvaginal scan showing a tubo- transvaginal scan showing free fluid

ovarian abscess associated with PID 79
 PID treatment
• Where PID is suspected treatment should be started
immediately to reduce the risk of complications.
• Outpatient regimens
• These include:
• Ceftriaxone 500 mg intramuscular single dose;
then doxycycline 100 mg twice daily +
metronidazole 400 mg twice daily for 14 days
• Oral ofloxacin 400 mg twice daily plus oral
metronidazole 400mg twice daily for 14 days
80
• Inpatient regimens
• Ceftriaxone 2 g intravenous daily + doxycycline 100 mg intravenous twice
daily (oral doxycycline may be used if tolerated); followed by oral
doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily
for a total of 14 days
• Clindamycin 900 mg intravenous three-times daily + gentamicin (2 mg/kg
loading dose) intravenous followed by 1.5 mg/kg three-times daily (a single
daily dose of 7 mg/kg may be substituted) followed by either:
– oral clindamycin 450 mg four-times daily
or
– oral doxycycline 100 mg twice daily + oral metronidazole 400mg twice daily to
complete 14 days.
• Inpatient intravenous drug regimens should be continued 24 hours after
clinical improvement, after which they can be switched to oral antibiotics

81
 Follow up
• Partner must be screened and treated
• No sexual intercourse until both have
completed treatment
• Full STI screen recommended – including HIV,
hepatitis B and C
• Further contact tracing (other sexual partners
in the last few months)

82
 Complications
• The most common and important
complications are:
• tubal factor infertility (20%)
• ectopic pregnancy (10%)
• chronic pelvic pain (20%)
• tubo-ovarian abscess.

83
 ACUTE SALPINGITIS
• Infection of the tubes.
• S/S- Main symptom: PV discharge which could be foul smelling/
profuse/purulent or blood stained.Pain in lower abdomen. High
grade fever>38 C, toxicity, In severe cases. peritonitis, Urinary
symptoms may or mat not be there.
• O/E- Suprapubic tenderness, or tenderness in affected iliac fossa.
cervical excitation on PV. If peritonitis-guarding ,rigidity
• INV-High vaginal swab for c/s , endo cervical swab (to r/o GC&
Chlamydia), PCR for same. FBC will show raised WBC count
(leucocytosis)Blood culture, MSU for c/s.
• USG may show TO mass
• Rx and complications same as PID

84
 Chronic salpingitis
Pathology: unrecognised, unresolved,or inadequately treated PID.
 

•Inflammation leads to à fibrosisà adhesions between pelvic organs

à causing chronic pain and complications as mentioned above. Hydro
salpinx or pyosalpinx may happen.
•S/S- Pain, discharge, dysmenorrhea, menorrhagia, dysparuenia.
•O/E- uterus may be retroflexed, fixed, tender. Tender tubular mass in
fornix may be palpated on PV exam.
•Management : Inv as above.

•1-AB- long for longer period. (Doxycycline,Metro)

•2-pain relief.
•3-laparoscopy which confirms diagnosis and same time
allows removal of TO mass and adhesiolysis. 

85
 Infections of the lower genital tract

• Normal physiological vaginal discharge is clear, odourless, with a

pH of 3.2-4.2. Lactobacilli and epithelial cells are normal findings
in a smear.
• Pathological discharge is seen in infections,
inflammations(chemical irritation due to douches, sprays,
FB,IUCD .
• PLAB FAV:
• 1-Offensive bloody discharge-suspect cancer,
• 2-Pelvic pain +discharge suspect PID.
• 3-Toxic shock syndrome ( by group A streptococci) – Uncommon
but serious infection .Becomes fatal within hours. Toxins released
cause multi organ failure. Admission in ICU for aggressive
treatment. Clincher- tampon users.
86
 VAGINITIS AND CERVICITIS
Causative S/S Diagnosis Treatment
Organisms
Bacterial Asymptotmatic AMSEL Criteria 1. Metronidazol 2
vaginosis- Poly No pruritis to diag.bact.vag: gm po/ 400 mg
microbial: 1. Vaginal TDS x 7 days (5
No inflammation days if
mostly discharge pregnant)
Bacteroids & Complications – àthin white  
Myco.hominis. preterm labour, yellow 2. Clindamicin 2%
intra- amniotic homogenous cream x 7nights
inf., post-    
partum sepsis, 2. Microscopy  
risk of second àclue cells
  Treating partners
trimester misc. If does not reduce
3. pH of vag
infected in first >4.5 relapse
trimester.  
4. Fishy odour
on adding
10%KOH

87
Candidiasis Red, sore, HVS for C/S First line: Topical
(Thrush) fissured   anti-
Smear àadd
Second most Vulva Fungals.
common single drop of Clotrimazole,
KOH àwill show fenticonazole
pseuedohyphae
Infection Strawberry red with budding Second line: Oral if
C. Albicans 95% vagina/petechial yeast cells topical fails
C. Glabrata rash   Fluconazole
(difficult to For recurrent
treat) Extreme pruritis infections GTT

Maybe Curdy white or  

associated with cheesy
oral thrush, discharge.  
nails, vulva
  Pre-disposing  
factors:
  AB, DM, Preg.,  
OCP,

  Steroids  
  Not an STI  

88
Trichomonas Dysuria, Wet film – Metronidazol 2
vaginalis severe motile gm PO
itching,

Trichomonas thin frothy flagellae stat for non-

is a (drop of NS)
flagellated greenish pregnant
anaerobic yellow   patient.
Pap smear à
discharge

protozoa. It O/E: corkscrew 400 mg BD for

is an STI strawberry shaped 5 days if
that may co- red organism pregnant
exist with cervix à

Gonorrhoea erythematou    
s cx with
Treat partner
punctuated and refer to
areas of GUM for other
STIs.

  Exudation    

89
90
Gonorrhoea Greenish 1. Endocervi Ceftriaxone
yellow 1000mg IM
cal swab Stat or
(notHVS)
N. purulent Cipro 500 mg
discharge 2. Rectalswa PO Stat (only
gonorrhoea if known to be
àgram b sensitive)
 
negative Dysuria, Complicatio (3 negative
kidney proctitis ns: arthritis, smears at
shaped endocarditit weekly
diplococcic. s, iritis intervals -
Intracellular,   negative
present in diagnosis)
groups of 4-   Partner
8. notification
must
Incubation    
period: 2-
10 days    

91
 PROLAPSE
• Weakness of the pelvic ligaments that support the pelvic
organs leading to sagging of the pelvic organs within the
vagina.
Major ligaments :Uterus is held in place by several peritoneal ligaments, of which the
following are the most important (there are two of each):

Name From To

Uterosacral ligament : Posterior cervix Anterior face of sacrum

Cardinal ligaments Side of the cervix Ischial spines

or Transverse cervical lig. :

Pubo cervical ligament:  Side of the cervix  Pubic symphysis

92
93
•Risk factors àMultiparity, chronic cough,
constipation, increased BMI

•S/S: Dragging sensation in lower

abdomen, feeling of something coming
out of the vagina, back ache, heaviness
in lower abdomen, difficulty in
micturition and defecation.
94
• The most common types of prolapse are:
• Anterior wall prolapse (cystocele) – when the bladder bulges
into the front wall of the vagina.
• Posterior wall prolapse (rectocele) – when the rectum bulges
into the back wall of the vagina.
• Uterine prolapse – when the uterus hangs down into the
vagina. Eventually the uterus may protrude outside the body.
• Vault prolapse – after a hysterectomy has been performed,
the top (or vault) of the vagina may bulge down.

95
 Management:
• Lifestyle changes: reduce weight, avoid
constipation, smoking that can lead to chronic
cough
• Pelvic floor exercises
• Topical estrogens
• Ring pessary, donut pessary, hodge pessary
• Surgery: vaginal hysterectomy with pelvic floor
repair
96
URINARY INCONTINENCE

97
 URINARY INCONTINENCE
• Types:
• Urge incontinence a.k.a overactive bladder or detrusoroveractivity.
• S/S: Patient complains of urgency i.e. leaking of urine before reaching the toilet. Here sphincter is normal
but the detrusor muscle in bladder is overactive.
• Investigation: Cystometry
• Treatment:
• Lifestyle changes- caffeine reduction , wt loss
• Bladder training
• Medications:
• Oxybutaline (solifenacine, tolteradine) Botuliun toxin (neuromodulator)

• Stress incontinence: sphincter abnormal and detrusor activity is normal

• (Clinchers: sneezing, coughing, laughing, jumping - if question mentions any of these, go for stress
incontinence)
• Management: pelvic floor exercises, lifestyle management, drugs: duloxetine, surgery Surgery àTVT (Trans
Vaginal Tape), TOT (Trans Obturater Tape), Burchcolposuspension

• True incontinence: congenital abnormalities like Ectopia Vesicae, ectopic ureters invagina.

• Vesico Vaginal Fistula: due to surgery like hysterectomy, trauma àobstructed labour, radiotherapy
• S/S: continuous dribbling of urine, patient may be unaware of being wet Management:
• Small fistula - catheterisation for 6-8 weeks -leads to spontaneous repair
• Big fistula - surgical repair
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 INFERTILITY
• Failure of conception after 1 year of regular unprotected intercourse.
 
• Causes: Male & Female
• Problem with ovulation: PCOS, hyperprolactanemia, POF, stress and chronic illness,
anorexia nervosa,chemo/radiation
• Problem with fallopian tubes, uterus, cervix: PID, endometriosis, large submucosal fibroid
• Male problems: Azoospermia, hypothyroidism, erectile dysfunction (ED),varicocoeal

• INV:
• Day 21 serum progesterone (marker forOvulation)
• Test for tubal patency: HSG, diagnostic laporoscopy with dye
• Semen analysis: volume count, morphology
• Other tests: screening for Chlamydia, hormone tests for prolactin and thyroidfunction
 
• Management: Depending on the cause

99
 ENDOMETRIOSIS
• Endometrial tissue outside the endometrial cavity causing adhesions and tubal blockage. Pathology:
• Sampson’s Theory: retrograde menstruation
• Regresses during pregnancy due to increase in progesterone levels
 
• S/S:
• Cyclical pelvic pain of > 6 months duration, thigh pain, pain on defecation (dyschezia) , Severe
dysmenorrhoea
• Deep dyspareunia , Infertility
• Bleeding from or into other sites e.g. bleeding into ovary leading chocolate cyst of the ovary,
bleeding into myometrium - adenomyosis
• O/E: Fixed retroverted uterus, pelvic tenderness(tender Pouch of Douglas), nodules on uterosacral
ligament, enlarged tender boggy uterus (adenomyosis)
 
• INV ( NICE Guidelines)
• USS
• Laparoscopy - investigative simultaneously therapeutic

100
 Management
Treatment options for endometriosis symptoms include analgesia and/or hormonal
treatment, depending on the woman's needs and preferences.
• For pain relief:
– Offer a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen, naproxen, or
mefenamic acid unless contraindicated.
– Offer paracetamol if NSAIDs are contraindicated or not tolerated, or in addition to an NSAID if
the response is insufficient.
• If the woman does not wish to conceive, consider prescribing a 3–6 month trial of
hormonal contraception (off-label use):
– combined oral contraceptive (COC) preparations containing 30–35 micrograms of
ethinylestradiol and norethisterone, norgestimate, or levonorgestrel are usually first choice.
– Oral (desogestrel 75 micrograms), depot (Depo-Provera® or SAYANA PRESS®), subdermal
implant (Nexplanon®), and intrauterine progestogen-only (Mirena®) contraceptives may also be
considered.
• If the woman does not want to take hormonal contraception, offer an oral
progestogen, such as:
• Medroxyprogesterone or norethisterone

101
GESTATIONAL TROPHOBLASTIC NEOPLASIA
• This could be premalignant – complete or partial mole Malignant – invasive,
choriocarcinoma or PSTT
• Complete mole – all genetic material comes from the father, no fetal tissue but when it
invades the myometrium it becomes an invasive mole

• Risk Factors – Age <16 or >45, previous molar preg, Asian women
• Partial mole – two sperm fertilize one ovum at the same time Hydatiform mole: benign &
Choriocarcinoma: malignant
• Pathology: fertilised ovum forms abnormal trophoblast but no fetus
 
• Hydatiform Mole
• S/S:
• Short period of amenorrhea (uterine size > period of amenorrhoea)
• Irregular vaginal bleeding with history of passing grape like structures
• Hyper-emesis

102
INV:
Investigation of choice - quantitative BHCG – very very high levels USG – will show snow
storm appearance
Definitive investigation – histopathological exam of products of conception
 
Management: (RCOG Guidelines)
1. Suction andevacuation
2. Follow up:
Follow up of GTD is highly individualised.
If hCG has reverted back to normal within 56 days of pregnancy event, then follow up will be
for 6 months from the date of uterine evacuation.
If hCG has not reverted back to normal within 56 days of the pregnancy event, then follow
up will be for 6 months from the normalisation of the hCG level.
 
3. Contraceptive advice – barrier contraception till BHCG is normal. COCP after that. IUCD is
contraindicated due to risk of perforation

103
Hydatiform mole

104
 CONTRACEPTION
• (Best source www.fsrh.org)

• Divided into temporary and permanent Temporary is divided into hormonal and non
hormonal

• A.TEMPORARY:
• Barrier method: condoms, cap, sponge, spermicidal gel (failure rate for Male condom 2%,
female condom5%)
• IUCD: made of plastic with copper wire wound around it and a plastic thread from the tail
Mechanism of action: inhibits ovulation, impairs sperm migration. Should be changed after 8-
10 years. Side effect: irregular bleeding PV and dysmenorrhea. (Failure rate :0.6%)
 
• Missing thread of IUCD- next step in Mx = do TAS
 
• IUCD with hormones =IUS:
• Mirena – contains levonorgestrel which is released slowly over 5 years (Failure
rate:0.1%)Irregular bleeding and spotting are common in the first six months with an LNG-
IUS. Explain to women that 90% will experience reduced menstrual flow ultimately and some
will be amenorrhoeic. 
105
Hormonalcontraception
COCP : containsE+P
Mechanism of action: inhibits ovulation, causes thinning of endometrium thereby
prevents implantation, makes Cx mucous hostile to sperms.
Advantages: Effective, Doesn’t interfere with sex, Helps dysmenorrhea,
menorrhegia, protective in benign breast tumours, protects in ovarian, endometrial
and colorectal cancer, Protects against PID

Disdvantages – people may forget to take it, Does not protect against STI, Increased
risk of VTE, breast cancer and cervical cancer, increased risk of stroke and IHD

UKMEC 3 - >35yrs smoking less than 15 sticks per day, BMI >35Kg/m2, migraine
without aura, Family history of thromoboembolic dx, controlled HTN, Immobility,
carrier of breast cancer mutation Failure rate:0.3%
 
UKMEC 4 - >35Yrs smoking >15 sticks, migraine with aura, history of
thromboembolic disease or mutation, history of stroke or IHD, Uncontrolled HTN,
Current Breast cancer, Major surgery with prolonged immobilisation.
 
 
106
POP: Progesterone Only Pill contains either norethesterone or Levonorgestrel. Used
where COCP is CI. Best method for lactating mothers (Failure rate0.3%)
Mechanism of action: low dose progesterone renders cervical mucous hostile (thick),
also inhibits ovulation
 
Advantages – Effective, doesn’t interfere with sex, breastfeeding mothers, used in people
with VTE
 
Disadvantages – can cause irregular bleeding, increases incidence of functional cyst.
NEXPLANON is contraceptive of choice in Young people.
Concept of missed pill.
 
E+P – patches, vaginalrings
 
LARC: Long Acting ReversibleContraception.
DMPA: Depot Medroxy Progesterone Acetate given every 12weeks
Implants: IMPLANON. Progesterone coated rod inserted in the medial aspect of arm. Has
to be changed in 3 years time. It is a flexible rod that contains etonogestrel which is
implanted sub- dermally.
 
MirenaIUS

107
Emergency Contraception (PLABFAV):

Morning after pill to be used within 72 hours unprotected intercourse Levonorgestrel:

Levonell (1.5 mg) singlepill
MOA: Primarily inhibits ovulation, also prevents follicular rupture causing luteal dysfunction
 
 
IUCD within 5 days or 120hours
MOA: inhibits fertilisation by direct toxicity, affects implantation by inducing inflammatory
reaction in endometrium. Cu may inhibit sperm transport.
 
ELLA-ONE (Ulipristol acetate): single pill to be taken within 120 hours (5 days) MOA:
Primarily inhibits/ delays ovulation, alterations toendometrium

 
B. PERMANENT :
Male: Vasectomy (after 8 weeks of Sx check 2 semen samples @ 3-6 weeks gap, if no sperm
then sterile; meanwhile use some extra precautions) Failure rate0.1%
 
Female : Tubal sterilisation (failure rate is 1:200=0.5%)
 
 
108
 Copper T
• Absolute contra-indications[10]
• Infection
• History of pelvic inflammatory disease (PID) or purulent cervicitis,
• Recent exposure to sexually transmitted infection (STI).
• Septic abortion or postpartum endometritis in the previous three
months.
• Uterine abnormality distorting the uterine cavity - eg, fibroids, 
bicornuate uterus. 
• Gynaecological cancers
• Ovarian, cervical or endometrial cancer.
• Malignant trophoblastic disease.
• Undiagnosed irregular vaginal bleeding/suspicion of genital malignancy.
109
110