Gynaecology: - wickUP



Near patient testing:General screening tests:Condition:TestPositive if:Negative if:Pregnancy testGravindexNo clumpingFlocculationSyphilisRPR FlocculationNo clumpingRhesusRapid RhFlocculationNo clumpingAnaemiaCuSO4Drop sinks ≈ ≥ 10g/dlDrop floats ≈ < 10g/dlFetal lung maturityTap-testFew bubbles> 5 bubblesGardnerella vaginalisWhiff test (K-OH)Fishy odourNo odourCandida albicansK-OH wet mountHyphae (microscopy)No hyphae (microscopy)Trichomonas vaginalisNaCl wet mountMobile pear-shaped protozoaNo visible organismsCervical cancerAcetic acid testWhite lesionNo whiteningWhat diseases are screened for?IdentifiableHigh prevalence in target populationLong latent periodNatural history must be known/understoodAcceptable/effective treatment availableScreening test must be suitable/acceptableCost effectiveAdequate resources for treatment & F/UCharacteristics of a good screening test:SafeAcceptableSimple to performLow costRepeatable resultsSensitive (probability of positive result in a diseased patient)Specific (probability of negative result in a non-diseased patient)High predictive value (probability of having the disease if you test positive)Screening for breast cancer (BRCA):Risk factors for developing BRCA:Personal or family history of BRCA (1st degree relative)Personal of family history of other adenocarcinomas:ColonOvaryEndometriumAdvanced ageHigh socio-economic status/developed world → obesityPrevious atypical epithelial hyperplasiaEarly menarche; late menopauseSub-fertilityNot lactating (breastfeeding)Screening techniques:Self-screening of patientMammography (economic considerations)FNA (practical considerations – needs skill)Management of breast lumps – stepwise approach:Clinical palpation → mammography (± augmentation by US) → FNA → biopsyGood clinical practice:Public education → awarenessTeaching self-examinationMammography for high-risk womenR/F for assessment should a lump be detectedNote: Screening for gynaecological CA (see pelvic masses below)Early pregnancy loss:Definition: Loss before 24wk gestation:Ectopic pregnancy (EP):Possible implantation sites:TubalLigamentous (broad ligament)Ovarian (ovarian cortex) → can bleed profusely!!Abdominal (usually progressed past 20wk) → massive bleed due to blood supply from liver, peritoneum etc.Cervical → massive haemorrhageAx:Embryonal factors:Chromosomal & structural abnormalities → poor implantationMaternal factors:Previous salpingitis (ASO or “PID”)EndometriosisTubal surgeryCongenital abnormalities e.g. blind-ending tubal mucosaAssisted reproduction e.g. IFV & GIFTIUCDSx:Incidentally – during USAmenorrhoeaPain (iliac fossa)!! – due to parietal peritoneum stretchingAdnexal massPVB (if pregnancy aborts; also associated with ↑↑ pain in one iliac fossa)Extra-uterine pregnancyRuptured ectopic (PAIN!!!)Definitions:Acute EPSymptoms:Severe LAP (sudden; colicky/constant)N&V; dizzinessShoulder-tip pain (due to intra-peritoneal irritation of diaphragm)Amenorrhoea for some time & NOW ± PVBSigns (examination):ShockPallorDistended abdomen – blood (± tenderness; ± rebound tenderness)Peritonitis if not distendedCervical excitation tenderness (CET)Chronic EPSymptoms:LAP (localized to 1 iliac fossa) → ↑ in severity over tieAdnexal massPositive pregnancy test &/or amenorrhoeaSigns (examination):Generally well (NO SHOCK; NO PALLOR; NO PERITONISM)Localized rebound tenderness over iliac fossaTender unilateral adnexal mass on bimanual PVAcute on ChronicSymptoms:Mild LAP → WORSE!!! – along with amenorrhoeaSigns (examination):Shocked + tender abdomen + pallor + adnexal mass felt (bimanual PV)Differential Dx:Gynaecological: Spontaneous abortion (see below); ASO; ruptured corpus luteum cyst; ovarian torsionSurgical: Appendicitis; mesenteric adenitis; ruptured spleen; perforated bowelMedical: Acute pyelonephritis; porphyriaDx:Bloods: Hb; HcT; ABO & RhPregnancy testParacentesis (transabdominal fluid aspiration – blood)Culdocentesis (transvaginal fluid aspiration via pouch of Douglas – blood)US – abdominal &/or vaginal (not a sensitive examination → NEVER DELAY LAPAROTOMY IF SHOCKED!!)Laparoscopy – if diagnosis still uncertainLaparotomy – if patient is shocked-42545297815Resuscitation – ABC’s:Large bore IV infusion of Ringer’s lactateUrinary catheterABO/Rh cross-match (BUT DON”T DELAY LAPAROTOMY!!)Get informed consent to operation & for possible salpingectomyOperatively:If tube ruptured:SalpingectomyInspect other ovary & fallopian tubeSuctioning to remove blood products (don’t remove all blood as it’ll get reabsorbed and serve as iron reserve)Inspect abdomen:HaemostasisAdhesions esp. between liver & diaphragm (Fitz-Hugh-Curtis sybdrome)If unruptured:Try to preserve tubeIf diagnosis is made early (non-emergency) → laparoscopic removalPost-operative information about future pregnancies:Explain procedureExplain how rest of reproductive organs look esp. other tubeDiscuss any evidence of previous pelvic infections e.g. adhesionsDiscuss prognosis for falling pregnant againDiscuss risk of recurrenceDiscuss what she should do if she fell pregnant again:Report immediately to clinic for US (vaginal) at 6-8wk to confirm intra-uterine pregnancy00Resuscitation – ABC’s:Large bore IV infusion of Ringer’s lactateUrinary catheterABO/Rh cross-match (BUT DON”T DELAY LAPAROTOMY!!)Get informed consent to operation & for possible salpingectomyOperatively:If tube ruptured:SalpingectomyInspect other ovary & fallopian tubeSuctioning to remove blood products (don’t remove all blood as it’ll get reabsorbed and serve as iron reserve)Inspect abdomen:HaemostasisAdhesions esp. between liver & diaphragm (Fitz-Hugh-Curtis sybdrome)If unruptured:Try to preserve tubeIf diagnosis is made early (non-emergency) → laparoscopic removalPost-operative information about future pregnancies:Explain procedureExplain how rest of reproductive organs look esp. other tubeDiscuss any evidence of previous pelvic infections e.g. adhesionsDiscuss prognosis for falling pregnant againDiscuss risk of recurrenceDiscuss what she should do if she fell pregnant again:Report immediately to clinic for US (vaginal) at 6-8wk to confirm intra-uterine pregnancyMx:Abortion:Classification:Definitive classification:Spontaneous:Sporadic – occurring at irregular intervals in relation to other pregnanciesRecurrent – 3 consecutive abortions before 20wk gestationInduced:Therapeutic – TOP actUnlawful – sttempt to determine if this was the caseClinical classification:Safe:Uncomplicated incomplete abortionNo antibiotics are neededTetanus toxoid if the woman hasn’t been immunized beforeManaged as outpatients:MVASystemic analgesisUnsafe:T? > 37.2?C &/OR Foul-smelling products of conception &/ORAny other complicationRegarded as severe if:Sx of peritonitisUterus size ≥ 16wk Sx of MODS:CNS: Confusion; LOCCVS: Hypotension; ↑ HR; cold/clammy extremities; pulmonary oedema; hepatomegaly; arrhythmias; ECGRS: ↑ RR; cyanosis; ↓ saturation; blood-gas; CXRLiver: Jaundice; hypoglycaemia; ↑LFT; ↑LDHRenal: ↓ Urine output; UKEHaematological: Anaemia; petechiae; echhymoses; FBC; D-dimers; clottinf profileMetabolic: UKETherapeutic: According to termination of pregnancy actAx:Early spontaneous abortion – 12-14wk:Idiopathic (most common cause)Sporadic chromosomal abnormalitiesEnvironmental factors e.g. drugs; toxins; smoking; IxOvary can’t maintain pregnancyCorpus luteum defectPoor placentationUterine septum (if implantation occurs here – it is fibrous)Auto-immuneSimilar HLA status of partner → ↓ normal immune response to trophoblast (necessary for continuation of pregnancy)Late spontaneous abortion – 14-28wk (associated with recurrent losses → investigate further esp. if after 20wk):Uterus can’t hold pregnancy – Hx of quick, painless labour with ROM → live fetusIncompetent CxCongenital abnormalities of uterus e.g. uterus didelphysSubmucus myomataPoor placentationIx:SyphilisChlamydiaMycoplasmaAFIS – Dx: Pus cells on smear from inter amnion-chorion spaceCMV; rubellaToxoplasmosisMedica; factors:HypothyroidismDMSx:Threatened abortion: Light PVB ± backache ± abdominal painInevitable abortion: Increasing pain & PVB ± clots ± uterine tenderness; cervical tendernessIncomplete abortion: Passed products of conception (POC) → ↓ cramps; SGA uterus; Cx open; POC feltComplete abortion: ≥16-18wk gestation; whole fetus & placenta expelledMissed abortion: IUD without expulsion; patient may have only amenorrhoea and nothing elseDifferential Dx:Threatened abortion: Anovulatory or implantation bleed; anembryonic pregnancy (“blighted”); early ectopicInevitable: Incompetent cervical os (but here there is no pain & no/little bleeding)Mx:Threatened:Pregnancy test & US (if positive)If sac but no fetus AND ≥ 8wk gestation = “blighted ovum” → Rx: MVAIf Dx uncertain → repeat in 2wkIf empty uterus → suspect ectopic pregnancyIf no US available → expectorant approach (60% don’t abort)Inevitable:Resuscitate patient if necessaryOxyticin IV → control bleedingIf in 1st TM → Evac/MVAIf in 2nd TM → give oxytocin and await spontaneous abortion → evacuate retained productsIf placenta is completely aborted (only after 16-18wk) → omit evacuationIncomplete:ResuscitationOxytocin IV → control bleedingAs for inevitable abortion except if uterus size < 14wk → then perform evacuation despite gestation Complete:Observe for haemorrhageUsually a cause for abortion → SEEK!!Note whether fetus is fresh or maceratedIf fresh fetus → take blood from fetal heart or calve (put in tissue culture medium) → detect congenital abnormalities (chromosomal analysis)If fetus normal → review Hx → look for incompetent Cx os OR AFISExamine placenta → smear/histologyIf macerated → think syphilis; other congenital Ix; poor placentationMissed:If size < 12wk → evacuate directlyIf size ≥ 12wk → induce with Prostaglandins e.g. MisoprostalOther important investigations & considerations: Hb (at admission & D/C)Rh status → if negative give antiD-Ig 100μg IMI STATRPR, FTA, TPHA or VDRLPAP smear if ≥ 30yrIf recurrent abortions, look for:Corpus luteum defects → measure s-progestorone levels at next ovulationUterine septum – do hysterosalpingogram or hysteroscopyCollagen disease – measure platelet count; collagen screen; anti-cardiolipin antibody (ACA)Balanced translocations – chromosomal analysis of woman & partnerEmotional support & allow her to grieve – 5 steps:ShockDenialAngerDepressionAcceptanceContraceptive counselingPlan for future pregnancies e.g.:If sporadic early abortion reassure her that the risk of recurrence is not increasedIncompetent Cx → R/G McDonald suture should be consideredIf recurrent → Mx depends on DxHb (at admission & D/C)Rh status → if negative give antiD-Ig 100μg IMI STATRPR, FTA, TPHA or VDRLPAP smear if ≥ 30yrIf recurrent abortions, look for:Corpus luteum defects → measure s-progestorone levels at next ovulationUterine septum – do hysterosalpingogram or hysteroscopyCollagen disease – measure platelet count; collagen screen; anti-cardiolipin antibody (ACA)Balanced translocations – chromosomal analysis of woman & partnerEmotional support & allow her to grieve – 5 steps:ShockDenialAngerDepressionAcceptanceContraceptive counselingPlan for future pregnancies e.g.:If sporadic early abortion reassure her that the risk of recurrence is not increasedIncompetent Cx → R/G McDonald suture should be consideredIf recurrent → Mx depends on DxMale & female infertility:Ax:Female infertility:Tubal considerations:Post-PID obstruction & adhesionsCogenital abnormalitiesPevic considerations:EndometriosisAdhesionsOvulatory considerations:AnovulationsHypothalamic or pituitary disordersHyperprolactinaemiaOvarian diasease e.g. dysgenesis; tumor; failureSystemic disease e.g. thyroid; liver; kidney; obesityUterine considerations:Congenital abnormalitiesIntrauterine adhesionsCervical considerations:Congenital abnormalitiesStenosis due to Ix or ?Hostile/deficient cervical mucusMale infertility:Endocrine considerations:Hypothalamic or pituitary dysfunctionHyperprolactinaemiaExogenous androgen useThyroid or adrenal diseaseAnatomic considerationsCongenital absence of vas deferensEjaculatory systemVas deferens obstruction (post infection)Absence duct ciliaSpermatogenic considerations:Chromosomal abnormalitiesPrevious orchitisCongenital cryptorchidismTesticular damage due to injury; irradiation; chemicals0297180Exclusion criteria – the following patient DO NOT qualify for further assessment → terminate the interview; give explanation, advice & encouragement:Single personsCouples where 1 of the 2 refuses to be examined or participate in tests/investigationsCouples with 2/more alive children (in their current family structure)Women older than 40Known HIV patientsTreat patients for any current disease(s) esp. PID before offering infertility testingInitial tests – 3 options:Serological testing for syphilis (RPR; FTA; TPHA; VDRL) & HIV testingSperm analysisHysterosalpingogram (contrast evaluation of uterine/tube patency/obstruction)Majority of patient – there is no treatment (no medical way to open tubes available)± Reconstructive surgery (selection criteria very strict) – e.g. patients with terminal (fimbrial) occlusion of tubeEncourage remainder → NO MORE TESTS (esp. for 2? infertility)Prevention:Early Dx & Mx of PID & STD’sTreat syphilis properlyCounseled HIV positive patients00Exclusion criteria – the following patient DO NOT qualify for further assessment → terminate the interview; give explanation, advice & encouragement:Single personsCouples where 1 of the 2 refuses to be examined or participate in tests/investigationsCouples with 2/more alive children (in their current family structure)Women older than 40Known HIV patientsTreat patients for any current disease(s) esp. PID before offering infertility testingInitial tests – 3 options:Serological testing for syphilis (RPR; FTA; TPHA; VDRL) & HIV testingSperm analysisHysterosalpingogram (contrast evaluation of uterine/tube patency/obstruction)Majority of patient – there is no treatment (no medical way to open tubes available)± Reconstructive surgery (selection criteria very strict) – e.g. patients with terminal (fimbrial) occlusion of tubeEncourage remainder → NO MORE TESTS (esp. for 2? infertility)Prevention:Early Dx & Mx of PID & STD’sTreat syphilis properlyCounseled HIV positive patientsMx:Referral guidelines:Referral to specialized units most helpful in 1? infertilityOffer assistance for taxing tests & investigations, which the patients are facingIndications for referral:Suspected anovulation (IF tubes are patent)Anatomical abnormalities of gentitaliaDeficient sperm analysisEndocrine diseasesTreatable conditions e.g. myomataTubal obstruction (minority of cases)Diagnostic tests:LaparoscopySophisticated USCx mucus evaluationImmunologica testsTearapeutic options:Ovulation inductionArtificial inseminationIVFGIFTICSIAbnormal uterine bleeding, galactorrhoea & hirsutismIncreased uterine bleeding:Definitions:Abnormal uterine bleeding – menstruation ≥ 80ml; acyclical bleeding:Menorrhagia: Excessive cyclical bleedingMetrorrhagia: Acyclical bleedingMeno-metrorrhagia: Excessive acyclical bleedingDx:Hx of many pad use; clots“Bleeding calendar” or “menstrual calendar”Pool of blood in the bed upon wakingAx:DysfunctionalAnovulatory – no dominant follicle growth & ovulation → thick endometrium remains proliferative since progesterone not produced → outgors its own blood supply & sheds → oligomenorrhoeaOvulatory – 2 mechanisms:Corpus luteum retains function → produces progesterone (up to 6wk) → oligomeonorrhoea + severe bleeding + painInsufficient progesterone levels → short luteal phase → polymenorhhoeaOrganic:Uterus:Endometrial hyperplasia – unopposed eostrogen stimulationEndometrial CA – excessive continuous acyclical bleedingEndometrial polyps – usually benign (intermenstrual bleeding)Adenomyosis/myomata (excessive cyclical bleeding)Submucus myomata (intermentstrual bleeding)Cervix:Cervix CA – excessive continuous acyclical bleedingCervical polyps – usually benign (intermenstrual bleeding)CervicitisPedunculated prolapsing myomata (contimuous excessive acyclical bleeding)Fallopian tubes:PID (excessive cyclical bleeding)Ectopic pregnancyOvarian:Oestrogen producing tumorsOvarian cystsOther:Endometriosis (excessive cyclical bleeding)Vulvar/vaginal tumors or lacerationsNon-genital causes:Contraception e.g. IUCDLong acting progestogenic contraceptionBreakthrough bleeding on oral contraceptivesEndocrine:Hypothyroidism OR hyperthyroidismHyperprolactinaemiaMedication – anticoagulant RxHaematologic – bleeding disordersNeighbourhood bleeding:PRHaematuria or bladder bleeding-514350191770Detailed Hx & ExPregnancy test; CuSO4 /HbExclude organic pathology → US; endometrial biopsy; hysteroscopyIf found → Rx accordingly (remember to Rx anaemia + pain)If not found, assume dysfunctional bleeding & continue to step 4.Blood tests to confirm dysfunctional uterine bleeding:FBCTFT’sProlactin levelsRx for cessation of bleeding & restoration of normal menstrual cycle – 2 option:Hormonal – oral contraception (effective; simple; contraceptive; discontinued in 6-8mo for re-assessment):Regime for STRONG BLEEDI NG AT TIME OF CONSULTATION – 2 options::Ovral 1 tab. q6hr x4d → stops bleeding on day 1 → wirthdrawal bleedin (less severe) om day 5/6 → start next packet of ovral in normal way → with each cycle the bleeding becomes lighter → discontinue Rx after 4months & reassessMedroxy progesterone acetate 5mg bd x10d → stops withing 2-3d → withdrawal bleed after tablets are finishe (less severe) → repeat Rx q4wk after initial course to re-establish cycleProgestogen dominant monophasic pill – double dosage may be required for severe bleeding:Nordette (150μg levo-norgestral)Nordiol (250μg levo-neorgestral)Ovral (500μg levo-norgestral)Newer preparations – less severe bleeding:Femodene (75μg gestodene)Minulette (75μg gestodene)Non-hormonal:Anti-fibrinolytic agent e.g. tranexamic acid (cyclocapron) 1g q6-8hr for 3-4d then ↓ doseC/I – previous thrombosisNSAID esp. for excessive cyclical bleeding e.g. NaproxenRefer as for organic disorder if 1st line of Rx is not successfulIf medical management not successful → consider ? if patient has completed family:Hysterectomy ORDestruction of endometrium by lazer/cautery00Detailed Hx & ExPregnancy test; CuSO4 /HbExclude organic pathology → US; endometrial biopsy; hysteroscopyIf found → Rx accordingly (remember to Rx anaemia + pain)If not found, assume dysfunctional bleeding & continue to step 4.Blood tests to confirm dysfunctional uterine bleeding:FBCTFT’sProlactin levelsRx for cessation of bleeding & restoration of normal menstrual cycle – 2 option:Hormonal – oral contraception (effective; simple; contraceptive; discontinued in 6-8mo for re-assessment):Regime for STRONG BLEEDI NG AT TIME OF CONSULTATION – 2 options::Ovral 1 tab. q6hr x4d → stops bleeding on day 1 → wirthdrawal bleedin (less severe) om day 5/6 → start next packet of ovral in normal way → with each cycle the bleeding becomes lighter → discontinue Rx after 4months & reassessMedroxy progesterone acetate 5mg bd x10d → stops withing 2-3d → withdrawal bleed after tablets are finishe (less severe) → repeat Rx q4wk after initial course to re-establish cycleProgestogen dominant monophasic pill – double dosage may be required for severe bleeding:Nordette (150μg levo-norgestral)Nordiol (250μg levo-neorgestral)Ovral (500μg levo-norgestral)Newer preparations – less severe bleeding:Femodene (75μg gestodene)Minulette (75μg gestodene)Non-hormonal:Anti-fibrinolytic agent e.g. tranexamic acid (cyclocapron) 1g q6-8hr for 3-4d then ↓ doseC/I – previous thrombosisNSAID esp. for excessive cyclical bleeding e.g. NaproxenRefer as for organic disorder if 1st line of Rx is not successfulIf medical management not successful → consider ? if patient has completed family:Hysterectomy ORDestruction of endometrium by lazer/cauteryMx:Decreased menstrual bleeding:Definitions:1? Amenorrhoea – absence of menstruation by age 16/older2? Amenorrhoea – absence of menstruation for ≥ 6months in ♀ with previously normal menstruationOligomenorrhoea – ↑ interval between menstrual periods ≥ 35dAx:1? Amenorrhoea:Genetic:46XY karyotype; Testicular fiminatization (androgen insensitivity)46XY & 46XX gonadal dysgenesis45XO gonadal dysgenesis (± Turner’s stigmata)Development:Mullerian dysgenesis (with absent unterus &/or vagina)Imperforate hymenComplete transverse vaginal septumHypothalamic (rare) – Defects in production/transport of GnRH2? Amenorrhoea:PrergnancyOvarian:Premature ovarian failureDestruction due to infection/irradiation/surgeryPituitary:Sheehan’s syndrome - ↓ pituitary blood supply after severe post-partum bleedingProlictinomaHypothalamic:Severe weight lossAnorexia nervosaSevere stressSerious exerciseObesitySystemic disorders:Hypothyroidism OR hyperthyroidismAsherman syndrome – endometrial fibrous occlusionIf associated with hirutism:Polycystic ovarian syndromeCongenital (or late onset) adrenal hyperplasia – rareOvarian or adrenal tumorsMx: 1? Amenorrhoea – do karyotyping:Genetic Ax → counseling on Ax, fertility & oestrogen Rx46XY karyotype → remove intra-abdominal gonads (possess a CA risk)Imperforate hymen/transverse septum → ?Mullerian agenesis → R/F for specialized ?2? Amenorrhoea:Pregnancy test → if negative → continueTFT’s & prolactin levels → if abnormal, treat accordingly (remember – hypothyroidism → hyperprolactinaemia)Do progestogen challenge test:Medroxyprogesterone 5mg bd x5dIf she has withdrawal bleed, she is producing oestrogenIf she has no hirsutism/alactorrhoea → Dx = mild hypothalamic dysfunction → COC RxIf she has hisutism → do LH → if ↑↑ → Dx = PCOSIf she has galactorrhoea → Dx = ProlactinomaIf she has no withdrawal bleed → investigate further – see point (d):Gonadal failureSerious hypothalamic dysfunctionAsherman syndromeDo oestrogen stimulation test (with Premarin 50mg/d x 21d), followed by progestogen challenge test:If she bleeds → Dx = oestrogen deficiency (severe hypothalamic dysfunction/1 ovarian failure)Do FSH/LH:If ↑ → Dx is primary ovarian failure (premature menopause)If ↓ → Dx is severe hypothalamic failureGive pulsatile GnRH stimulation & test response (if fertility required)If no response → Dx = pituitary problemIf response → Dx = hypothalamic problemGive FSH/LH Rx & test response (if fertility required)If response → Dx = pituitary problemIf no response → Dx = ovarian problemIf she doesn’t bleed → search for outflow obstructionDo USTreat cause:PCOS – cosmetics (hirsuitism); cyproterone (anit-androgen); COC; clomiphene (if fertility required)Prlolactinoma – withdraw drugs; address hypothyroidism; exclude prolactinoma (CT)Hypothyroidism/hyperthyroidism – RxPrimary ovarian failure – COC OR hysterectomy & oestrogen HRTSecondary ovarian failure:If fertility require - options:FSH/LH RxhCG to mimic mid-cycle LH surge → induce ovulationClomiphene – blocks hypothalamic oestrogen receptors → stimulates GnRH & subsequent FSH/LH secretionIf clomiphene doesn’t work → pulsatile GnRH → stimulates LH/FSH1? Amenorrhoea – do karyotyping:Genetic Ax → counseling on Ax, fertility & oestrogen Rx46XY karyotype → remove intra-abdominal gonads (possess a CA risk)Imperforate hymen/transverse septum → ?Mullerian agenesis → R/F for specialized ?2? Amenorrhoea:Pregnancy test → if negative → continueTFT’s & prolactin levels → if abnormal, treat accordingly (remember – hypothyroidism → hyperprolactinaemia)Do progestogen challenge test:Medroxyprogesterone 5mg bd x5dIf she has withdrawal bleed, she is producing oestrogenIf she has no hirsutism/alactorrhoea → Dx = mild hypothalamic dysfunction → COC RxIf she has hisutism → do LH → if ↑↑ → Dx = PCOSIf she has galactorrhoea → Dx = ProlactinomaIf she has no withdrawal bleed → investigate further – see point (d):Gonadal failureSerious hypothalamic dysfunctionAsherman syndromeDo oestrogen stimulation test (with Premarin 50mg/d x 21d), followed by progestogen challenge test:If she bleeds → Dx = oestrogen deficiency (severe hypothalamic dysfunction/1 ovarian failure)Do FSH/LH:If ↑ → Dx is primary ovarian failure (premature menopause)If ↓ → Dx is severe hypothalamic failureGive pulsatile GnRH stimulation & test response (if fertility required)If no response → Dx = pituitary problemIf response → Dx = hypothalamic problemGive FSH/LH Rx & test response (if fertility required)If response → Dx = pituitary problemIf no response → Dx = ovarian problemIf she doesn’t bleed → search for outflow obstructionDo USTreat cause:PCOS – cosmetics (hirsuitism); cyproterone (anit-androgen); COC; clomiphene (if fertility required)Prlolactinoma – withdraw drugs; address hypothyroidism; exclude prolactinoma (CT)Hypothyroidism/hyperthyroidism – RxPrimary ovarian failure – COC OR hysterectomy & oestrogen HRTSecondary ovarian failure:If fertility require - options:FSH/LH RxhCG to mimic mid-cycle LH surge → induce ovulationClomiphene – blocks hypothalamic oestrogen receptors → stimulates GnRH & subsequent FSH/LH secretionIf clomiphene doesn’t work → pulsatile GnRH → stimulates LH/FSHNote: Other causes of abnnormal PVB:Post-coital bleeding → exclude Cx CA/CIN/cervicitis; cervical ectopy; ectropionPost-menopausal bleeding (see above)Glactorrhoea – approach:Mx:398145109220Establish cause:Pituitary e.g. prolactinomasEndocrine e.g. hypothyroidism; stress induced hyperprolactinaemiaMedications:PhenothiazinesMetoclopramideα – methyldopaOestrogensNipple stimulation e.g. “runner’s nipples”Chest wall stimulationThoracic surgeryHZVSx of prolactinoma:HeadacheVisual disturbancesGlactorrhoeaRx – ALWAYS R/F:Bromocriptine initially? removal may be required later00Establish cause:Pituitary e.g. prolactinomasEndocrine e.g. hypothyroidism; stress induced hyperprolactinaemiaMedications:PhenothiazinesMetoclopramideα – methyldopaOestrogensNipple stimulation e.g. “runner’s nipples”Chest wall stimulationThoracic surgeryHZVSx of prolactinoma:HeadacheVisual disturbancesGlactorrhoeaRx – ALWAYS R/F:Bromocriptine initially? removal may be required laterHirsutism – approach:Exclude tumors of ovary; PCOS; CAH; adrenal gland tumors & Mx conditionPain, dysmenorrhoea & PMSClassification of pelvic pain:Pelvic pain syndromes:DysmenorrhoeaPelvic pain syndromeOvulatory painDyspareuniaPMSEndometriosisDiseases of female internal genital organsCx of pregnancyGynatresiaMyomataAdenomyosisUterine perforationPIDOvarian causes of painDiseases or syndromes of non-genital organsGITUrinary tractVascular painOrthopedic painExtra-abdominal referred painPsychogenic painAnatomic considerations:Somatic pain:OrganInnervationSpinal segmentLower abdominal wallAnterior vulvaClitorisUrethraIlio-inguinalGenito-femoralL1 & L2Posterior vulvaPerineumLower vaginaPosterior femoral cutaneous nerve of the thighPudendal nerveS1 – S3S2 – S4Visceral pain – 2 types:Referred painOrganSpinal segmentOvaryT10Fallopian tubesT11 & T12UterusT10-12 & L1CervixT11-12 & S2-4Splanchnic pain – diffusely localized pain transmitted directly from the organ:DysmenorrhoeaLabour painsDistended viscus painVarious stimuli are responsible for visceral pain:Hollow viscus distention e.g. unruptured ectopic pregnancyRapid stretching of solid organ e.g. haemorrhage into ovarian cystChemical irritation of peritoneum e.g. ruptured ovarian teratomaTissue ischaemia e.g. torsion of ovarian tumor/cystNeuritis 2? to inflammation/neoplasia/fibrosisPelvic pain syndromes:Dysmenorrhoea:Definition: When there is physiological pain and discomfort @ menstruation → compromised lifestyle:Classifications, Sx & characteristics:1? Dysmenorrhoea – not associated with any palpable pelvic pathology:Ax: ↑ Prostaglandin production → ↑ myometrial activityBegins at ovulatory (not menses) onset (15-16yr) →mid 20’sNOTE: PAINFUL MENSES AT MENARCHE INDICATE OBSTRUCTIVE LESIONPain – mid-line; colicky; radiates to lower back/upper thighs; ± N&V; ± diarrhea; ± anxiety; ± headaches; ± syncopeBegins few hours before menses until flow fully establishedRarely lasts beyond 2nd day2? Dysmonorrhoea:2? to organic pathology:PIDEndometriosisAdenomyosisAdhesionsOccurs well before menses → later during full flow (longer than 1?)Mx:Primary dysmenorrhoea:Prostaglandin synthetase inhibitors e.g. NSAIDs (ibuprofen); mefanamic acidIf PGI’s don’t work → ovulation inhibition e.g. COC’sIf COC’s don’t work → investigate further for 2? Ax e.g.:EndometriosisSub-mucus myomataAdenomyosisSecondary dysmenorrhoeaR/F for full assessment (± laparoscopy)Rx is medical/surgical depending on AxChronic pelvic pain syndrome:Charcteristics:Multi-parous in their mid-thirties presenting with lower abdominal painPain accentuated at time mensesAssociated with:Lower backacheDyspareuniaPost-coital aching & discomfortProlonged sitting or standingDecrease with lying downOther associations:HeadacheAbnormal uterine bleedingNon-offensive vaginal D/CA degree of sexual dysfunctionAx:Dilated & congested pelvic veinsThought to be oestrogen dependant → dilate veinsSx:Normal size uterusRetrovertedMild tenderness just above fornicesSpecial investigations:Pelvic US – look for dilated veins in the following areas:UterusBroad ligamentAround the ovary927735205105RassuranceSymptomatic Rx e.g. analgesis± Medroxy-progesterone acetate 30mg/d PO or as depot?: Ventral suspension of uterus (usually unsuccessful)TAH & BSO – sometime the only cure00RassuranceSymptomatic Rx e.g. analgesis± Medroxy-progesterone acetate 30mg/d PO or as depot?: Ventral suspension of uterus (usually unsuccessful)TAH & BSO – sometime the only cureMx – usually medical (unsatisfactory results):Ovulatory pain (“Mittelschmertz”):Definition: Mid-cycle LAP:Associated with:± Malaise± Nausea± Abdominal tendernessAx – 3 hypotheses:Follicle ruptureDistension of ovarian capsuleSmall haemoperitoneumMx: Reassurance & sometimes ovulation suppressionDyspareunia:Definition: Painful sexual intercourse:Classifications:Superficial – if it occurs with attempted penetration:Usually psychogenic in nature – most often due to:Hx of sexual problemsHx of sexual abuseFear of pain it 1st coitusCommon in prostitutes (when they have a stable & loving relationship)Can be organic e.g. STD’sDeep penetration – if it occurs with deep penetration:Usually from organic lesions (see below)Organic lesions:Examples:Thickened hymenTransverse vaginal septumShort, blind perineal pouch – due to Mullerian agenesis OR androgen insensitivity syndromeInflammatory lesions e.g. vulvar/vaginal oedema or excoriationBartholin’s abscessCystEndometriosisAcute/chronic salping-oophoritisSmall mass in pouch of DouglasPost-operative scarringAnterior/posterior colporraphyVulvar/vaginal atrophy (due to oestrogen deficiency)Mx: Rx organic lesion AND demonstrate normal anatomy to patient (if the patient’s anatomy is normal) to reassure herPremenstrual syndrome (PMS):Definition: Cyclical appearance of Sx in the pre-menstrual period (2nd half of cycle), with disappearance in the post-mentrual period for atleast 3 cycles:Ax:3 categories:PsychologicalBehaviouralSomatic (physical)Common symptoms (fit into the fore-mentioned categories):BloatedWeight gainHeadacheAnxietyTenderness & swelling of breastsDepressionIrritabilityNote: Associations with the following have been made – but aren’t common to all patients with PMS:Previous child abuseMarital disharmonyPoor work performanceAbsenteeismSuicide & criminal actsDx:Detailed Hx & clinical assessment“Menstrual diary” kept by patient – record dates; symptoms; severity of Sx; weight gain“PM Cator” – patient decides on 3 most worrying Sx & records their frequency & severity dailyTo continue with diary/PM Cator throughout cycle & treatment phase to assess improvementMx:center100965Conservative measures:Exclude organic pathologyCounseling & reassurance if no organic pathologyDiet manipulation or supplementation↓ Dairy products↓ Saturated fats & refined sugars↓ Caffeine – coffee; tea; cocoa; chocolate; colaLimit alcohol to 1 drink/daySupplementation – little evidence of benefit:Evening of primrose oil ORVitamin E 2 tab. per dayMgCl2 1-2 tab. nocteMedical:Generalized Sx’s:Dysfunctional bleeding: NSAIDsDysmenorrhoea: NSAIDsContraception: Progesterone dominant COCSpecific Sx’s:Breast pain: Bromocriptine 2.5mg/nocte from day 10 of cycleMetergoline 4mg tds from day 10 of cycleFluid retention: Spironolactone 25mg qid in 2nd ? of cycleDepression: SSRI’s OR TAD’s & psychiatric evaluation/guidance00Conservative measures:Exclude organic pathologyCounseling & reassurance if no organic pathologyDiet manipulation or supplementation↓ Dairy products↓ Saturated fats & refined sugars↓ Caffeine – coffee; tea; cocoa; chocolate; colaLimit alcohol to 1 drink/daySupplementation – little evidence of benefit:Evening of primrose oil ORVitamin E 2 tab. per dayMgCl2 1-2 tab. nocteMedical:Generalized Sx’s:Dysfunctional bleeding: NSAIDsDysmenorrhoea: NSAIDsContraception: Progesterone dominant COCSpecific Sx’s:Breast pain: Bromocriptine 2.5mg/nocte from day 10 of cycleMetergoline 4mg tds from day 10 of cycleFluid retention: Spironolactone 25mg qid in 2nd ? of cycleDepression: SSRI’s OR TAD’s & psychiatric evaluation/guidanceEndometriosis:Definition: Presence of endometrial tissue (glandular & stromal) at any other site outside the uterine cavity:Sx – classic triad of either:Sever pelvic pain:Gradual onset → with increasing severityStarts prior to onset of menstruationDue to congestion of pelvic organs (fixed)Continues throughout menstruation & ↑ due to peritoneal irritationOften felt sacrally or referred to rectum, perineum &/or lower limbs (esp. if retroverted – reason unknown)↑↑ If associated with rupture of endometriomaDyspareunia may indicate a retroverted uterus & adnexaeDysmenorrhoea (due to congested endometrial deposits) AND/OR Dyspareunia (due to adhesions → frozen pelvis):Infertility (due to tubal damage) – due to:Interference of tubal function due to deposits &/or adhesions (affect fimbrial pick-up mechanism)Other – depend on deposition site & presence of adhesions:Menometrorrhagia (advanced disease – due to ovarian adhesions → an/dysovulation)Constipation & diarrhea Haematuria (bladder involment)Ex:Bluish nodules in vaginal fornicesCETRetroverted uterusTender, mobile semi-solid adnexal mass (“chocolate cyst”)Thickened/nodularity of recto-vaginal septum (on bimanual PV)Dx:Patient in late 20’s/early 30’sHx of dysmenorrhoea in ovulatory cycles (in adolescence); late child-bearingSpecial investigations:Laparoscopy for visualization & biopsyAx:Retrograde menstruationMetaplasia of multipotenitial coelomic epitheliumHaemotlogic/lymphatic spread of endometrial cellsAuto-immune factorsFamilial factors (no proven link thus far)Racial factors (no proven link thus far)Pathology:Brownish, purple nodule on peritoneum – associate with scarring or puckering (as result of old lesions)Can involve tubes; ovaries; omentum; pouch of Douglas; bowel (→ obstruction & IBS picture)Adhesions are common → frozen pelvis &/or eventual ovarian destruction → infertility (as well as ↓ ovum migration due to tubal damage)Repeated intra-ovarian haemorrhage → endometrioma – cyst with diameter of 15-20cm, filled with chocolate colored material (old blood)center150495Medical:Hormonal manipulation (suppression of ectopic endometrial tissue):COC ORMild disease: Injectable progestogen (MPA)Moderate/severe:Progesterone derivatives e.g. Gestrinoneα - methyl testosterone testosterone derivatives (Danazol)GnRH Rx – can completely suppress menstruation (if given constantly) → ectopic endometriotic tissue atrophy – S/E hot flushes; osteoporosisSugical:Conservative:AdhesiolysisEndometrioma removal (ovarian cystectomy)Cautery of small endometriotic depositsRadical:TAH & BSO00Medical:Hormonal manipulation (suppression of ectopic endometrial tissue):COC ORMild disease: Injectable progestogen (MPA)Moderate/severe:Progesterone derivatives e.g. Gestrinoneα - methyl testosterone testosterone derivatives (Danazol)GnRH Rx – can completely suppress menstruation (if given constantly) → ectopic endometriotic tissue atrophy – S/E hot flushes; osteoporosisSugical:Conservative:AdhesiolysisEndometrioma removal (ovarian cystectomy)Cautery of small endometriotic depositsRadical:TAH & BSOMx – choice depends on future fertility; grade of severity on laparoscopy:Diseases of the internal genital organs, which present with pain:Complications of pregnancy:AbortionEctopic pregnancyGynatresia Cx: Can for haematocolpos, which → painAx:Imperforate hymenTransverse vaginal septumCervical atresiaNon-communicating horn of abnormally developed uterusAfter cervical cautery/cone biopsy Atrophic stenosis (post-menopausal ♀) – associated with endocervical/endometrial malignancy OR radiotherapy for these malignanciesMx: ?Myomata:Types: Degeneration/torsion → pain OR red-degeneration (in pregnancy) due to congestion.Character:Red-degeneration: Crampy ± associated peritoneal irritationPedunculated: Acute colicky-like painSubmucus (aborting through Cx): Labour-like pains associated with meno-metrorrhagiaAssociated with peritoneal irritationMx: Laparotomy (to exclude appendicitis)If red myomata is found → leave it in-situ (removal could result in massive haemorrhage)Rx: AnalgesiaAdenomyosis:Definition: Ectopic endometrial tissue within the myometrium (which is thickened & hypertrophied):Characteristics:Patient usually 30-40’sPresents with 2? dysmenorrhoea associated with menorrhagiaUterus symmetrically enlarged & tender to palpation (esp. at menstruation)± Feeling of pelvic heaviness &/or aching &/or dyspareuniaMx: Hysterectomy (diagnosis made retrospectively)Pelvic inflammatory disease (PID):Character:Severe bilateral LAPAssociated with:WeaknessFeverCET± Adnexal massesWCC & ESR both ↑Note: PID is a differential for endometriosisCx:An acute abscess can develop → severe persistent pain (location depending on abscess site); Sudden pain due to rupture (esp. if associated with collapse & rapid deterioration)If not properly Rx → chronic inflammation → intermittent pain aggravated by menstruation, dyspareunia & infertility.Pain of ovarian origin:Note: This kind of pain is rare (the ovarian itself is insensitive to pain):Ax: Tumor Cx → pain, e.g.:TorsionHaemorrhageIxNecrosisRupturePost-hysterectomy:Ax: Deep dyspareunia (due to adhesions between vaginal vault & ovaries = “Residual ovary syndrome”Mx: OophorectomyPelvic adhesions:Ax: Previous PID; prvious surgery; burnt-out endometriosisMx: Adhesiolysis during laparotomy OR laparoscopyPain from non-gynaecological pelvic organs:Classification & Ax:Urinary tract – urine dipstix may show blood/white cells:Acute cystitisUreteric calculiPost-surgeryOver-enlarging uterus → bladder pressure (e.g. retroverted & pregnant) → pain & central massIntestinal:AppendicitisRegional ileitisDiverticulitisIntestinal obstructionIBSCancer → obstruction → painThrombophlebitis of pelvic veins after surgery OR due to sepsis → pain + swinging fever + tender pelvic sidewall on PV.Mesenteric obstruction (venous) → severe abdominal painOrthopedic Ax:OsteoarthritisSpondylolisthesisFibromatosisExtra-intestinal causes:PancreatitisCholecystitisHepatitisExtra-abdominal causes:PorphyriaDrug withdrawalPsychogenic pain:Note: Diagnosis of exclusionSx & associations:No organic/functional pelvic pathologyGenerally diffuse, poorly localized & non-radiatingAggravated by menstruation & sexual intercourseAssociated with malaise, headaches & depressionHx of unhappy childhood, absent parental affection or interest1/3 of these women were sexually abused as children± Left home early or married young± Unsuccessful marriages with ↓ libido± Lack of interest in child-bearing± Sexual dysfunction &/or dyspareuniaMx:center114300ReassurancePsychotherapy (with partner involvement)ExerciseBiofeedbackAcupunctureTranscutaneous electrical stimulation00ReassurancePsychotherapy (with partner involvement)ExerciseBiofeedbackAcupunctureTranscutaneous electrical stimulationVulvar lesions:Classification:Red lesions:CandidiasisContact dermatitisVulvodyniaSystemic skin disorders:PsoriasisDermatosisWhite lesions:Dystrophies:Lichen sclerosis (↓ skin growth)Vulvar hyperplasia (↑ skin growth)Vulvar intraepithelial neoplasiaVitiligoDark lesions:NeviMalignant melanomaUlcers:Genital herpesSyphilisLymphogranuloma venereum (LGV)Granuloma inguinaleHuman immunodeficiency virusCarcinoma (see large tumors)Small tumors:CondylomataSebaceous cystsInclusion cystsFibroepithelial polypsBartholin abscessCarcinoma (see large tumors)Large tumors:FibromaLipomaLarge condylomataCarcinomaRed lesions:Candidiasis:Note:Not an STDNormal flora in vagina – controlled by the microclimate of the vagina, which is hormone dependantSx – involvement includes labia minora & majora:Severe pruritisBurningWhitish discharge (thin or thick)OedematousRedTender to touchCx – recurrences after medical treatment, due to:Systemic antibiotics – prolonged/repeated useDMCorticosteroid use e.g. asthmaCOC’s esp. high dose oestrogen types↓ Immunity e.g. HIVCandida species other than C. Albicans.Mx – manage medically:center-7620Nitroimidazole creams or pessaries – taken daily for 3-6dClotrimazoleEconazoleMiconazoleTerconazoleOral imidazole derivatives:FluconzaoleItraconazoleImprove genital hygiene:Cotton panties onlyTight clothing avoidedPerfumed soap/toiletries avoidedFront to back wipingSoaking baths avoided00Nitroimidazole creams or pessaries – taken daily for 3-6dClotrimazoleEconazoleMiconazoleTerconazoleOral imidazole derivatives:FluconzaoleItraconazoleImprove genital hygiene:Cotton panties onlyTight clothing avoidedPerfumed soap/toiletries avoidedFront to back wipingSoaking baths avoidedContact dermatitis:Note:2nd most common lesionDiagnosis of exclusionHx:New soap or deodorantPerfumed toiletries incl. bath saltsMx: Omission of suspected irritant agentVulvodynia:Definition: Painful vulva (uncommon but distressing)Dx: BiopsyMx: R/FSystemic skin disorders:Note: Vulva also affected by systemic skin disorders e.g. SLEMx: R/FWhite lesions:Vulvar dystrophies (uncommon):Classification & management:Lichen sclerosis – vulva frequently involved; all ages affected:Sx:Pruritis (severe)± Burning“White ring” surrounding vulva ± anus – hard; leathery; thinAtrophy of labia minora“Buried clitoris” – clitoris buried underneath skinDx: Biopsy (R/F)Mx: Corticosteroid or testosterone creamVulvar hyperplasia – due to chronic irritation:Sx:PruritisBurningSkin may appear whitish & oedematousDx: Biopsy (R/F)Cx: Can be pre-malignant (if atypia is present = VIN)Mx: Corticosteroid creamVulvar intraepithelial neoplasia:Note: If any biopsy indicates hyperplasia AND atypical cells → regard as pre-malignant (VIN):Mx:R/F?: VulvectomyReconstructionVitiligo:Note: Benign Sx: Widespread, congenital white discolouration of skinHair unaffected (retain pigment)Mx: ReassuranceDark lesions:Nevi:Note: Regard as PRE-MALIGNANT!!!Mx: ? – excision biopsyMalignant melanoma:Note: Rare but aggressive tumorsSx:Black± Speckled with areas of white skin± Raised with irregular papules or patches of skinDx: Excision biopsy (done at referral centre)Mx: R/F promptly? (Excision biopsy)Further cytotoxic Mx e.g. chemoradiationUlcers:Genital herpes:Note:HSV IIIncubation of ≈ 7d1st attack can last up to 4wkRecurrences not as severe as initial attackSx:Acutely painfulVesicles (3-5mm) → ulcerateRedness & swelling± 2? Ix (often) → purulent dischargeMx – symptomatic:800100-2540If mild-moderately ill:AnalgesiaAntibiotics (for 2? Ix)Sitz baths q4hr (NaCl or chlorhexidine H2O)Acyclovir (topical or PO)If seriously ill:Acyclovir IVIR/F2nd & subsequent attack aren’t as severe as the 1st but Mx remains the same00If mild-moderately ill:AnalgesiaAntibiotics (for 2? Ix)Sitz baths q4hr (NaCl or chlorhexidine H2O)Acyclovir (topical or PO)If seriously ill:Acyclovir IVIR/F2nd & subsequent attack aren’t as severe as the 1st but Mx remains the sameSyphilis:Sx:1? Syphilis:Chancre:Painless± Unnoticed on Cx2? Syphilis:Condylomata lata:MultipleFlatRoundShallowPainfulcenter176530RPR:If positive → Rx for syphilisIf negative → R/F urgently for CA exclusionSyphilis Rx:Benzathine penicillin 2.4million units IMI STAT weekly x3 (1.2million units in each buttock)00RPR:If positive → Rx for syphilisIf negative → R/F urgently for CA exclusionSyphilis Rx:Benzathine penicillin 2.4million units IMI STAT weekly x3 (1.2million units in each buttock)Mx:Lymphogranuloma venereum:Note:Ax: C. TrachomatisFound in warmer areasClassified as an STDSx:Ulcer: SmallInguinal lymphnodes: HugeVulvar skin:RedPainfulInduratedAfter acute healing → ± scarring → narrowing vagina & anus → severe painDx: Chlamydia serology (very common Ix)center145415Tetracylines 500mg q6h x21dIf no response after 1wk → R/F urgently to exclude CA00Tetracylines 500mg q6h x21dIf no response after 1wk → R/F urgently to exclude CAMx:Granuloma inguinale:Note:Ax: CalymmatobacteriumClassified as an STDSx:Ulcers → ± great tissue loss:HugeShallowRedSpreadingSurrounding tissue: OedematousInguinal lymphnodes:Enlarged± SuppurationDx: Donovanosis (bacteria encapsulated in leukocytes) on imprint cytology or biopsyMx:center-7620Tetracyclines 500mg q6h x3wkVulvar biopsy to exclude CA (mandatory in GI)Sitz baths (as for HSV II)00Tetracyclines 500mg q6h x3wkVulvar biopsy to exclude CA (mandatory in GI)Sitz baths (as for HSV II)Human immunodeficiency virus (HIV) ulcers:Note: Ulcers of varying types & appearances (±)Always do HIV VCTPATIENTS WITH 1 SEXUALLY TRANSMITTED DISEASE MAY HAVE MORE; ALWAYS DO RPR, CERVICAL CYTOLOGY & HIV COUNSELING & TESTINGSmall tumors:Condylomata acuminata:Note:Ax: Human papilloma virus (HPV)STDSx:Warty2? Ix → purulent dischargeAnus & perineum most commonly involved but vulva may also be involvedMay occur on Cx (and → Cx CA)0164465If surrounding skin is red, white or forms raised lesions → R/F for biopsy to exclude VIN & CACx cytology & examination to exclude cervical involvementSmall lesions:Podophylin ointment applied to warts 2-3x/wkProtect surrounding skin with vaselin ointmentLarge lesions → R/F:ElectrocauteryLazer? – Excision00If surrounding skin is red, white or forms raised lesions → R/F for biopsy to exclude VIN & CACx cytology & examination to exclude cervical involvementSmall lesions:Podophylin ointment applied to warts 2-3x/wkProtect surrounding skin with vaselin ointmentLarge lesions → R/F:ElectrocauteryLazer? – ExcisionMx:Sebacous cysts:Ax: Small obstructed para-follicular glands (i.e. glands next to hair follicles):Sx:Benign natureSmoothFirmLight yellowLeaking of sebum → pruritisMx: Excise (if causing pruritis)Inclusion cysts:Note: Often found in old episiotomy repair sitesSx: Small, firm, moderately tender cysts ± superficial dyspareuniaMx: ExcisionFibroepithelial polyps (very common):Sx:Small – usually asymptomaticLarge (due to getting entangled in pubic hair/underwear):≥ 5mmPainMx: ExcisionBartholin’s abscess – abscess in Bartholin’s gland:Ax:Neisseria gonococciChlamydia trachmatisStaphylococciStreptococciSx:Pain, swelling & warmth over area of Bartholin’s gland (beneath labia minora, within labia majora, where anterior 2/3 meets posterior 1/3.1167130114935Skin drainage – under local/GAMarsupialization esp. if recurringAnalgesia e.g. ibuprofen &/or paracetamolAntibiotics e.g. Tetracyclines for 10dSitz baths00Skin drainage – under local/GAMarsupialization esp. if recurringAnalgesia e.g. ibuprofen &/or paracetamolAntibiotics e.g. Tetracyclines for 10dSitz bathsMx:Large tumors:Fibromas & lipomas:Sx: Benign; from fibrous/fatty tissue respectively; occur at any siteMx: Large vulvar tumors require R/F & ? removalLarge condylomata acuminata:Note:↑ size esp. in pregnancyDifficult to differentiate from CAMx: R/F & biopsyCarcinoma of vulva:Note:35-75yr5% of gynaecological CASx:Small tender “ulcer” initially → growLarge ulcer ORExophytic tumorInguinal lymphnode involvement Dx: Biopsy (in this case will indicate squamous CA – due to underlying HPV Ix)Mx:center22225R/F? – Radical vulvectomy with groin node dissection± RadiotherapyPost-operative nursing – wound carePalliation 00R/F? – Radical vulvectomy with groin node dissection± RadiotherapyPost-operative nursing – wound carePalliation Pruritis vulvae:Ax:Candidia albicansTrichomonas vaginalisContact dermatitisGeneralized skin diseasesDrug reactionsMx:center41910Avoid irritantsImprove genital hygieneAll pts. given trial of anti-candida Rx:If improvement → repeat dose prnIf no improvement → add metronidazole STATPersistent Sx’s benefit from long term application of anti-candida medicationsConsider anti-pruritis for systemic pruritis with vulvar manifestations00Avoid irritantsImprove genital hygieneAll pts. given trial of anti-candida Rx:If improvement → repeat dose prnIf no improvement → add metronidazole STATPersistent Sx’s benefit from long term application of anti-candida medicationsConsider anti-pruritis for systemic pruritis with vulvar manifestations Vaginal discharge:Classification of vaginal discharge:Diffuse dischargePhysiologicalInfectiousVaginitisTrichomonasCandida spp.Bacterial vaginosisEndocervicitis:Neisseria gonohorrhoeaChlamydia trachomatisAtrophicIrritants & allergensLocalized dischargeForeign bodyFistulaNeoplasiaCervical dischargePhysiologicalPathologicalEndocervicitisNeoplasiaPhysiological vaginal discharge:Characteristics:Fluctuates with menstrual cycles (with regards to amount & consistency)No malodorous, irritating or blood stainedClear or whiteNon-homogenous/flocculatingpH < 5Whiff test is negativeNo vulvar ulcers, rash, erythema, CETEpithelial cells & lactobacilli on wet mount smearAx:Oestrogen → stimulation of lactobacilli → ↑ lactic acid formation (from glycogen in the discharge) → ↓ pH → infection non-friendly environment. (The rest of the discharge consists of endocervical mucus, exfoliated epithelial cells & vaginal transudate)center208915ReassureNo specific RxNo further investigations/testsIf pt. still unhappy → R/F for 2nd opinion, or R/F microscopy, or do vaginal swab & send for M, C & S00ReassureNo specific RxNo further investigations/testsIf pt. still unhappy → R/F for 2nd opinion, or R/F microscopy, or do vaginal swab & send for M, C & SMx:Atrophic vaginosis:General:PostmenopausalSx’s of genital atrophyAx:↓ Oestrogen (MP) → ↓ discharge & glycogen → non-flourishing lactobacilli → ↑ pH → 2? bacterial IxSx:↓ SC fat → less prominent labia majoraIntroitus narrowsEpithelium → pale & shiny↓ Vaginal rugae± Small bleedingsCx → smaller with smaller diameter; ↓ intravaginal portion; no endocervical mucus± Urethral mucosa prolapse (may be small) Dx:Vaginal pH ↑ → 6.5-7.0On wet mount – more pus cells (polymorphs) than epithelial cells AND no lactobacilliMx:center-5080Exclude CA & other causes for PMB 1st !!! (If excluded → proceed to point 2.)Cx cytologyCx biopsy (if any suspicious lesion is found)Endometrial biopsy (if the discharge is bloodstained)Oestrogen cream 0.5-1 applicator nocte PV x1wk↓ Oestrogen to every other night x2wkContinued every week prnAdd progestogens if long term oestrogen Rx is requires (if the patients uterus is still in-situ)00Exclude CA & other causes for PMB 1st !!! (If excluded → proceed to point 2.)Cx cytologyCx biopsy (if any suspicious lesion is found)Endometrial biopsy (if the discharge is bloodstained)Oestrogen cream 0.5-1 applicator nocte PV x1wk↓ Oestrogen to every other night x2wkContinued every week prnAdd progestogens if long term oestrogen Rx is requires (if the patients uterus is still in-situ)Vaginal discharge due to infections:Trachomonas vaginalis:Sx & characteristics:Red vagina; ± Cervical/vaginal swellingPain & dyspareuniaDysuria & frequency± “Strawberry-red” appearance of cervixMalodorousProfuse, grey-white to yellow-green discharge± BubblespH > 5.0 (discharge’s pH)Dx: Motile trichomonads of NaCl wet mount smear (microscopy)center133985If not pregnant: Metronidazole 2g STAT PO (Warn her not to take alcohol during until ≥ 24hr after dose)If pregnant: Clotrimazole pessaries 100mg nocte x6nightsCounseled about STD nature of disease → Rx consortCounseled on responsible sexual behaviour:CondomsCOC’sCounseled on risk for other STD’s & HIV:Test for other STD’s (picture often mixed)HIV VCT00If not pregnant: Metronidazole 2g STAT PO (Warn her not to take alcohol during until ≥ 24hr after dose)If pregnant: Clotrimazole pessaries 100mg nocte x6nightsCounseled about STD nature of disease → Rx consortCounseled on responsible sexual behaviour:CondomsCOC’sCounseled on risk for other STD’s & HIV:Test for other STD’s (picture often mixed)HIV VCTMx:Vaginal candidiasis:Sx & characteristics:Watery to thick white dischargeScant to moderateClumpedPlaques on vaginal wallspH < 5.0Vulvar pruritis (aggravated during last week of menstruation)Vaginal/vulvar/introital redness & inflammationDx: Budding yeast cells OR hypae on K-OH wet mount (microscopy)Mx:center114300Anti-fungal Rx:PV administration types:Clotrimazole 100mg bd x6 OR 500mg STATMiconazole 200mg bd x7Econazole 150mg/d x3d OR 150mg depot STATOral type:Fluconazole 150mg STATIf associated vulvitis → prescribe extra antifungal cream Exclude/remove predisposing factors:Personal habits:Deodorant useDouchesPerfumed toilet paperBubble bathsTight nylon underwearPregnancyPills:Braod spectrum anti-bioticsCorticosteroidsContraceptives (with high oestrogen content)Physical disease:ImmunosuppressionDM00Anti-fungal Rx:PV administration types:Clotrimazole 100mg bd x6 OR 500mg STATMiconazole 200mg bd x7Econazole 150mg/d x3d OR 150mg depot STATOral type:Fluconazole 150mg STATIf associated vulvitis → prescribe extra antifungal cream Exclude/remove predisposing factors:Personal habits:Deodorant useDouchesPerfumed toilet paperBubble bathsTight nylon underwearPregnancyPills:Braod spectrum anti-bioticsCorticosteroidsContraceptives (with high oestrogen content)Physical disease:ImmunosuppressionDMBacterial vaginosis:Sx & characteristics:Thin, malodorous dischargeHomogenousWhite to greypH > 5.0No vaginal/vulvar rednessDx:Positive whiff testClue cells on NaCl wet mount smear (epithelial cells coated by coccobacilli → granular appearance/indistinct margins)Cx:PrematurityPROMPostpartum endometritisRisk of Ix after gynaecological proceduresNOTE: TREAT ALL SYMPTOMATIC PATIENTS AS WELL AS ASYMPTOMATIC PATIENTS THAT ARE PREGNANT OR SCHEDULED TO UNDERGO A GYNAECOLOGICAL PROCEDURE OR OPERATIONMx:center3810Metronidazole 400mg tds PO x7d (deferred until end of 1st TM in pregnancy)Counsel patient:STD’s & HIVCondom useTreating her consort or sexual contactsTest for & treat any other STD’sHIV VCT00Metronidazole 400mg tds PO x7d (deferred until end of 1st TM in pregnancy)Counsel patient:STD’s & HIVCondom useTreating her consort or sexual contactsTest for & treat any other STD’sHIV VCTVaginitis caused by foreign bodies, irritants & allergens:Foreign body vaginitis:Sx & characteristics:Watery, profuse & malodorousForeign body visible on careful speculum examinationForgotten tamponsPessariesIUCDPlastic, wood etc. (accidentally placed in vagina)center159385Remove foreign bodySitz baths or douching (NaCl water)No antibiotics (clearance of obstruction → clearance of Ix)If caused by IUCD:Place patient on suitable & alternative contraception (unless patient has PID → REMOVE!!)00Remove foreign bodySitz baths or douching (NaCl water)No antibiotics (clearance of obstruction → clearance of Ix)If caused by IUCD:Place patient on suitable & alternative contraception (unless patient has PID → REMOVE!!)Mx:Allergenic/irritant induced vaginitis:Sx & characteristics:Hx of irritant use e.g. soaps, lubricants, spermacide, perfumed toilet paper/sanitary towels, powders or feminine hygiene productsDischarge not prominentInflamed &/or oedematous vulva/vaginapH > 5 due to alkaline douchesAll other causes of pruritic discharge are excluded:Whiif test negativeWet mount smear negativeCandida culture showed no growth (only done if a smear can’t be done)Mx:1510030-2540Stop offending agents1% Hydrocortisone cream bd x7d00Stop offending agents1% Hydrocortisone cream bd x7dVaginal discharge due to neoplasia:Sx & characteristics:Associated with postcoital/spontaneous bleeding± Responds poorly to normal RxWatery, malodorous± BloodstainedLocalized CA on careful inspection e.g. CxCAMx:center80010If suspicious lesion → punch biopsyCervical smear – cytologyAntibiotics – trial of Rx (while awaiting biopsy results):Amoxil 250mg tdsMetronidazole 200mg tds00If suspicious lesion → punch biopsyCervical smear – cytologyAntibiotics – trial of Rx (while awaiting biopsy results):Amoxil 250mg tdsMetronidazole 200mg tdsVaginal discharge due to fistulas:Rectovaginal fistula:Ax:Obstetric traumaIrradiationMalignancySx & characteristics:± Incontinence of faeces/flatus (continually or only when she has diarhhoea)Faecal soiling of vagina± Vaginal opening of fistula may be seenMx:center10160R/F for ? repairAntibiotics while awaiting transfer:Amoxil 250mg tdsMetronidazole 200mg tds00R/F for ? repairAntibiotics while awaiting transfer:Amoxil 250mg tdsMetronidazole 200mg tdsUrinary fistula:Ax:Previous pelvic surgery (most commonly accidents done by gynae’s themselves)Obstetric traumaRadiationMalignancySx & characteristics:Urinary incontinence (usually continuously)Urine draining observed on examinationVaginal opening of fistulaMx: R/FAcute cervicitis & pelvic inflammatory disease:Acute cervicitis:Ax:Chlamydia trachomatisNeisseria GonorrhoeaHSVGram negatives (mixed)Gram positives (mixed)Hx:Intermenstrual/post-coital bleeding (differential for CxCA)C. Trachomatis usually asymptomaticHVS is painless & presents with small blisters & ulcers on CxSpread to ligaments of uterus or bladder (lymphatic spread) → pain on intercourse &/or micturitionSx:Purulent discharge; muco-purulentCx redness & oedemaCx ulceration (HSV)± Cx tenderness NOTE: CET IMPLIES FALLOPIAN TUBE INVOLVEMENT AN SALPINGITIS IS THEN DIAGNOSED & TREATEDDx:Wet mount smearClinical diagnosisMx:53340024765PAP smear – if HVS is suspected, wait for results before commencing RxNon-pregnant patients:Ciptofloxacin 500mg PO STAT OR Ofloxacin 400mg PO STAT PLUSDoxycycline 100mg q12h x10d OR Tetracycline 500mg q6h x10dPregnant patients:Ceftriaxone 250mg IMI STAT OR Spectinomycin 2g IMI STATPLUSErythromycin 500mg q6h x10Counsel:STD’s & HIV VCTTreat consort & contactsCondomiseCOC (if non-pregnant)00PAP smear – if HVS is suspected, wait for results before commencing RxNon-pregnant patients:Ciptofloxacin 500mg PO STAT OR Ofloxacin 400mg PO STAT PLUSDoxycycline 100mg q12h x10d OR Tetracycline 500mg q6h x10dPregnant patients:Ceftriaxone 250mg IMI STAT OR Spectinomycin 2g IMI STATPLUSErythromycin 500mg q6h x10Counsel:STD’s & HIV VCTTreat consort & contactsCondomiseCOC (if non-pregnant)Pelvic inflammatory disease (PID):Note:Ascending genital IxGeneral term, which includes:EndometritisSalpingitisPeritonitisTuno-ovarian abscessAx: Sexually transmitted vectors e.g. sperm & trichomonads ↑ spread of the following (polymicrobial disease):GonococciChlamydiaNOTE: SUPERSESSION BY 2? GRAM NEGATIVES &/OR ANAEROBESPathogenesis: Mild salpingitis involves tubes (swollen & red BUT still mobile & open) → spreads to adjacent pelvis → tubal/tubo-ovarian abscess → ± rupture → generalized peritonitis → severe illness & ± death. Scarring of pelvic organs (fibrosis) → tubo-ovarian complex &/or hydrosalpinx → chronic salipngitis (Asymptomatic) Recurrent re-infections now occur more easily – syndrome is called chronic PID.Risk factors:Young & sexually activeMultiple sex partners, new partner or partner with multiple partnersOther STD’sHIV positive patientsIUCD – in the light of Ix → accelerate ascending spread of pathogens through CxSx:LAP + vaginal discharge + feverFlu-like symptomsGIT & bladder (dysuria) SxInfertility (late Sx)Fever & tachycardiaTenderness on abdominal ExRebound & guarding of lower/whole abdomen (severe sign)Purulent/infectious dischargeCETTender adnexal masses suggests infective (esp. if semi-cystic & bilateral) – tubo-ovarian complexStaging of PID:Stage IEarly salpingitis; local tendernessStage IISalpingitis & localized peritonitis (rebound & guarding)Stage IIIAs for I & II + inflammatory mass (guarding may hinder palpation)Stage IVRupturing of inflammatory mass → acute abdomen; generalized peritonitis; failure to respond to medical Rx; septic shock picture → R/F ? MxDifferential Dx:Cx of pregnancy – ectopic; abortionsGIT – appendicitisUTIx & kidney stonesEndometritisCx:Infertility↑ Risk of ectopic pregnancyOvarian destruction± Need to perform hysterectomy (stages III & IV)STD’sDeathcenter226695↓ Risk:MonogomyCondoms (male or female condoms)COC or IJ-contraceptionPregnancy (almost impossible to get it during pregnancy – not a recommended method of prevention)Outpatient Rx – only stages I & early II:Ciptofloxacin 500mg PO STAT OR Ofloxacin 400mg PO STAT PLUSDoxycycline 100mg q12h x10d OR Tetracycline 500mg q6h x10dMetronidazole 400mg bd x10dF/U arrangements or told to return if they deteriorate → admitInpatient Rx – Late stage II, stages III & stage IV:If generalized peritonitis present:R/F promptlyIV line & resuscitation + 1st dose of antibioticsAnalgesia (consider morphine)Symptomatic Rx:AnalgesiaAdequate fluidsMonitor vitals esp. T?, pulse & abdominal signsAnti-biotics:Regimen 1:Cefoxitin 2g IV q6hr PLUSDoxycycline 100mg IVI q12hrRegimen 2:Ampicillin 1g IV q6hr PLUSGentamycin 1.5mg/kg IV q8hr PLUSMetronidazole 1g PR q12hr OR 500mg IV q8hrRegimen 3:Clindamycin 900mg IV q8hr PLUSGentamycin 1.5mg/kg IV q8hrContinue IV Rx for 48hr after clinical responseDischarge with the following antibiotics:Doxycycline 100mg bd PO ANDMetronidazole 400mg tds POIf ≥ 2 organ systems failed (MODS) incl. the genital system; is black cervix present; perforated uterus rupture; deteriorating & unresponding to Rx → consider hysterectomy00↓ Risk:MonogomyCondoms (male or female condoms)COC or IJ-contraceptionPregnancy (almost impossible to get it during pregnancy – not a recommended method of prevention)Outpatient Rx – only stages I & early II:Ciptofloxacin 500mg PO STAT OR Ofloxacin 400mg PO STAT PLUSDoxycycline 100mg q12h x10d OR Tetracycline 500mg q6h x10dMetronidazole 400mg bd x10dF/U arrangements or told to return if they deteriorate → admitInpatient Rx – Late stage II, stages III & stage IV:If generalized peritonitis present:R/F promptlyIV line & resuscitation + 1st dose of antibioticsAnalgesia (consider morphine)Symptomatic Rx:AnalgesiaAdequate fluidsMonitor vitals esp. T?, pulse & abdominal signsAnti-biotics:Regimen 1:Cefoxitin 2g IV q6hr PLUSDoxycycline 100mg IVI q12hrRegimen 2:Ampicillin 1g IV q6hr PLUSGentamycin 1.5mg/kg IV q8hr PLUSMetronidazole 1g PR q12hr OR 500mg IV q8hrRegimen 3:Clindamycin 900mg IV q8hr PLUSGentamycin 1.5mg/kg IV q8hrContinue IV Rx for 48hr after clinical responseDischarge with the following antibiotics:Doxycycline 100mg bd PO ANDMetronidazole 400mg tds POIf ≥ 2 organ systems failed (MODS) incl. the genital system; is black cervix present; perforated uterus rupture; deteriorating & unresponding to Rx → consider hysterectomyMx:Sexually transmitted diseases (STD):0233680If genital ulcer:HSV II & LGV excluded clinicallyRx for syphilis & haemophilus ducrei (Chancroid):Do RPR (treat only for syphilis & LGV/GI if positive or if test not available else only for LGV/GI if negative)Benzathine benzylpenicillin LA 2.4million units IMI STAT PLUSCiprolfloxacin 500mg PO STAT OR Oflaxacin 400mg PO STATORErythromycin 500mg PO daily x5d (if pregnant/allergic to penicillin)If vaginal discharge:Ciproflaxacin 500mg PO STAT OR Oflaxacin 400mg PO STATPLUSDoxycyline 100mg PO q12hr x10d OR Tetracycline 500mg PO q6hr x10dPLUSMetronidazole 400mg PO q12hr x7dIf urethral disachrge (males):Ciproflaxacin 500mg PO STAT OR Ofloxacin 400mg PO STATPLUSDoxycycline 100mg PO q12hr x10d OR Tetracycline 500mg PO q6hr x10dORAzithromycin 1g PO STATCounseling: Behavioural changes:Abstinence Monogomous relationshipsNon-penetrative sex (relative risk reduction but not 100% effective)Barrier contraceptionCOC’s, IJ-contracptions, IUCDTest for other STD’sHIV VCTTrace & treat contacts00If genital ulcer:HSV II & LGV excluded clinicallyRx for syphilis & haemophilus ducrei (Chancroid):Do RPR (treat only for syphilis & LGV/GI if positive or if test not available else only for LGV/GI if negative)Benzathine benzylpenicillin LA 2.4million units IMI STAT PLUSCiprolfloxacin 500mg PO STAT OR Oflaxacin 400mg PO STATORErythromycin 500mg PO daily x5d (if pregnant/allergic to penicillin)If vaginal discharge:Ciproflaxacin 500mg PO STAT OR Oflaxacin 400mg PO STATPLUSDoxycyline 100mg PO q12hr x10d OR Tetracycline 500mg PO q6hr x10dPLUSMetronidazole 400mg PO q12hr x7dIf urethral disachrge (males):Ciproflaxacin 500mg PO STAT OR Ofloxacin 400mg PO STATPLUSDoxycycline 100mg PO q12hr x10d OR Tetracycline 500mg PO q6hr x10dORAzithromycin 1g PO STATCounseling: Behavioural changes:Abstinence Monogomous relationshipsNon-penetrative sex (relative risk reduction but not 100% effective)Barrier contraceptionCOC’s, IJ-contracptions, IUCDTest for other STD’sHIV VCTTrace & treat contactsMx: Syndromic approach (primary health care) – you must, however, know individual treatment:HIV in gynaecology:HIV & gynaecological neoplasia:HPV, CIN & CxCA:Higher association of HPV in HIVDx hindered by ↑ presence of associated STD’s i.e. Gonococcus; Trichomonas; Chlamydia →must have higher index of suspicion6 monthly Cx cytology (PAP smear) → R/F for colposcopy for any cellular atypiaTreat any other STD’s before repeating PAP smearCxCA usually presents in more advanced stagesEarly aggressive Rx of CIN I → don’t F/U but rather do LLETZHIV doesn’t affect surgical MxVulvar/vaginal neoplasia:Condylomata (progresses quickly: Mx – thorough perineal hygiene & Rx with lazer/cauterySquamous CA: Mx – vigilant F/U & early biopsy due to early metastases (esp. ano-rectal involvement); later presentation; more aggressive progression HIV & gynaecological infection:Vulvovaginal candida: Mx – prolonged local & systemic Rx often neededSTD’s (↑ resistance to Rx & ↑ recurrence rate): Mx – Rx actively → ↓ HIV transmissionPID: Mx – often need longer hospitalization & more frequent change in antibiotics; also suspect TB PIDHIV & contraception:Methods:“Brace & belt” method: IJ/tubal ligation (recommended) PLUS CondomsContraception not preferably used in HIV:COC’s – ↑ failure rate IUCD – ↑ risk of IxHIV & fertility considerations:Note: Fertility ↓ due to recurrent & ↑ Ix; weight loss (which leas to anovulation)Assisted reproduction not considered on ethical or social grounds – to prevent vertical transmissionHIV & menstual disorders:Note:↑ Menorrhagia due to chronic endometritisRx actively (↑ risk of transmission during menstruation & ↑ risk of sever anaemia)HIV & gynaecological ?:Note:No significant ↑ in morbidity or mortality (if asymptomatic); no effect on rate of immune suppressionSymptomatic patients usually have ↓ weight, anaemia etc. → ↑ ? risks? should be planned with limited objective/goal in mind (with small incision)? has limited palliative role in AIDS – patient with low CD4 not given routine ?Pelvic masses:Classification:Benign disease:Female internal genitalia:UterusPregnancyMyomataOvariesSolid benign tumorsFunctional cystsFallopian tubes ± ovarian involvementExtra-uterine pregnancyInflammatory massesEndometritisOther pelvic organs:Bladder – full bladderBowelFaecal impactionDiverticulosisChronic inflammatory massesRetroperitoneal organsPelvic kidneyMassively enlarged LN’sPsoas muscle abscessMalignant disease:Female internal genitaliaUterusCxCAEndometrial CASarcomaOvariesOvarian CAOther pelvic organs:Bladder CABowelColon CARectal CARetroperitoneal organsSarcomas or soft-tissuesGynaecological US – indications:Bleeding in early pregnancySuspected ovarian cystsPMBPIDIVFUrinary incontinenceCx CASuspected congenital abnormalities of uterus/vaginaMyomatous uterus:Dx:Hx:Painless ORDoscomfort; backache; heavy-feeling; pressure Sx’s of bladder/bowel↑ Blood loss during menstruation (usually cyclical) →Dysmoenorrhoea & anaemiaEx:± AnaemiaDistension; lower abdominal pelvic mass (rarely fills abdomen like term pregnancy)Cervix displaced & smallUterus ± enlarged/globular OR single palpable myomata (soild; non-tender; mobile)± Fill whole pelvis & hollow of sacrum → determined on PRMx:center111760Oserved under following conditions:Mayomata not growing fas & relatively asymptomaticUterus size < 16wk & Dx relatively certainPatient premenopausal not wishing to have surgeryR/F for ?, esp. if:Excessive menstrual lossAnaemia↑ size of masses esp. if growth rapidMassess associated with pain, distension &/or bowel Sx’sBladder Sx’s?:TAH ORMyomectomy (in pts. wishing to retain uterus):Not always feasible, due to:AdhesionsMultiple myomataIntra-operative bleedingCx:Future fertility no guaranteed± Severe re-bleeding/recurrence00Oserved under following conditions:Mayomata not growing fas & relatively asymptomaticUterus size < 16wk & Dx relatively certainPatient premenopausal not wishing to have surgeryR/F for ?, esp. if:Excessive menstrual lossAnaemia↑ size of masses esp. if growth rapidMassess associated with pain, distension &/or bowel Sx’sBladder Sx’s?:TAH ORMyomectomy (in pts. wishing to retain uterus):Not always feasible, due to:AdhesionsMultiple myomataIntra-operative bleedingCx:Future fertility no guaranteed± Severe re-bleeding/recurrenceFunctional cysts:Note: Only in woman of reproductive age, not using contraception & has menstrual cycle.Sx:Vague pain in fossa iliaca± Menstrual disturbancesMass palpable on PV:CysticNon-tender (relatively)< 6cm in diameterFreely mobile & unilateral;center229870F/U in 6-8wk → if still present → R/F COC or short course MPA (to suppress ovulation & “shrink” tumor) → F/U 1-2wk later → if persistent → R/FSpontaneous resolution → if this doesn’t happen → R/F? for persistent or potentially harmful cyst – cystectomy & ovary preservation prferred:LaparoscopicLaparotomyAt referral centre US is done before any decision is made00F/U in 6-8wk → if still present → R/F COC or short course MPA (to suppress ovulation & “shrink” tumor) → F/U 1-2wk later → if persistent → R/FSpontaneous resolution → if this doesn’t happen → R/F? for persistent or potentially harmful cyst – cystectomy & ovary preservation prferred:LaparoscopicLaparotomyAt referral centre US is done before any decision is madeMx – 4 options:Benign solid ovarian tumors:Note: Regard as CA until proven otherwise → R/F!!! for histology & MxInfectious masses:Dx:Hx:Young & almost in reproductive yearsHx of previous pelvic Ix ± previous ?Ex:See PID & stagingBilateral masses on bimanual PV:Fixed to uterusSize < 10wk ± poorly circumscribed± Not freely mobileSemi-cystic0226060Rx for Ix but F/U to exclude CA (R/F to surgery if Dx uncertain or change in clinical picture)Rx any active Ix as for PID → ↓ size of initial mass & improve SxNo antibiotics Rx in burnt out disease (hydrosalpinx)F/U – providing mass doesn’t ↑ size & patient remain asymptomatic 00Rx for Ix but F/U to exclude CA (R/F to surgery if Dx uncertain or change in clinical picture)Rx any active Ix as for PID → ↓ size of initial mass & improve SxNo antibiotics Rx in burnt out disease (hydrosalpinx)F/U – providing mass doesn’t ↑ size & patient remain asymptomatic Mx:Gynaecological malignancy:Cervix cancer:Screening for CxCA: PAP smear (90% sensitive & 80% specific)3 smears in a lifetime: At 35; 45 & 55yr (RSA)Cervical carcinogenesis – pathogenesis:Normal cervix has multi-layered squamous epithelium on outside (ecto-cervix) & columnar mucus producing epithelium in the cervical canal (endo-cervix) – where they meet is called the squamo-columnar junction..Proliferation of endocervix, under the influence of estrogen (from puberty → menopause) grows outwards, which is protected from acidic vagina (low pH) by squamous metaplasia of the outer layer. This regresses when estrogen ↓ e.g. menstruation.The transition zone is the area of exposed columnar epithelium under this metaplastic squamous covering. Since these cells are rapidly dividing, any carcinogen exposure at the time of this dynamic process → dysplasia of the squamous cells → CIN lesion.Carcinogens: HPVRisk factors for cervix cancer development:Young 1st coitus ageMultiple sex partnersPartner with HPV (through intercourse)Partner with HIVLow socio-economic statusPre-malignant lesions – graded according to the depth of involvement of dysplastic cells – cells mature from the inside towards the outside (on Papinicolaou smear):CIN I: Dysplastic cells in lower 1/3CIN II: In lower 2/3CIN III: Full thicknessReasons for false positive (i.e. patient diagnosed has having CIN when she doesn’t)Viginal atrophyTrichomonas vaginalis infectionSevere folic acid deficiencyLaboratory errorsReasons for false negatives (Tested negative but has disease)Cervix not visualizedSmear not taken from transformation zoneToo few cells on the slideNot properly fixed to slideLaboratory errosDifferential diagnosis:CarcinomaHPV & CINHSVBilharziasisOther granulomaLarge condylomata acuminataReporting of results: Bethesda classification (cytology) vs. CIN classification (histology) – now used interchangeablyBethesda classificationCIN classificationSquamous atypiaSquamous atypiaSquamous intra-epithelial lesion (low grade)HPVCIN ISquamous intra-epithelial lesion (high grade)CIN IICIN IIIBethesda classification (complete):AbbreviationMeaningMxASC-USAtypical squamous celss of undetermined significanceRepeat PAP q6mo x3; if it persists → R/F colposcopyASC-HAtypical squamous cells – cannot exclude HSILR/F colposcopyAGCAtypic glandular cells Rx antibiotics & repeat smear in 6wk; If persists → R/F colposcopyAGV – favour neoplastic (Endocervical adenocarcinoma in-situ)Atypic glandular cellsR/F colposcopyLSIL (low grade SIL)HPV OR CIN 1Repeat PAP q6mo x2; If persists R/F colposcopyHSIL (high grade SIL)CIN 2 or CIN 3R/F colposcopyCancerSqamous/adenocarcinomaR/F immediately for colposcopyUnsatisfactoryNo Dx can be madeRepeat PAPUnsatisfactory for evaluationReason will be givenRepeat PAPProcedure for abnormal smear:If “atypia”. “HPV” or “CIN I” are found → repeat at 3-6mo:If next smear normal → repeat annuallyIf still abnormal → R/F for cervix colposcopyIf “HPV + CIN I”, “CIN II” or “CIN III” → R/F for cervix colposcopyIf “Sx of invasive CA” → R/F to large centre for cancer work-up & treatmentColposcopy (bath cervix in 3-4% acetic acid – lesions appear white) – 3 options:On-the-spot removal & treatment under local anaesthesia – Lazer/LLETZBiopsied only & treatment later (Lazer; LLETZ; hysterectomy)If not visualized → cone biopsy under GATreatment – 2 options:Wishes to retain her uterus & fertility: Lazer/LLETZ/cone biopsyFamily completed: Hysterectomy (vaginal or abdominal)F/U – 2 cervical smears 4 months apartAlternatives to cytology – not as effective:Naked eye examination – sensitive but not specific (cervix bathed in 3-4% acetic acid)Cervicography (photograph) → consult specialistCxCA – staging & Mx:StageDescriptionMxStage I (confined to Cx)Ia (depth dependant)≤ 5mm deep; ≤ 7mm wideIa1≤ 3mm deep; ≤ 7mm wideCone biopsy or simple hysterectomyIa23-5mm deep; ≤7mm wideSimple hysterectomy or radical tracelectomy & bilateral pelvic LN dissectionIb (width dependant)≥ 5mm deep; ≥ 7mm wideIb1≤ 4cm diameterRadical hysterectomy & bilateral pelic LN dissectionIb2≥ 4cm diameterPrimary radical chemo-radiationStage II (spread direction)IIa (vertical spread)Lesion from cervix to vaginal fornixPrimary radical ? or chemo-radiationIIb (horizontal spread)Lesion extends to parametria but not to pelvic side-wallPrimary radical chemo-radiationStage III (↑ spread)IIIa (vertical)Lesion to lower 1/3 of vaginaPrimary radical radiationIIIb (horizontal)Lesion to pelvic side wall(s) &/or hydronephrosisPrimary radical radiationStage IV (infiltration & metastases)IVaBladder/rectal involvemnentPalliative care ± diversion ?IVbDistant metastasesPalliative careOvarian cancer:Screening for ovarian cancer (OCA): No screening test meets criteria satisfactorily:What can be done to ↑ detection of OCA:center53340Good clinical & risk assessment:↑ risk:Family history of OCA (1st degree relatives)PostmenopausalInfertility due to anovulationAbnormal menstrual cycles (during menstrual years)Other adenocarcinomas e.g. colon, breast & endometrium↓ risk:Young ageUse of COCMultiparityPelvic US (by vaginal probe)Ca-125 (non-specific tumor marker raised in OCA)Color Doppler flow studies of tumor00Good clinical & risk assessment:↑ risk:Family history of OCA (1st degree relatives)PostmenopausalInfertility due to anovulationAbnormal menstrual cycles (during menstrual years)Other adenocarcinomas e.g. colon, breast & endometrium↓ risk:Young ageUse of COCMultiparityPelvic US (by vaginal probe)Ca-125 (non-specific tumor marker raised in OCA)Color Doppler flow studies of tumorSx – non-specific:Chronic non-specific GIT complaintsAbdominal discomfort OR feeling of fullness CachexiaAbdominal massAscitiesInterpretation of US – Suggestive of CA:Size ≥ 5cm in diameterSolid OR semi-solid OR semi-cysticIf cystic:Multi-cystic, visible papillary growths on the septae or surfaceThick septaeNon-homogenous, non-echo-free contentsMx:center26670R/F if suspectedBlood tests:FBCUKELFTTumor markers – CA125; CA19-9?:TAH & BSOOmentumectomyAscites removedExcise seeds to omentum (conservative ?)ChemotherapyGood clinical practice:Advised to report chronic Sx esp. GIT SxRegular check-ups (annually in post-menopausal patients)Good clinical & risk assessment00R/F if suspectedBlood tests:FBCUKELFTTumor markers – CA125; CA19-9?:TAH & BSOOmentumectomyAscites removedExcise seeds to omentum (conservative ?)ChemotherapyGood clinical practice:Advised to report chronic Sx esp. GIT SxRegular check-ups (annually in post-menopausal patients)Good clinical & risk assessmentEndometrial cancer (ECA):Sx:Abnormal uterine bleeding (e.g. after menopause)“Screening tests” – no effective test meeting criteria – diagnosis made on clinical assessment:Good clinical & risk assessmentUS (endometrial thickness)Endometrial biopsy (pipelle or z-sampler) – indications:PMBExcessive & intermenstrual bleeding in the peri-menopause (menometrorhagia) i.e. ≥ 40yrLate menopause (≥ 55yr)Endometrial cells reported on PAP smear in post-menopausal patientBleeding while on HRT – not related to placebo pills (opposed oestrogen HRT)♀ on tamoxifen for metastatic breast CA (annually)Risk factors for ECA:PostmenopausalObesityHx of chronic abnormal menstruationInfertility due to anovulationAssociated DM &/or HTPolycystic ovarian syndromeHx of unopposed oestrogen therapy with uterus still intactHx of other adenocarcinomas (see above)Decreased risk for endometrial carcinoma:Slender (not obese)COC useOpposed oestrogen (with progestogen) HRT at menopauseDifferential Dx for post-menopausal bleeding (in order of incidence):Atrophy (hypo-oestrogen induced) – 45% ( DIAGNOSIS BY EXCLUSION ?)Endometrial CA/cervix CA/endometrial hyperplasia – 25%Polyps/submucus myomata – 15%HRT induced bleeding – 10%Non-gynaecological bleeding e.g. PR; trauma; bladder – 5%Mx:center-2540If abnormal histology found → R/F for ?:Endometrial ablation Rx (not preferred)HysterectomyGood clinical practice:Uterus-in-situ → opposed oestrogen HRTDon’t take PMB lightly – investigate thoroughlyEducate women about PMB when they enter menopauseRegular check-ups (annually in high-risk women)US to asses endometrial thickness00If abnormal histology found → R/F for ?:Endometrial ablation Rx (not preferred)HysterectomyGood clinical practice:Uterus-in-situ → opposed oestrogen HRTDon’t take PMB lightly – investigate thoroughlyEducate women about PMB when they enter menopauseRegular check-ups (annually in high-risk women)US to asses endometrial thicknessGeneral metastatic work-up:Staging of disease:FBCUKELFTBiopsy (if indicated e.g. suspicious Cx lesion) – types (see indications):Cone (Cx)LLETZ (Cx)FNA (BRCA)Pipelle (Endometrial CA)Excision biopsy (CA in-situ)Punch biopsy (Cx & vulva CA)Tumor markersCA 19-9CA 125ALPLDHCXRBone scanPelvic sonar:TransvaginalSuprapubic transcutaneousAbdominal sonarCT/MRI scan (esp. of brain)Cystoscopy/proctoscopyAngiography/DopplerLN biopsy e.g. sentinel node in BRCAAnaesthetic risk assessment:VitalsGeneral indicators of diseaseFull systemic examinationGestational trophoblastic disease:Classification:Hydatiform mole (complete or partial)Invasive moleChoriocarcinomaHydatiform mole:Sx:Sx’s of early pregnancy e.g. ↑ N&V; ↑ breast tendernessAmenorrhoeaPostive pregnancy testPVBPassage of vesicle PVHyperemesis gravidarumUterus large for dates± Bilateral theca lutein cysts with ovarian enlargement20% have proteinuria & hypertension10% have feature of thyrotoxicosisDx:US – enlraged uterus with echolucent black hole with white rimsCXRQuantitative βHCGFBCBlood group testingTFTsMx:center-5080Uterus evacuated by suction & curettage (if size ≥ 14wk do this under US guidance)Give Oxtocin IVSend curettings for histologyD/C with reliable contraceptionF/U with βHCG measurements q2wk until normal (< 10IU/l) → monthly F/URisk of recurrence – rule out with subsequent pregnancies00Uterus evacuated by suction & curettage (if size ≥ 14wk do this under US guidance)Give Oxtocin IVSend curettings for histologyD/C with reliable contraceptionF/U with βHCG measurements q2wk until normal (< 10IU/l) → monthly F/URisk of recurrence – rule out with subsequent pregnanciesInvasive mole:Sx:Ongoing bleeding after molar pregnancy evacuationSx’s from metastases esp. vagina (blue-black nodules)Enlarged uterusPersistent bilateral ovarian enlargementS-βHCG measurable beyond 6-8wk after evacuationDx – do CT/upper abdominal US if any of the following are abnormal:CXRLFT’sPelvic USS-βCHG ≥ 40000IU/l Mx:center114300Repeat suction evacuationIf quantitative S-βHCG levels decrease → F/UChemotherapy is usually required00Repeat suction evacuationIf quantitative S-βHCG levels decrease → F/UChemotherapy is usually requiredChoriocarcinoma:Sx:Uterus contains tumorsPVBSx’s of metastatic disease:Lungs: HaemoptysisVagina: Bleeding & nodulesBrain: Seizures; ↓ LOC; focal neurological Sx’sLiver: Pain; jaundiceKidney: HaemturiaBowel: Rectal bleedingSpleen: PainSx’s of mailignancy:FatigueLoss of appetiteWastingDx: Scoring based on the following:S-βHCGCXRCT (brain)Abdominal USScore0124Age≤ 39> 39Antecedent pregnancyMoleMiscarriageTermS-βHCG<10001000-1000010000-100000>100000Interval (months)<44-67-12>12Largest tumor (cm)3-5>5Site of metastasesSplee/kidneyGIT/liverBrain# of metastases1-44-8>8Prior chemotherapySingle drug2/mor drugsMx:center85090Chemotherapy:Low-risk – single drug e.g. Methotrexate/Actinomycin DHigh-rsik – combinationMonitor treatment with serial S-βHCGContinue treatment until βHCG is normal± radiotherapy (cerebral metastases)? – for defined indications:Removal of a focus of chemoresistant diseaseLife-threatening haemorrhageTreatment of infection00Chemotherapy:Low-risk – single drug e.g. Methotrexate/Actinomycin DHigh-rsik – combinationMonitor treatment with serial S-βHCGContinue treatment until βHCG is normal± radiotherapy (cerebral metastases)? – for defined indications:Removal of a focus of chemoresistant diseaseLife-threatening haemorrhageTreatment of infectionFemale urinary incontinence:Definitions:Urinary incontinenceDemonstrable involuntary loss of urineContinenceAbility to retain urine in bladder between voluntary episodes of micturitionResidual urine volumeAmount of urine in bladder after voidingDetrussor pressureAmount of intra-vesicular pressure due to contraction of bladder musculatureUrethral pressurePressure within length of urethraUrine flowMaximal volume of urine passed per unit time (ml/sec)Bladder complianceChange in intra-vesical pressure with change in volume (indicates contractility & suppleness)Abdominal pressurePressure around bladder due to abdominal effects e.g. musculature/contents (urodynamic studies needed)UrgencyStrong & almost unbearable desire to pass urine, accompanied by fear of leaking/painUrge incontinenceInvoluntary loss of urine associated with urgency (due to detrussor instability)Urinary frequencyUrination at unacceptable short intervals (also seen in UTIx – burns)NocturiaNeed to urinate more than twice/night (nocturnal part of urgency)Stress incontinence↑ Loss of small volumes of urine with ↑ abdominal pressure (bladder neck dislocation/detrussor instability)Detrussor instability:Risk:Older women± Idiopathic± Psychosomatic± Neurological (hyper-reflexive response of UMNL)Sx:PolyuriaNocturiaUrgencyUrge incontinenceEnuresisDysuriaIncontinence on sexual intercourse± Stress incontinenceDx:UrinalysisM, C & SDifferential Dx:UITIxBladder stonePrevious radiationHypo-oestrogenismcenter215265Clear explanation & reassuranceBladder training:Empty bladder 1st thing in the morning → refrain from passing urine for ? - 2hrOnce the preset goal has been achieved → increase interval in ? hr to 1hr incrementsDrug enhancement of bladder taining:Imipramine OROxybutiline chlorideOther drugs:AnticholinergicsAnti-spasmodicsTAD’sCalcium channel blockersTopical or systemic oestrogens (esp. post-menopausal females)00Clear explanation & reassuranceBladder training:Empty bladder 1st thing in the morning → refrain from passing urine for ? - 2hrOnce the preset goal has been achieved → increase interval in ? hr to 1hr incrementsDrug enhancement of bladder taining:Imipramine OROxybutiline chlorideOther drugs:AnticholinergicsAnti-spasmodicsTAD’sCalcium channel blockersTopical or systemic oestrogens (esp. post-menopausal females)Mx:Stress incontinence:Note: Commonly found in association with genital prolapse:Ax or contributing factors:Previous NVD’s (esp. multiparous women)Menopause/ageing → ↓ urogenital tissue → ↓ intra-urethral tissueObestity/asthma & chronically ↑ intra-abdominal pressureDx:Bonney test positiveUrinalysisM, C & SUrodynamic studies (if mixed picture suspected i.e. additional detrussor instability)center130175Conservative – if ? is contra-indicated:PhysiotherapyElectrical stimulation Rx &/ORWeighted vaginal cones? – relapses may occur:Burch colopsuspensionNeedle-type suspensionsSlings (beneath bladder neck)Anterior colporrhapy with special anti-stress incontinence measures (if associated with marked vaginal wall prolapse)00Conservative – if ? is contra-indicated:PhysiotherapyElectrical stimulation Rx &/ORWeighted vaginal cones? – relapses may occur:Burch colopsuspensionNeedle-type suspensionsSlings (beneath bladder neck)Anterior colporrhapy with special anti-stress incontinence measures (if associated with marked vaginal wall prolapse)Mx:Overflow incontinence:Definition: Leakage of urine in over-distended bladder, with no detrussor instability & no ↑ abdominal pressure:Ax:Chronic over-distension → ↑ capacity (≥ 450ml – up to 1000ml can occur) → an a-contractile bladderImpaired bladder sensation → over-distensionSx:Intermittent wetness not related to a specific eventDay or night time incontinence± Precipitated by physical activityFrequencyLarge residual volumeUTIx (recurrent)Dx:Large over-distended bladderLarge residual volume after micturitionUrinalysisM, C & SCystoscopy (to rule out intra-vesicular causes of urethral obstruction e.g. tumorsMx:center-2540Medical Mx not very successfulSurgical reduction of bladder size also show minimal successIntermittent self-catheterisation tdsOestrogen cream for painful urethral orifice (with catheterization)00Medical Mx not very successfulSurgical reduction of bladder size also show minimal successIntermittent self-catheterisation tdsOestrogen cream for painful urethral orifice (with catheterization)True incontinence:Note: Patient always wet due to total loss of continence mechanisms:Ax:Congenital abnormalities:Ureteric duplication with ectopic ureteric orificesDuplication of ureter systemsAbnormally short urethrasBladder abnormalitiesUrinary fistulas – due to:?TraumaChildbirthTumorRadiation RxSx: vagina contains a pool of urine & leakage is continuousMx: R/F to large centre for ? repairNeurologically abnormal bladder:Ax:Spinal cord injuryDMMSSx:Hyper-reflexic or a-contractile depending on level of injuryMx – depends on Ax → R/F for Mx:Intermittent self-cathterisation? repairClimacteric & menopause:Important effects of oestrogen on genital organs & body - growth:CervixGrowth of glandular cells; mucus productionEndometriumGrowth of endometrial glands & stromaVaginaThickening of vaginal skin/muscle; ↑ in intra-cellular glycogen (lactobacilliary & pH maintenance)MyometriumGrowth of uterine muscleBreastGrowth & enlargement after puberty; growth of milk ductsBoneOsteoblastic new bone formation (growth)BladderGrowth of eipethelial cellsSkinStimulation of collagen softening (skin softens)LiverSHBG formation; ↑ clotting factorsBlood lipids↓ LDL; favourable HDL/LDL ratio; protects against coronary hear diseaseImportant effects of progesterone – secretion & stabilization:CervixProduction of thick viscous mucucEndometrium↓ EM gland proliferation; ↑ EM gland secrtetions; EM stabilization (↑ blood flow); ↓ uterine contractilityBreastGrowth & enlargement during & after puberty; growth of milk glandsTemperatureSlight ↑RespirationHyperventilation especially in pregnancyBoneImilar to oestrogenOestrogen deficiency:Sx:VasomotorHot flushesNight sweatsUrogenital atrophyAmenorrhoeaAtrophic vaginitisDyspareuniaBreast atrophySterile dysuria-frequencyPsychologic Sx’sAnxietyIrritabilityMemory lossMinor depression↓ normal sleep habitsOther:↓ Libido↓ SkinturgorCx:Osteoporosis → fractures of vertebral bodies (kyphosis), femur neck & wristsRisk factors:♀Post-menopausal & hypo-oestrogenicPositive family HxCaucasianThin, physically inactiveSmokingLow dietary calciumHigh dietary phosphateNon-exposure to sunlight (vitamin D deficiency)Coronary artery diseaseAlzheimer’s diseaseDx:Sx’s of menopauseAmenorrhoea for 6months↑ FSH & ↑ LHContra-indications to oestrogen Rx:Undiagnosed PVBCurrent/recurrent/recent DVT ± PTECurrent BRCA or ECACurrent severe liver diseaseSide-effects of oestrogen Rx → reduce dose or try another drug:Breast tendernessBleeding on oestrogen & progesterone RxRed discolouration of skin, face & palm of handscenter347980HRT if not contra-indicated:Initial dose: Oestradiol valerate 2mg/d; Conjugated oestrogens 0.625mg/d; Micronised oestradiol 50μg/d – preparations include:Oral:Sequential Oestrogen + Progesteone: Prempak; Trisequens; Climen → continued menstruationCombined oestrogen + progesterone: Kliogest → little bleedingOestrogen only: Premarin; Estrofem (C/I in women with uterus intact is unopposed)Skin patches:Estraderm TTS 2x/wk for 3-4dEvorel 2x/wk for 3-4dPellets q3mo – only in patients who have had hysterectomy (estradiol)Vaginal cream/tablet – lower genital tract atrophy:Alternatives:Osteoporosis:BisphosphonatesVitamin-D preparationsCalcitoninFuorideHRT esp. if mastalgia remains a problem:Tibolone (oestrogen analogue)Hotflushes:ClonidineBelladona alkaloidsSERM e.g. Raloxifen:No uterine/breast effectsNo improvement in hot flushesDoes prevent osteoporosis & improve blood lipidsSSRI’s; TAD for depression, where HRT is contr-indicatedF/U 2 months after starting HRT:Ask about side-effectsAsk about toleranceProgesterone – no proven added benefitAndrogens – to ↑ libido (controversial)Plan to use HRT for 7-12yr (there is no more advantage after 75yr of age)00HRT if not contra-indicated:Initial dose: Oestradiol valerate 2mg/d; Conjugated oestrogens 0.625mg/d; Micronised oestradiol 50μg/d – preparations include:Oral:Sequential Oestrogen + Progesteone: Prempak; Trisequens; Climen → continued menstruationCombined oestrogen + progesterone: Kliogest → little bleedingOestrogen only: Premarin; Estrofem (C/I in women with uterus intact is unopposed)Skin patches:Estraderm TTS 2x/wk for 3-4dEvorel 2x/wk for 3-4dPellets q3mo – only in patients who have had hysterectomy (estradiol)Vaginal cream/tablet – lower genital tract atrophy:Alternatives:Osteoporosis:BisphosphonatesVitamin-D preparationsCalcitoninFuorideHRT esp. if mastalgia remains a problem:Tibolone (oestrogen analogue)Hotflushes:ClonidineBelladona alkaloidsSERM e.g. Raloxifen:No uterine/breast effectsNo improvement in hot flushesDoes prevent osteoporosis & improve blood lipidsSSRI’s; TAD for depression, where HRT is contr-indicatedF/U 2 months after starting HRT:Ask about side-effectsAsk about toleranceProgesterone – no proven added benefitAndrogens – to ↑ libido (controversial)Plan to use HRT for 7-12yr (there is no more advantage after 75yr of age)Mx:Genital prolapse:Types:Uterine prolapse:Grade I:Uterus has descended but still within the vaginaGrade II:Cervix descends to outside the introitus; body of uterus still in vaginaGrade III:Body of uterus also outside vaginaAnterior wall prolapse:Urethrocele: Prolapsed urethraCystocele: Prolapsed posterior bladder wallPosterior wall prolapse:Rectocele: Prolapse of anterior rectal wallEnterocele: Prolapse of pouch of DouglasVaginal vault prolapse:Vault prolapse after hysterectomy:Risk factors:Childbirth:MultipairtyLong labourLarge babiesFamily Hx – not totally predictiveHypo-oestrogenism:PostmenopausalPuerperalMechanicalUterine or ovarian massesChronic coughingObesityChronic constipationConstitutional – CaucasiansSx:Heaviness in pelvisLow bachacheProjection of mass through inroitus± Ulceration of prolapse (severe), due to atrophy & venous congestionCystocele – bladder neck may be dislocated → stress incontinenceIf cystocele is large → urine accumulation in bladder → UTIx, dysuria & frequencyDifficulty voiding; ± Having lo lift prolapse up to void/pass urinecenter212090Mild: Treat symptomaticallyModerate/severe – R/F for ? Rx:Uterine prolapse: Vaginal hysterectomyCystocele: Anterior repairRectocele: Posterior repairEnterocele/vault prolapse: Sacrocolpopexy – vault fixed to anterior sacral ligamentsSacrospinous fixation – vault fixed to pelvic sacrospinous ligamentsUrinary stress incontinence: See incontinenceOestrogen RxPelvic floor exercises esp. young patients – performed many time a day – “pulling & sucking” anus into abdomen or by simulating anal sphincter pinching actionPessaries – plastic rings, which stretch vaginal walls (esp. older patients)00Mild: Treat symptomaticallyModerate/severe – R/F for ? Rx:Uterine prolapse: Vaginal hysterectomyCystocele: Anterior repairRectocele: Posterior repairEnterocele/vault prolapse: Sacrocolpopexy – vault fixed to anterior sacral ligamentsSacrospinous fixation – vault fixed to pelvic sacrospinous ligamentsUrinary stress incontinence: See incontinenceOestrogen RxPelvic floor exercises esp. young patients – performed many time a day – “pulling & sucking” anus into abdomen or by simulating anal sphincter pinching actionPessaries – plastic rings, which stretch vaginal walls (esp. older patients)Mx:Note: Premature menopause = menopause < 35yr, due to 2? amenorrhoea e.g. auto-immune diseases → ovarian failure; majority of cases are idiopathic; also require HRTcenter132715Exercise (weight bearing e.g. walking) – should last ≈ 1hrDietary modifications:↑ Calcium food e.g. leafy green vegetablesCalcium supplementationSelf-care – symptomatic treatment of minor symptomsRecognition of dangerous symptoms e.g. PVBSexual function:Lubrication &/or aqueous cream± AndrogensPsychosocial adaptation:Explanation & reassurance00Exercise (weight bearing e.g. walking) – should last ≈ 1hrDietary modifications:↑ Calcium food e.g. leafy green vegetablesCalcium supplementationSelf-care – symptomatic treatment of minor symptomsRecognition of dangerous symptoms e.g. PVBSexual function:Lubrication &/or aqueous cream± AndrogensPsychosocial adaptation:Explanation & reassurancePost-menopausal lifestyle modifications:Paediatric gynaecology:Tanner classification of pubertal development:Age:Growth:Menstruation:Thelarche:Pubarche:Axillary hair:< 10Pre-adolescent: papillae elevated; no breast budNone10Slight papillae elevation11Elevation of breast & confluent areolaeSparse; long; slightly pigmentedGrowth spurt12Darker; coarser; curlyAxillary hair13MenarcheAreolae & papillae project above breastAdult type on pubis only14Adult type reaching inner aspects of thigh15Papillae projected & mauture shapeVaginal bleeding in children:Ax:Bacterial vaginitis (most common) due to atrophic vaginal atrophy under the relative hypo-oestrogenicity Prolapse of urethral mucosa (blood stained discharge)Exogenous estrogen useTrauma (bright red blood; may have small quantity)Foreign bodies (blood stained discharge)Precocious puberty (menstruation)Oestrogen producing tumors (menstruation)Dx:Obtain specimen for M, C & SExamine under GA is tumor suspected-228600230505Bacterial vaginitis – red & inflamed; usually following a bout of diarrhea:Topical oestrogen cream bd x1wkBroad spectrum antiobiotic syrupProlapsed urethral mucosa – purplish-red sweilling; very sensitive; urethra at centre:Pass transurethral catheter (can be removed after 2-3d)Oestrogen cream 2-3x/d for 2-3wkTrauma:Have high index of suspicion for sexual abuseExamine under GA?: Wound repairAnus trauma (repair if present)If instrument injury - ↑ risk of perforation → do speculum examination under GAIf perforation injury → do laparotomy to exclude internal organ perforationIf continuous bleeding PV → laparotomy to exclude internal organ perforationIf adequate visualization is inadequate – can use laparoscopy or cystoscopeHaematomas of vulva: Conservatively:AnalgesiaLocal cold dressingsLigation of bleeding vessels – if haematoma continues to growExogenous estrogens – still need full examination00Bacterial vaginitis – red & inflamed; usually following a bout of diarrhea:Topical oestrogen cream bd x1wkBroad spectrum antiobiotic syrupProlapsed urethral mucosa – purplish-red sweilling; very sensitive; urethra at centre:Pass transurethral catheter (can be removed after 2-3d)Oestrogen cream 2-3x/d for 2-3wkTrauma:Have high index of suspicion for sexual abuseExamine under GA?: Wound repairAnus trauma (repair if present)If instrument injury - ↑ risk of perforation → do speculum examination under GAIf perforation injury → do laparotomy to exclude internal organ perforationIf continuous bleeding PV → laparotomy to exclude internal organ perforationIf adequate visualization is inadequate – can use laparoscopy or cystoscopeHaematomas of vulva: Conservatively:AnalgesiaLocal cold dressingsLigation of bleeding vessels – if haematoma continues to growExogenous estrogens – still need full examinationMx & Sx:Vaginal discharge in child:Ax:Foreign bodiesAtrophic bacterial vaginitisThreadworm or pinworm infestationMycotic infestationsSTD’sSx:Burning on micturitionDx:Discharge specimen sent for M, C & SStick tape spatula → microscopy examination of worm ovacenter234950Foreign objects – e.g. rolled tissues; stones; paper-clips etc.; foul-smelling dischargeRemove using thin surgical forcepsIf difficult of high up – do under GAMaintain vaginal hygieneNo bubble baths Nor strong soapsWash vulva with gentle soapWorm infestations- pruritic; discharge:Paediatric mebendazoleSexually transmitted diseases esp Trichomonas – frothy discharge; diagnosed microscopically:Metronidazole00Foreign objects – e.g. rolled tissues; stones; paper-clips etc.; foul-smelling dischargeRemove using thin surgical forcepsIf difficult of high up – do under GAMaintain vaginal hygieneNo bubble baths Nor strong soapsWash vulva with gentle soapWorm infestations- pruritic; discharge:Paediatric mebendazoleSexually transmitted diseases esp Trichomonas – frothy discharge; diagnosed microscopically:MetronidazoleMx:Labial adhesions:Ax: Hypo-pestrogenismSx: Recurrent vulvar irritationDysuriaInfectionMx:center81915Oestrogen cream daily x1wkSevere adhesions – separate by pulling with thumbsIf painful → separate under general anaesthesia (as above)Maintain normal genital hygiene00Oestrogen cream daily x1wkSevere adhesions – separate by pulling with thumbsIf painful → separate under general anaesthesia (as above)Maintain normal genital hygieneCondylomata acuminata – HPV:Mx:center39370Exclude sexual abuse:Look for other signs of abuseLook for other STD’s?: Electrocautery under GA00Exclude sexual abuse:Look for other signs of abuseLook for other STD’s?: Electrocautery under GAAdditional paediatric problems:Macroscopic genital abnormalities: R/F for further evaluationPrecocious puberty:Definition: Development of 2? sexual characteristics < 8yr & menstruation < 10yr:Classification:GnRH dependentIdiopathic precocious pubertySeveral intracranial lesionsGnRH independentExogenous oestrogen useEndogenous production of oestrogen by ovarian/adrenal tumorsSevere thyroid diseasePartial sexual precocityPremature thelarche – breast tissue before 8yrPremature menarche – as for GnRH dependant sexual prococityPremature pubarche – pubic hair before 8yrCx:Premature closure of growth plates → stunted growth/short statureMx: center13970GnRH dependant → R/FGnRH independent → R/F to find source of exogenous oestrogenPremature thelarche → R/FReassurancePremature menarche → R/F as for GnRH dep. PrecocityPremature pubarche → R/F to exclude androgen producing tumor00GnRH dependant → R/FGnRH independent → R/F to find source of exogenous oestrogenPremature thelarche → R/FReassurancePremature menarche → R/F as for GnRH dep. PrecocityPremature pubarche → R/F to exclude androgen producing tumorDelayed puberty:Definition: If thelarche hasn’t occurred by 13 & menarche hasn’t occurred by 15.Classification:Delayed menarche with adequate 2? sexual developmentCongenital abnormalities of the genital tractAndrogen insensitivity syndromePoor feedback of hypothalamo-pituitary-ovarian axisDelayed puberty with inadequate or absent 2? sexual characteristicsHypothalamic or pituitary dysfunction (serious)Ovarian failure/dysgenesisDelayed puberty with virilisationAdrenal hyperplasiaAndrogen producing tumorsHeraphroditismMx: R/FAdolescent with excessive uterine bleeding:Pathogenesis: Immature HPO axis → anovulatory cycles (≈1-2yr) → irregular cycles, which may be heavy. Other symptoms e.g. pain seldomly presentOther causes: Bleeding disorder; genital tumor; pregnancy complicationsDx:Pregnancy testFBC – leukaemia; thrombocytopeniaESRVWF – Hx of bleeding (dental-work/IJ) since birth228600228600Exclude serious disease (see above)COC – 2 options:Progestogen dominant pillNordette – 150μg of levo-neorgestrel x3-4moFemodene/Minulette – 75μg gestodene x3-4monMPA 5mg 1-2x/d x14d, repeated on same calendar days each month for 3-4moReassess after 3-4months i.e. discontinue drugs as see if cycle has become more regularMenstural diaryIf tumor is suspected → R/F for examination under GA & special investigations00Exclude serious disease (see above)COC – 2 options:Progestogen dominant pillNordette – 150μg of levo-neorgestrel x3-4moFemodene/Minulette – 75μg gestodene x3-4monMPA 5mg 1-2x/d x14d, repeated on same calendar days each month for 3-4moReassess after 3-4months i.e. discontinue drugs as see if cycle has become more regularMenstural diaryIf tumor is suspected → R/F for examination under GA & special investigationsMx:Gynaecological tumors in children:Mx: R/FOvarian tumors:Types:Older children: Germ-cell tumorsYoung children/adults: Benign cystic teratoma:Growing cystic abdominal mass → ± torsion; ± rupture; ± bleedAll complications will cause much pain & shockPrecocious puberty: Granulosa cell tumorsAndrogen producing tumorsMx: R/FContraception:Pearl index = 100 x 12 x (# of pregnancy)/Total number of months in useClassification:Highly reliable:Tubal ligationVasectomyDepomedroxyprogesterone acetate injections (Depo-provera)IUCDVery reliable:COCDeponorethisterone oenanthate injections (Nur-isterate)Reliable:Progestogen only pillMale or female condome with spermacidesUnreliable:Conventional methods of contraceptionOral contraception – 2 options: POP’s vs. COC’sCOC’s – Combined oral contraception: Oestrogen (E) & Progestogen (P) in each pill:Monophasic – E & P in every tab.Gonane containing preparations:High dose oestrogen: Abnormal uterine bleeding & emergency contraceptionOvral – Ethinyl oestradiol (EE) 50μg & Norgestrel (NG) 500μgNordiol – EE 50μg & Levo-NG 250μgLow dose oestrogen: Cycle control – good 1st choiceNordette – EE 30μg & Levo NG 150μg3rd Generation gonane low dose: Androgenically neutralFemodene – EE 30μg & gestodene 75μgMinulette – as for femodene3rd Generation gonane very low dose: To be take at same time each day ELSE ineffective in FSH suppressionMelodene – EE 20μg & gestodene 75μgMarvelon – EE 30μg & desogetrel 150μg (oestrogenicity)Mercillon – EE 20μg & desogestrel 150μgPregnane preparations:Diane-35 – EE 35μg & cyproterone acetate 2mg (oestrogenic anti-androgen) used for acne & hirsutismBiphasic – E constant in all 21 tab., low P in the 1st 11 and higher dose in remaining 10Gonane preparations:Biphasil/Nomovlar – for people needing some oestrogenicity:11 Tab. – EE 50μg & Levo-NG 50μg10 Tab. – EE 50μg & Levo-NG 125μgTriphasic – Varying E concentrations & increasing P concentrationsTriphasil/Logynon-ED – good cycle control:6 Tab. EE 30μg & L-NG 50μg5 Tab. EE 40μg & L-NG 75μg10 Tab. EE 30μg & L-NG 125μgTriodene/Tri-minulette – good first choice; good cycle control:6 Tab. EE 30μg & gestodene 50μg5 Tab. EE 40μg & gestodene 70μg10 Tab. EE 30μg & gestodene 100μgPOP’s – Progestogen only pill: Progestogen dose fixed in each pillExluton – Lyno-estrenol 550μgFemulen – Ethyndiol diacetate 500μgMicro-novum – Norethisterone 350μgMicroval – Levo-norgestrel 30μgCOC:Mechanism of action: COC → Constant GnRH stimulation → FSH suppression → No FSH peak → impaired follicle development & anovulation. Mid-cycle LH peak also absent.Advantages vs. disadvantages of COC:AdvantagesDiadvantages – can cause morbidity in diseased patientsProgrammed menstruation↑ Clotting factors↓ Menstrual loss and other Sx’s↑ LDL (progestogens)↓ Incidence of benign breast disease & ovarian cysts↑ RAAS (oestrogen)↓ Incidence of acne & anaemia↑ BPSome protection against tichomonas & other upper genital tract infectionsGlucose intoleranceProtection against development of ovarian & endometrial CAGroup selection: 1st line drug for most first-time contraceptive usersContraindicated groups:Absolute:PregnancyUndiagnosed vaginal bleeding at any age≥ 35yr + smoke + DM, hypercholesterolaemia or gross obesityHx of IHD, CVA, or arterial &/or venous thrombosisSevere untreated HTFocal migraineHeart valve lesionsHepatitis, Hx of cholestatic jaundice of pregnancy, or gall-bladder diseaseCurrent breast or endometrial CARelative:DMEpilepsyIntestinal malabsorption syndromeMajor depressionChronic renal or hepatic diseasePlanned major surgery with immobilizationPossible porphyriaS/E’s of COC:Intermenstrual bleeding:If in 1st half of cycle = endometrium doesn’t proliferate enough & break down → add oestrogenIf in 2nd half of cycle/menstrual blood is ↑↑ = progestogen deficiency → add progestogenTotal loss of cycle control → temporary Nordiol for 3-4months → back on COC’sHeadaches:If during placebo pill = oestrogen deficiency/withdrawal → monophasic balanced preparation used continuously (without placebos) for 4 packets → reduces headache incidence to 3-4x/yrIf during last part of cycle → triphasic pill (simulates normal cycle)Post-pill amenorrhoea (rarely occurs for more than 2-3months):Reassure patientIf more than 6 months = PATHOLOGICAL!!! → work-up as for 2? amenorrhoeaProgestogenic S/E:AcneWeight gain (1-2kg)IrritabilityFatigueSexual arousal phase dysfunctionDepressionOestrogenic S/E:ChloasmaMastalgia↑ Vulvobaginal candida incidence± NauseaMaintenance of amenorrhoea: Use continuous monophasic preparations without placebos; if currently on triphasic COC’s use only last 10 active pills of monophasic preparation after completion of current packet (less effective)Forgetting pills: A missed pill might allow a dominant follicle to develop since its suppressive effect is no longer present. If a dominant follicle develops, the risk of ovulation ↑. The following regime can be used to minimize this risk with missed pills:center106680If 1 missed: Take A.S.A.P. i.e. as oon as rememberedIf only discovered next day: Take 2If 2 days’ pills missed: 2 pills on each of next 2 days (only maintains cycle control NOT CONTRACEPTION); use condoms as well (for 1 month)If 3 days’ pills missed: Discard current pack & start new pack + condoms (for 1 month)00If 1 missed: Take A.S.A.P. i.e. as oon as rememberedIf only discovered next day: Take 2If 2 days’ pills missed: 2 pills on each of next 2 days (only maintains cycle control NOT CONTRACEPTION); use condoms as well (for 1 month)If 3 days’ pills missed: Discard current pack & start new pack + condoms (for 1 month)Complications of COC’s:Gestodene & desogestrel: ↑ Risk of throbo-embolism & stroke – increased risk in the following patients:AT III deficiency; Protein C & S deficiency; Activated protein C resistance; Lupus anti-coagulant; Anticardiolipn antibody syndrome; Factor V Leiden mutation≥ 35yr + smoke + heart/vascular disease have ↑ risk of thrombo-embolismDrug-interactions – oestrogen induces hepatic microsomal enzymes:Anti-convulsants e.g. phenytoin; barbiturates; carbamazepine; ethsuxamide; primidoneRifampicin & griseofulvinSpironolactoneChlorpromazine & chloral hydrate0149860Individual needs of patient – used for 3-4months before final assessment of acceptability/Side effects madeStart with monphasic/triphasic:Triphasic – better cycle controlModern monophasic – new low dose BUT high potency progestogens had excellent cycle controlS/E may indicate a progestogen (P) excess with oestrogen (E) deficiency or vice verse:↑ P but ↓ E – Consider more oestrogenic preparations e.g. Marvellon (biphasic) ↑ AppetiteAcneVaginal drynessShortened menstruation ORAmenorrhoeaIrritabilityMood swaingsDepressionHeadaches during placebo tablets↑ E but ↓ P – Consider more progestogenic preparation e.g. Nordette; Triphasil; Logynon-ED:Excessive menstruationBreakthrough bleedsMastalgiaHeadaches during active pillsLeucorrhoeaCorneal oedemaBEFORE CHANGING COC’S → FINISH CURRENT PACKET00Individual needs of patient – used for 3-4months before final assessment of acceptability/Side effects madeStart with monphasic/triphasic:Triphasic – better cycle controlModern monophasic – new low dose BUT high potency progestogens had excellent cycle controlS/E may indicate a progestogen (P) excess with oestrogen (E) deficiency or vice verse:↑ P but ↓ E – Consider more oestrogenic preparations e.g. Marvellon (biphasic) ↑ AppetiteAcneVaginal drynessShortened menstruation ORAmenorrhoeaIrritabilityMood swaingsDepressionHeadaches during placebo tablets↑ E but ↓ P – Consider more progestogenic preparation e.g. Nordette; Triphasil; Logynon-ED:Excessive menstruationBreakthrough bleedsMastalgiaHeadaches during active pillsLeucorrhoeaCorneal oedemaBEFORE CHANGING COC’S → FINISH CURRENT PACKETMx – choice of COC’s:POP:Important considerations:Less effective than COC’sWork by thickening cervical → unfavourable implantation conditions for blastocyst in endometriumReliable during lactation & puerperiumS/E’s – rarely encountered:Irregular menstruation± Weight gainHeadaches↓ LibidoInjectable contraception:Types:Depo-medroxyprogesterone acetate 150mg/ml IMI q90d(Depo-provera)Depo-northisterone oenanthate 200mg/ml IMI q60d (Nur-isterate)Mechanism: Inhibits FSH & LH → Endometrium becomes thin & cervical mucus thick; ↓ motility of fallopian tubesGroup selection: Women planning long-term pregnancy postponementContra-indicated groups:PregnancyUndiagnosed PVBUncontrolled HHTMajor depressionFocal migraineChronic hepatitisPorphyriaS/E profile:AmenorrhoeaSlight, irregular PVBSevere bleeding in some users – Mx as follows:Oestrogen dominant COC for 1 month e.g. Biphasil ORConjugated oestrogen 0.625-1.25mg/d until 1 week after bleeding stops ORRepeat DMPA 150mg (only useful if near next IJ date)Weight gain of 5kgProgestogenic S/E’s – Vaginal dryness; dyspareunia; headaches; minor depression; ↓ libidoImplantable contraception:Method: 6 x 34mm x 2.4mm silastic norgestrel rods are implanted SC → 5yr contraceptionMechanism: As with injectablesS/E profile: Progestogenic:Intra-uterine contraceptive device:Types:Polyethylene base with copper wire coil:MultiloadNova-TCopper T Slimline (copper on arms as well)Medicated IUCD – progestogen in the stem: Has good cycle controlMirenaInert plastic or polyethylene IUCD e.g. Lippes Loop (now obsolete)Mechanism – 4 way: Stimulate foreign body reaction → phagocytosis of sperm/blastocyst. Copper ions are also spermotoxic.Induces dicidual changes → unfavourable for implantationThickening of cervical mucus → impenetrable for spermSelection group:Forgetful pill users OR steroid intoleranceCompleted families but don’t wish to have tubal ligationAdvantages:No systemic effectsNo coital interferenceLong actionSecrecy of contraceptionContra-indications:Absolute:PregnancyUndiagnosed abnormal uterine bleedingPelvic infectionPrevious ectopic pregnancyHIV infected womenRelative:If at risk for bacteraemia e.g. heart valve patientsUterine abnormalitiesSever dysmenorrhoeaAfter septic abortionAfter 2/more previous IUCD expulsionsS/E profile:Bleeding after insertion – common but mild↑ Menstrual bleeding – if severe:Remove IUCDProstaglandin inhibitors (Ibuprofen/Mefanamic acid) ORTranexamic acidPain after insertionAggravated dysmenorrhoe → may need prostaglanding inhibitorsCx:PIDPerforation of uterus at insertion2? Cx:PainAdhesionsInjury to intestines/bladder↓ CopntraceptionPregnancy:Ectopic ORIntruterine → if so & strings are visible → remove IUCD (halves risk for spontaneous abortion)Barrier contraception:Types:CondomsCervical diaphragm (female) – fitted prior to coitus + spermacides & left in for 8hr after intercourseFemale condomsSpermacides: Currently doubling-up as lubricant: I call it spermolube = Nonoxynol-9/Nonoxynol-11 (9-11)Important considerations:STD & pregnancy protection – although not as effective in preventing pregnancy as IUCD or IJCan break!!!Selection group:Infrequent/unplanned intercourse or when other methods e.g. COC’s not availableRemember – No COC’s then no COCKS, unless plastic socks!!!If ↑ risk for STD’sShort term contraception needed e.g. missed pillS/E profile:Contact dermatitis – needs change in contraceptionPsychological “obstructed” intimacy feelingsInteractions with some lubricants → weakening → ↑ rupture rateLatex allergies!!!Emergency post-coital contraception – Oops I did it again!!Types:Ethinyl oetradiol 100μg & Norgestrel 25-50μg x2 (i.e. 2 tab. within 72hr of intercourse followed by another 2 tab. 12hr later) e.g. Ovral & E-Gen-CInsert IUCD up to 5d after earliest estimate of ovulation BUT not more than 7d after intercourseMicroval - 25 Mini-pills x2 12hr apartHigh dose Oestrogens e.g Premarin for 5d after intercourseS/E profile & Mx:N&VMx: Anti-emeticsInsertional pain & slight PVB with IUCD (temporary)Contra-indication: Pregnancy – IT’S A WASTE!!Male & female sterilization – the great snip & tie:Female sterilization by tubal ligation:Selection criteria:Mature & autonomous (can make an informed decision)If not capable of the above, a request fro sterilization has to be made to the minister of health (e.g. mentral retardation)Informed of optionsDecision must be unhurriedPostponed if:DivorceAt time of deliveryHad a miscarriageYoungNo gynaecological problems i.e. normal menstruation; not pregnant; normal cervical cytologyTypes – 2 common types:Laparoscopic using clips (filshie clips) or silastic rubber band (Fallope rings) – if not pregnant; under GA/local anaesthesiaModified Parkland – under GA/epidural anaesthesia; using polyglactin/polyglycolic sute material to tie tube off:At C/S ORD1/D2 of puerperium (4-5cm subumbilical transverse incision) ORInterval procedure – if laparoscopic equipment & expertise aren’t available (6-8cm suprapubic transverse incision)Cx:Anaesthetic risks; laparoscopic risks; slight haemorrhage; wound IxFailure to ligate tubeEctopic pregnancyPost-tubal ligation syndrome – excessive abnormal uterine bledding, pain & dysmenorrhoea (Ax unknown)Failure rate due to – improper tube identification; incomplete ligation/occlusion; reanastamosis (RARE!)Reversal – possible if tubes were ligated & not cauterized/buried & if long enough wide-lumen sections are available; absence of adhesions. Success achieved in 2/3 of patientsMechanism – performed with microscopeMale sterilization by vasectomy:Selection group:VoluntaryMen with hereditary disease in their side of familyNote: Not advised to have vasectomy are men in unstable relationships; under financial or social pressureImportant considerations:Man/couple must use contraception for 12wk after procedureAfter 12wk semen analysis should be preformedWhen 2 analyses show azoospermia (no sperm) = SUCCESSIf persistent sperm → R/F urologistCx:Recanalisation (small risk)Circulating anti-sperm anti-bodies → decreased successful reversal even if perfectly re-anastamosedSpermatogenesis can continue for years after procedureRape & battering:Forensic examination – patient to report to police first to lay a charge, whereupon she should receive a “rape-kit” & be accompanied to the medical officer for evaluation → he must follow the instruction as stipulated in the J88 & SAP308 documents. He must make a copy, keep 1 and return the other to the investigating officer. Remember to sign all pages as indicated.0198120Thorough medico-legal Hx & ExComplete J88 & SAP308 formsCollect evidence in specially designed “rape-kit” incl. clothes, shoes, underwear etc.Rx injuries appropriatelyPrevent pregnancy by emergency contraception – do pregnancy testPrevent STD’s – do RPR & HIV VCT:Doxycycline 100mg bd PO x10dMetronidazole 2g PO STATCiprofloxacin 500mg PO STATAZT & 3TC anti-retroviral post-exposure prophylaxisSymptomatic Rx – for the following:Physical symptoms:Muscle crampsN&VStomach painsEating & sleeping disordersHeadachesVaginal dischargeItchingBurning sensation of micturitionGeneralized pain & agitationPsychological symptoms:Rape trauma syndrome – PTSDFears of:InjuryDeathMutilation & poor self-imageFeelings of: HumiliationDegradationHelplessnessAnxietyGuiltShameEmbarrassmentSelf-blameAngerIrritationHateDisbelief & denialRevengeMood swingsPoor concentrationDepressionPhobiasBlocking of thoughtsProper F/U examination at 3-10d for detection of disease & assessment of management & patient well-beingRepeat F/U at 6-8wk for RPR; HIV VCT & pregnancy testingIf patient becomes pregnancy she should be counseled for TOP or R/F for TOPNeeds of rape victim:Information – what to do; where to go after rape (medical; mental; health; social; legal)Immediate & F/U medical care as stipulated aboveImmediate & F/U professional counseling for emotional trauma/consequent social disruption (debriefing)Skilled, sensitive treatment by police, social workers, nurses, physicians, lawyers & others who may question/treat victimSupport form significant others – friends, family, spiritual leaders etc.Legal assistance incl. information about rights, advocacy, representation in criminal-justice system00Thorough medico-legal Hx & ExComplete J88 & SAP308 formsCollect evidence in specially designed “rape-kit” incl. clothes, shoes, underwear etc.Rx injuries appropriatelyPrevent pregnancy by emergency contraception – do pregnancy testPrevent STD’s – do RPR & HIV VCT:Doxycycline 100mg bd PO x10dMetronidazole 2g PO STATCiprofloxacin 500mg PO STATAZT & 3TC anti-retroviral post-exposure prophylaxisSymptomatic Rx – for the following:Physical symptoms:Muscle crampsN&VStomach painsEating & sleeping disordersHeadachesVaginal dischargeItchingBurning sensation of micturitionGeneralized pain & agitationPsychological symptoms:Rape trauma syndrome – PTSDFears of:InjuryDeathMutilation & poor self-imageFeelings of: HumiliationDegradationHelplessnessAnxietyGuiltShameEmbarrassmentSelf-blameAngerIrritationHateDisbelief & denialRevengeMood swingsPoor concentrationDepressionPhobiasBlocking of thoughtsProper F/U examination at 3-10d for detection of disease & assessment of management & patient well-beingRepeat F/U at 6-8wk for RPR; HIV VCT & pregnancy testingIf patient becomes pregnancy she should be counseled for TOP or R/F for TOPNeeds of rape victim:Information – what to do; where to go after rape (medical; mental; health; social; legal)Immediate & F/U medical care as stipulated aboveImmediate & F/U professional counseling for emotional trauma/consequent social disruption (debriefing)Skilled, sensitive treatment by police, social workers, nurses, physicians, lawyers & others who may question/treat victimSupport form significant others – friends, family, spiritual leaders etc.Legal assistance incl. information about rights, advocacy, representation in criminal-justice systemMx: ................
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