DSMIV Diagnostic and Statistical Manual of Mental LCR ligase chain reaction Disorders IV of the American Psychiatric LDL low-density lipoprotein. EC emergency contraception LSIL low-grade squamous lesion ED every day (preparations) LUF luteinized unruptured follicle syndrome EGF epidermal growth factor MAC Mycobacterium avium intracellulare.
The gynaecological history and examination
OVERVIEW
History
Examination
Symptoms
Abdo minal examinatio n
Examination 3
Pelvic examination
R ectal examination
Key Points
Investigations 5
Investigations
Chapter 2
EMBRYOLOGY
Development of the genital organs
Development of the uterus and Fallopian tubes
D evelopment of the va gina
Embryology 7
Development of the external genitalia
Deve lopment of the ovary
At the same time as the ovary descends extraperitoneally into the abdominal cavity, two ligaments develop and these appear to help control its descent, guiding it to its final position and preventing it.
ANATOMY
External genitalia The vulva
The labia minora are two thin folds of skin that lie between the labia majora. The urethra, the tubes of the Bartholin's glands and the vagina open into the vestibule.
The internal reproductive organs
Anatomy 9
Bartholin's glands, each about the size of a small pea, lie at the base of each bulb and open through a 2 cm duct into the vestibule between the hymen and the labia minora. In childhood, the vulva is devoid of hair and there is significant fatty tissue in the labia majora and pubic bone that is lost during childhood but reappears during puberty, at which time hair grows.
The vagina
The body of the clitoris contains two crura, corpora cavernosa, which are attached to the lower edge of the pubic rami. The vestibular bulbs are two elongated masses of erectile tissue that lie on either side of the vaginal entrance.
The uterus
The cervix is narrower than the body of the uterus and is about 2.5 cm long. The longitudinal axis of the uterus is approximately at right angles to the vagina and normally tilts forward.
The Fallopian tubes
Because of anti-flexion or retroflexion, the long axis of the cervix is rarely the same as the long axis of the uterine body. The lining of the endocervix has anterior and posterior columns from which folds radiate, known as the arbor vitae.
The ovaries
Anatomy 13
The tubules go into the rudimentary epoophoron canal, which runs parallel to the lateral fallopian tube. In some individuals, the caudal part of the mesonephric duct is well developed, running along with the uterus to the internal muscle.
The epoophoronium, a series of parallel blind tubules, lies in the broad ligament between the mesovarium and the fallopian tube. Located in the broad ligament, between the epoophore and the uterus, some rudimentary tubules, the parophore, are occasionally seen.
The urethra
Medial fibers from the pubococcygeus of the levator ani muscles insert into the urethra and vaginal wall. When they contract, they pull the anterior vaginal wall and the upper part of the urethra forward, creating an angle of approximately 1000 between the posterior wall of the urethra and the bladder base.
Th e ureter
During voluntary urination, the bottom of the bladder and the upper part of the urethra descend and this posterior angle disappears, so that the bottom of the bladder and the posterior wall of the urethra lie in a straight line. It has previously been suggested that the absence of this posterior angle is the cause of stress incontinence, but this is probably only one of several mechanisms responsible.
T he rectum
The pelvic muscles , ligaments and fasciae The pelviC diaphragm
The medial borders of the pubococcygeus muscles pass on both sides from the pubic bone to the preanal raphe. Together with fibers from the opposite muscle, they form a loop which maintains the angle between the back side of the urethra and the base of the bladder.
The perineal body
The muscle is described in two parts: the pubococcygeus, which arises from the pubic bone and the anterior part of the tendon arch in the pelvic fascia (white line), and the iliococcygeus, which arises from the posterior part of the tendon arch. and ischial spine. The medial border passes under the bladder and runs laterally to the urethra, into which some of its fibers insert.
The pelvic peritoneum
During micturition, this loop relaxes to allow the bladder neck and upper urethra to open and descend. The urogenital diaphragm (triangular ligament) lies below the levator ani muscles and consists of two layers of pelvic fascia, which fills the gap between the descending pubic rami.
The ovarian ligament and round ligam ent
The pelvic fascia and pelvic cellu lar tissue
Anatomy 17
Arteries supplying the pelvic organs The ovarian artery
The interna l iliac (hypog astri c) artery
In this part of its course it sends many branches into the substance of the uterus. The vaginal artery is another branch of the internal iliac artery that runs at a lower level to supply the vagina.
The superior rectal artery
The artery supplies a branch to the ureter as it crosses it, and shortly afterwards another branch is given off to supply the cervix and upper vagina. It ends in branches that supply the perineal and vulval structures, including the erectile tissue of the vestibular bulbs and clitoris.
The pelvic veins
It leaves the pelvic cavity through the sciatic foramen and, after wrapping around the ischial spine, enters the ischiorectal fossa, where it gives off the inferior rectal artery.
The pelvic lymphatics
L y mphatic d rainage from the genital tract
Anatomy 19
The ovary and fallopian tube have a plexus of vessels that drain along the infundibulopelvic fold to the para-aortic nodes on either side of the midline. Rectum: lymphatics from the lower anal canal drain into the superficial inguinal nodes and the remainder of the rectal drainage follows the pararectal canals.
Nerves of the pelvis
Most vessels drain to the internal iliac, obturator, and external iliac nodes, but the vessels also drain directly to the common iliac and lower para-aortic nodes, so radical surgery for carcinoma of the cervix should include removal of all these node groups. both sides of the pelvis. The bladder and urethra: drainage is to the iliac nodes, while the lymphatic vessels of the lower part of the urethra follow those of the vulva.
Nerve supply of the vulva and perineum
The corpus uteri: Almost all lymphatic vessels join the lymphatic vessels leaving the cervix and therefore reach similar groups of nodes. A few vessels at the fundus follow the ovarian ducts, and there is an inconsistent path along the round ligament to the inguinal nodes.
Key Points
Chapter 3
Normal and abnormal sexual development and puberty
Sexual differentiation
The Leydig cells produce testosterone, which promotes the development of the Wolffian duct, leading to the development of vas deferens, epididymis, and seminal vesicles. The absence of a Y chromosome and the presence of two X chromosomes mean that no Mullerian inhibitor is produced and the Mullerian ducts persist in the female (Fig. 3.2).
Abnormal development
The Sertoli cells are responsible for the production of Mullerian inhibitor, leading to Mullerian regression. The absence of testosterone means that Wolffian ducts regress, and the inability of androgen to influence the cloaca leads to an external female phenotype.
C hromos ome abnormalities
Testosterone by itself has no other effect on the cloaca; to exert its androgenic effects, it must be converted to dihydrotestosterone by the cloacal cells by the enzyme Sa-reductase.
Gonadal abnormalities
Mullerian structures remain and Wolffian structures regress, due to the absence of testes. In true hermaphrodites, the gonad may develop into either a testis or an ovary, or a combination of the two known as an ovotestis.
Internal genitalia ab normalities
Here, surprisingly, Wolffian structures develop only on the side of the testis, but all Mullerian structures regress. The external genitalia in this rare condition may be ambiguous, depending on the functional capacity of the testis.
Exte rna l genitalia abnormalities
The failure of cortisol production means that the feedback mechanism on the hypothalamus leads to an increase in adrenocorticotropic hormone (ACTH). The female child is then born with some degree of phallic enlargement, and the lower part of the vagina may be obliterated by the development of a male-type perineum, leaving a vaginal opening obscured.
Brain sex
Cloacal virilization can also occur if the fetus is exposed to androgens in an androgenic drug taken by the mother, or in many cases the virilization is idiopathic. At birth, examination of the chromosomes, endocrine status of the infant, and ultrasound of the internal organs will lead to a rapid diagnosis that will reveal whether the baby is a female with a virilization condition, most likely congenital adrenal hyperplasia. , or a man who was under-masculinized.
Puberty
This in turn stimulates the adrenal gland to undergo a form of hyperplasia, and the excessive production of steroid precursors (17-hydroxyprogesterone) means that the adrenal gland produces excessive amounts of androgen. This androgen enters the fetal circulation and affects the developing cloaca, leading to virilization.
The physiology of puberty
Five stages of puberty
Finally, the effect of estrogen on the femoral endplate causes fusion and growth arrest; By IS age, most girls have reached their final height. Menstrual loss can also vary greatly, due to the immaturity of the axis.
Common clinical presentations and problems (Table 3.1)
Eventually, the breast tissue grows to join the areola and the breast has then completed its development. It takes between 5 and 8 years from the time of menarche for women to develop ovulatory cycles 100 percent of the time.
Turner 'S syndrome
Individuals occasionally have associated features such as color blindness, coarctation of the aorta and short metatarsals (Fig. 3.9). The pregnancy then proceeds normally, although delivery may be difficult due to the small stature.
XV females
As the child grows, a wide carrying angle of the arms may become apparent, the neck may become webbed in appearance, and the chest becomes broad with widely spaced nipples. If this was not the case and the testes are still present, advice should be given that they should be removed due to the risk of malignancy.
Intersex
Estrogen will have to be administered to these women to maintain their female body habitus, but the failure of the development of the Mullerian structures means pregnancy is impossible, except in the cases of XY gonadal agenesis or the XY female with absent Mullerian inhibitor only.
Va gi nal a tre s ia
O bstru c tive outflow tract problems
In all of these cases, women have cyclic abdominal pain and the development of a pelvic mass as menstrual blood accumulates in the vagina, thereby expanding it. Excision of the midline septum results in proper drainage of the menstrual flow, thereby resolving the problem.
Menorrhagia in adolescence
Examination of these circumstances requires an ultrasound scan that will detect the presence of a hematocolpos (blood in the vagina) (Fig. 3.10). Cyclic abdominal pain occurs with increasing severity, but this time the patient is menstruating because the other hemi-uterus and hemi-vagina are functioning normally.
Precocious puberty
As most cases are idiopathic, treatment aims to down-regulate the pituitary using GnRH analogues. The presence of a Y chromosome determines male development; the absence of a Y chromosome leads to a female phenotype.
Additional reading
New d evelopm e nts
Chapter 4
Introduction
The ovary
Follicular phase
The selection of the dominant follicle is the result of complex signaling between the ovary and the pituitary gland. The interaction between the ovaries and the pituitary gland is crucial for the selection of the dominant follicle and the forced atresia of the remaining follicles.
O vulation
Luteal phase
The pituitary gland
The hypothalamus
Summary of ovarian events
The endometrium
Menstruati on
Later, the restoration of the endometrium and the formation of new blood vessels (angiogenesis) lead to the complete cessation of bleeding within 5-7 days from the start of the menstrual cycle. They are thought to increase the ratio of the vasoconstrictor prostaglandin (PG) F2O' to the vasodilator prostaglandin PGE2.
The prolife r at ive/follicular phase
Increased understanding of the agents involved in menstruation may improve efforts to control pathologically excessive menstruation. Prostaglandin synthetase inhibitors such as mefenamic acid (Ponstan) are widely used in the UK as a first-line treatment for menorrhagia.
T he secretory/luteal phase
Increasing evidence suggests that estrogen-induced glandular and stromal regeneration is mediated by epidermal growth factor (EG F). Although mefenamic acid reduces menstrual loss, the average reduction is only on the order of 20-25 percent in women with true menorrhagia, and the search for more effective agents therefore continues.
Summary of endometrial events
The normal menstrual cycle Clinical features
Menstrual cycles are longest immediately after puberty and in the 5 years leading up to menopause, corresponding to the maximum occurrence of anovulatory cycles. A menstrual loss of more than 80 ml is considered excessive - this level is quite arbitrary and corresponds to the threshold at which iron deficiency anemia can occur unless treated.
New deve lo p m ents
The length of the menstrual cycle is determined by the length of the follicular phase.
Clinical points
Pituitary-ovarian dialogue ensures selection of the dominant follicle and atresia of the remaining follicles.
Add i tional read in g
Chapter 5
Disorders of the menstrual cycle
MENORRHAGIA
Definition
Prevalence
Classification
Aetiology
There are more obvious reasons why many more women complain of menorrhagia now than a century ago.
Other physiology
Clinical features History
Is it relevant to determine the precise amount of menstrual loss in women
Menorrhagia 45
Initial investi gations
Treatments
Me dical treatments for menorrhag ia
Medical treatments for menorrhagia
Menorrhagia 47
For most women, this is a welcome side effect; however, there are a few women for whom it is not, so again a thorough discussion is necessary before the LNG-IUS is inserted.
Surgical treatments for menorrhagia
During normal menstruation, the upper functional layer of the endometrium is shed, while the basal 3 mm of the endometrium is preserved (see Chapter 4). Removal of the uterus and ovaries without the woman's consent (or without her full understanding of the nature of the procedure) is a recurring cause of litigation in gynecology (see Appendix 2).
DYSMENORRHOEA
It is therefore essential to obtain explicit consent for each part of the procedure before initiating a hysterectomy.
P rimary dysmenorrhoea
Dysmenorrhoea 49
Secondary dysmenorrhoea
Clinical features
Treatment
Nifedipine is widely used in Scandinavia but is not approved for this indication in the UK. Surgical treatments aimed at severing the nerve pathways from the uterus have been used, and there is some evidence of their long-term effectiveness.
AMENORRHOEA/OLIGOMENORRHOEA
Causes of amenorrhoea
Reproductive outflow tract abnormalities
Ovarian disorders
It is clear that in normal women ovarian failure occurs at menopause (at an average age of 51). It is not normally possible to differentiate between resistant ovary syndrome and ovarian failure without performing a full-thickness ovarian biopsy.
P ituitary d isorders
The last relatively common diagnosis in women with ovarian failure is that of gonadal dysgenesis (see Chapter 3). The supply of primordial follicles is either depleted in early childhood, leading to a lack of ovarian estrogen production and failure of development of the secondary sexual characteristics, or depleted in early adulthood, leading to premature ovarian failure.
Hypothalamic disorders
Recently it has become clear that some women present with symptoms, signs and blood results identical to those of ovarian failure, but that they actually have viable follicles in their ovaries. These follicles do not respond to elevated levels of gonadotrophins, giving rise to the term resistant ovary syndrome.
Clinical features of
Since this biopsy itself may remove any remaining viable follicles, it is not usually indicated. One of the most common chromosomal disorders seen in association with gonadal dysgenesis is Turner syndrome (XO chromosomal complement).
In some women, however, it can happen early (premature ovarian failure), possibly as a result of chemotherapy or radiotherapy or in connection with autoimmune disease.
Clinical examination
Step 1
Step 2
Step 3
The above examination schedule should determine in which area the cause of amenorrhea is. In young women, estrogen replacement can be given in the form of oral contraceptive pills.
POLYCYSTIC OVARIAN SYNDROME
In women whose endogenous estrogen levels are low (e.g. ovarian failure or hypogonadotropic hypogonadism), estrogen and progesterone replacement (e.g. in the form of HRT) can be given. This has the additional advantage that it prevents pregnancy if the cause of the amenorrhea spontaneously disappears.
Clinical features
Diagnosis
Laboratory tests
Ultrasound
Oligomenorrhoea/amenorrhoea
Polycystic ovary syndrome appears to run in families, and it seems likely that there is a gene or set of genes that are important for its development. Since PCOS is driven in part by insulin resistance, it is not surprising that metformin, a drug that increases insulin sensitivity, is partially effective in its treatment.
Hirsutism
S u bf ertil ity
Obesity
POSTMENOPAUSAL BLEEDING
However, around 10 percent of women with PMB are found to have endometrial cancer, the risk of which is higher in those not currently using HRT, and which gradually increases with age. In women using HRT, bleeding should be considered abnormal if its timing is unplanned or its amount is abnormal.
Differential diagnosis
The majority of women with PMB appear to have atrophic vaginitis, in which the vaginal epithelium thins and breaks down in response to low estrogen levels.
I nvestigati ons
PREMENSTRUAL SYNDROME
Differential diagnosis
CASE HISTORY
Chapter 6
CONTRACEPTION
Classificati on
Hormonal contraception
Combined oral contraceptive pills
Contraception 61
Contraindications to COC
Contraception 63
Combined hormonal patches
Progestogen-only contraception
All progestin-only methods work by having a local effect on the cervical mucus (making it hostile to ascending sperm) and on the endometrium (making it thin and atrophic), preventing implantation and sperm transport. The progestin-only pill (POP) is ideal for women who like the convenience of taking the pill, but cannot take COe.
Intrauterine contraception
Types
Contraception 65
It is associated with a dramatic reduction in menstrual blood loss and is approved for the prevention and treatment of menorrhagia.
Mode of actio n
Contra ind ications
P elvic infection and IUDs
Barrier methods of contraception Condoms
F em ale barri e rs
Feminine barriers provide protection against growing pelvic infection, but may increase the risk of urinary tract infection and vaginal irritation. Although a range of spermicidal agents used to be manufactured, only gels and pessaries are still available in the UK.
Coitus interruptus
Contraception 67
Natu r a l family pl ann ing
Emergency contraception
Hormon al e merg ency c ontraception
Hormonal EC is not 100 percent effective, but will prevent about three-quarters of pregnancies that would otherwise have occurred. The precise mechanism of action is not known, but probably involves disruption of ovulation or corpus luteal function, depending on the time in the cycle when hormonal EC is taken.
An IUD for emergen cy cont racep tio n
The original hormonal EC was a combination of estrogen and progestagen, but nausea and vomiting were common side effects. It is available with a doctor's prescription or over the counter in pharmacies, although it is relatively expensive to purchase.
Sterilization
Consent
Female sterilization
Very expensive technique. vascular) and in developing countries where laparoscopic equipment is not available. Sometimes it is not possible to visualize the pelvic organs at laparoscopy due to adhesions or obesity; it may then be necessary to proceed to mini-laparotomy.
V asectomy
Contraception 69
If two consecutive samples are free of sperm, the vasectomy can be considered complete. These do not cause symptoms, but if the vasectomy is reversed, pregnancy may not occur because the autoantibodies inactivate the sperm.
ABORTION
Although this issue has received widespread media interest, there is currently insufficient evidence to support an association and change current practice.
Incidence of legal abortion
Provision of abortion services
Abortion 71
The usual plate(:e -,f' .:3Sic.dnc£f the pregnant woman: with short capitals) the continuation of the lnc:y presented would involve a risk to the life of the pregnant woman greater than if it were interrupted pregnancy It is particularly important that women seeking abortion are not subject to unnecessary delays in their referral, as increasing pregnancy increases the risks and complexity of the abortion procedure.
Assessment and counselling
Many NHS regions have established abortion services to enable rapid referral and efficient management of women seeking abortion, staffed by individuals who are particularly sensitive and sympathetic.
Abortion techniques
First trimester
Abortion 73
Mid-trimester (14 w eeks)
Complications of abortion Incomplete abortion
Infe c tion and s ubfertility
Traumatic injuries
Psychologica l prob lems
Follo w -up
Contraception
New developments
Since compliance seems to be an important issue here, the injectable progestogen Depo-Provera or the subdermal implant Implanon would be options to consider with Miss X. She would need to be warned about possible irregular bleeding with either method and slight weight gain with Depo-Provera.
Re ference
Her only previous pregnancy was the result of conception when a condom popped; she had a recent termination at 14 weeks. She has no past medical history but was found to have an asymptomatic Chlamydia infection at the time of her termination.
Additional readin g
Abortion 75
Chapter 7
Epidemiology
All couples trying to conceive should be given general preconception advice on ways to improve the chances of conception and reduce the risk of pregnancy complications for the mother or the fetus (Table 7.2).
Causes of female subfertility
O v u lation prob lems
The diagnosis is based on the biochemical abnormalities (low concentrations of sex hormone binding globulin and high androgen concentrations) and the ultrasound appearance of the ovaries (an enlarged ovary with multiple subcapsular follicles and a dense stroma; Figure 7.5). Premature ovarian failure is a condition in which there is total failure of the ovaries in women under the age of 40.
Tub al dys fu nction
Disorders of impla n tation
Key Points: causes of female subfertility
Causes of male subfertility
Chromosomal abnormalities including microdeletions of the Y chromosome can also lead to impaired spermatogenesis. Disturbances in sperm transport are seen in men with congenital malformations of the epididymis or vas deferens as well as obstruction due to inflammation, infection or deliberate blockage of the outflow tract by vasectomy.
Key Points: causes of male subfertility
Disorders of spermatogenesis can occur when the scrotal temperature rises as a result of undescended testicles, varicocele, hot baths or tight underwear.
Nomenclature for some semen variables
History and examination
Investigations 81
Analysis of the mid-luteal progesterone level can be used to confirm ovulation, but the correct timing of the assessment is crucial. Alternatively, serial follicle tracking scans can be used in the middle of the menstrual cycle to confirm ovulation.
Asses s ment of tubal p atency
Investigations should include assessment of the hypothalamic-pituitary-ovarian axis, ovulation and fallopian tube patency. Laparoscopy and color intubation requires general anesthesia and direct visualization of the pelvic organs.
Semen ana lysis
Patency of the fallopian tubes is confirmed by visualizing the flow of Echovist contrast agent along the tube and into the abdominal cavity. Tubal patency is then tested by instilling methylene blue through the cervix and observing whether the dye emerges from the fimbrial endings.
Postcoital test
It is important to time the procedure to the preovulatory phase of the menstrual cycle to avoid the risk of causing an ectopic pregnancy.
Treatment of male and female subfertility
O vul ation p roblems
Tubal disease
Male subfertility
Men with obstructive azoospermia may be offered sperm aspiration followed by IVF with IeSI treatment.
Assisted conception
A typical IVF-embryo transfer cycle
During insemination, the prepared sperm is mixed with the eggs and incubated 4-6 hours after collection. With embryo transfer, the embryos are transferred into the uterus using a transcervical catheter on the second or third day of culture.
Intrauteri n e insem ina tio n
All good quality spare embryos can be subject to embryo cryopreservation, with storage in liquid nitrogen for use in a future frozen embryo exchange cycle. Luteal support can be provided by progesterone supplements in the form of vaginal pessaries, suppositories or injections.
In t racytoplasm ic sperm in jection
Donor insem ination
Donor eggs
Pre implantation diagnosis of genetic dise ase
Pregnancy is detected by urine pregnancy test or serum ~-hCG analysis 14 days after embryo transfer.
Regulation of ferti lity treatmenf
Chapter 8
The normal early pregnancy
Developm ent of the blastocyst
At the same time, blood vessels begin to develop in the extraembryonic mesoderm of the yolk sac, connecting stalk, and chorion. Conversely, the villi associated with the decidua basalis proliferate to form the chorion frondosum or definitive placenta.
Normal p lace ntatio n
In normal pregnancies, the extravillous trophoblast infiltrates the endometrium up to the myometrium, forming a continuous shell that obliterates the tip of the transformed spiral arteries. The trophoblastic infiltration of the myometrium is progressive and is reached before 18 weeks' gestation in normal pregnancies.
Ultras ound ima ging
In spontaneous abortions, there is a reduced trophoblastic infiltration, a fragmented or absent trophoblastic shell, and defective transformation of the spiral arteries. This extravillous trophoblast invades the inner third of the myometrium via the interstitial ground substance and affects its mechanical and electrophysiological properties by increasing its expansion capacity.
Symptomatology
Pregnancy tests
Urine testi n g
Plas ma testin g
Miscarriage Definition
Epidemiology and risk factors
Chromosomal abnormalities and materna I age
Miscarriage 93
Rare causes of miscarriage
Etiologies such as exposure to certain toxins are rare in the general population, but may become a significant problem in the context of ecological disasters. Some other causes, such as translocations or thrombophilia, may be more common with recurrent miscarriages.
P Understanding the pathophysiology
Miscarriage 95
A history of amenorrhea followed by vaginal bleeding with low abdominal pain and a positive pregnancy test is essential. Ultrasound will confirm the intrauterine location of the gestational sac and establish the viability of the pregnancy.
Management
Although most miscarriages are not treatable, the prognosis for future pregnancies depends directly on the type of abnormality and whether the mother or her partner carries it. Parental counseling regarding diagnostic evaluation processes, necessary treatments, prognosis, and risks for future pregnancies should always be provided in cases of early pregnancy failure.
EctopiC pregnancy Definition
Prostaglandin analogues have been used in the context of missed abortions, but results to date have been disappointing. This is because when administered vaginally, complete evacuation of the uterus is achieved in only half of cases due to the long interval required.
Epidemiology and risk factors
P Understanqing the pathophysiology
C linical features
The presence of fluid in the pouch of Douglas is a non-specific sign of ectopic pregnancy. The classic approach to the treatment of ectopic pregnancy has always been surgical (salpingectomy or salpingotomy), either by laparotomy or laparoscopy.
Gestational trophoblastic d isorders Definitions
The primary symptoms of choriocarcinoma are gynecological, i.e. vaginal bleeding, in only 50-60 percent of cases. The measurement of plasma heG is central in the diagnosis and follow-up of GTD.
New developmen ts
Pulmonary complications due to trophoblast embolization are often observed after evacuation of molar pregnancy, and the prognosis for these patients depends on the severity of symptoms. After evacuation of a molar pregnancy, hCG levels should be monitored weekly until undetectable, followed by monthly monitoring for 6-24 months.
Discussion
Addi tio nal reading
Chapter 9
Benign disease of the uterus and cervix
Epithelium: the uterine cervix
Cervic a l ectrop ion
The technique is sometimes confusingly called cocoagulation to distinguish it from more destructive diathermy or laser treatment of the cervix.
Naboth ian folli cle s
Endometrium
Asherman's s yn drom e
Treatment options for Asherman's syndrome include maintaining separation of the uterine walls by inserting a large inert IUCD such as a Lippes loop (now obsolete other than for this purpose) or hysteroscopic lysis of intrauterine adhesions. Other causes of Asherman's syndrome that are relevant in specific parts of the world are tuberculosis and schistosomiasis.
Complications of cervical stenosis
Myometrium: uterine fibroids Pathology
Autopsy studies with systematic histology of the uterus show a prevalence of up to 50 percent. There may be less uterine mobility than expected with a fibroid and general signs of cachexia.
I nvesti gati ons
Other causes of an abdominal pelvic mass in a woman of reproductive years should be considered. The uterus enlarged by fibroids is usually firm, unlike a uterus enlarged during pregnancy.
T r eatment
If the woman has no symptoms and the uterus is not enlarged, no treatment is indicated.
She has two children but still wants to preserve her fertility as she is planning a third. On examination, the abdomen is distended and there is a pelvic mass consistent with that of 20 weeks' gestation.
Discussio n
Endometriosis and adenomyosis
Pathogenesis
There is a common origin for the cells lining the Mullerian duct, the peritoneal cells and the cells of the ovary. Vascular and lymphatic embolization to distant sites has been demonstrated and explains the rare findings of endometriosis in sites outside the peritoneal cavity.
H istological subtypes
The word endometrioma is used to describe endometriotic (or chocolate) cysts in the ovary. Some symptoms may vary depending on the location of the ectopic endometrial lesion, but there are.
Physi cal examination
This overlap of symptoms means that many patients with endometriosis have a delay from the time of onset of symptoms to the time of diagnosis of the disorder. The presence of abnormal cyclical bleeding at the time of menstruation, from the rectum, bladder or navel, strongly suggests the presence of the disease.
No n-invasive te sts
It may be possible to relate various symptoms in patients with endometriosis to the location of the deposits (summarized in Table 10.2), but there is often a direct association with the more specific location of the lesions. Laparoscopy enables direct visualization of endometriotic lesions and the possibility of biopsy of suspicious areas, as well as determining the stage of the disease according to the extent of adhesions and the number and size of lesions.
Endometriosis and subfertility
However, this widely held view may be challenged following the publication of findings from a Canadian multicenter study comparing surgical (laparoscopic) ablation of deposits with no intervention. Although there is no standard treatment, nor a cure, it is important to tailor treatment to the individual based on her age, symptoms, extent of the disease and her desire to become pregnant in the future.
Drug therapy
Surgical destruction improved cumulative pregnancy rates in this study, but further confirmatory trials are awaited. For some patients, the label endometriosis itself can create its own problems, as it is known to be a recurring disorder throughout reproductive life.
S urgi c al trea tm ent
Adenomyosis
Endometriosis is one of the most common gynecological conditions and currently affects between 10 and 25 percent of women with symptoms of gynecological origin. Endometriosis is associated with damage to the tubes and ovaries and the formation of adhesions and can impair fertility.
Add ition al readin g
Pathology
P hysio lo gical cysts
Corpora lutea are not called luteal cysts unless they are more than 3 cm in diameter.
Benign germ cell tumours
Benign epithelial tumours
This is the most common benign epithelial tumor and is bilateral in about 10 percent. These account for 15-25 percent of all ovarian tumors and are the second most common epithelial tumor.
Benign sex cord stromal tumours
These represent only 1-2 percent of all ovarian tumors and are bilateral in 10-15 percent of cases. While ascites occurs with many larger fibroids, Meig's syndrome—ascites and pleural effusion associated with ovarian fibroids—is seen in only 1 percent of cases.
Age distribution of ovarian tumours
They are often difficult to distinguish from other ovarian tumors because of the variety of cells and early architecture.
Presentation
Asymptomatic
Pain
Abdominal swelling
Miscellaneous
Differential diagnosis of benign ovarian tumours
I nvestigati on
Gynaecol ogical h is tory
General history and exa m ination
Abdominal examination
Bimanual examination
U l trasound
Neither computed tomography nor magnetic resonance imaging have significant advantages over ultrasound in this situation, and both are more expensive.
U ltrasound-gui ded diagnostic o va rian c yst aspira tio n
Ra diologica l investigations
Blood test and serum markers
The asym ptomatic patient
However, ovarian cysts larger than 10 cm in diameter are unlikely to be physiological or resolve spontaneously. If the cyst persists, such women may be followed with 6-monthly ultrasounds and CA 125 evaluations as described above.
In these cases, if there is no change in the cyst at the second ultrasound in 3 months, a 6-month follow-up ultrasound and CA 125 assessment is safe. While the small cysts described above can be managed without surgery, there may be a small role for laparoscopic evaluation and treatment of larger (perhaps up to 10 cm) but otherwise apparently benign cysts.
T he patient with symptom s
In the second and third trimesters, treatment of an asymptomatic ovarian cyst can be either conservative or surgical. Treatment is usually surgical, although there may be some women in whom cyst aspiration is indicated.
Therapeutic ultrasound-guided cyst J aspiration
The pregnant woman with an ovarian cyst is a special case because of the dangers to the fetus during surgery. There may be a small place for cyst aspiration in women in whom surgery is considered high-risk, either because of coexisting medical problems or because close pelvic attachments enclose the ovaries.
Examination under an aesthesia
A tumor in a young woman that appears to be largely solid on ultrasound is likely to be a germ cell tumor and should be removed.
Laparo scopic p rocedures
Indications for laparoscopy
L apa roto my
This policy is made possible by the effectiveness of modern chemotherapy for germ cell tumors. Solid ovarian tumors are often malignant - in young women, these are usually germ cell or germ cell stromal tumors.
R e ferences
Since epithelial cancer is much more likely in a woman over 44 years of age with a unilateral ovarian mass, she is probably better advised to have total abdominal hysterectomy, bilateral salpingo-oophorectomy, and infracolic omentectomy. Ovarian cysts are very rarely malignant before the age of 35, especially when they are less than 10 cm in diameter.
Addi tio nal reading
Chapter 12
Malignant disease of the uterus and cervix
M alig n ant disease of the cervix Introduction
Aeti o logy
Because HPV infection is so common in association with cervical cancer, it stands to reason that one or more other factors must play a role in the development of the cancer. The range of types and proportions of each type varies considerably in different parts of the world.
Pathophysiology
It is likely that 80-90 percent of sexually active women will have HPV infection of the genital tract at some point in their lives, in the same way that most people are infected with the Epstein-Barr virus that causes glandular fever. While it is now technically possible to construct a large range of different vaccines, many years of field work will be needed to assess their efficacy, acceptability and effect on the prevalence of other HPV subtypes.
Such women are always urgently referred to colposcopy due to the high risk of invasive cancer of the cervix or endometrium. The specificity of cervical cytology is approximately 92 percent, with the result that approximately 8 percent of the normal Pap smear population will have a dyskaryotic result.
C olposcopy
Three normal smears are required before a woman can be returned to routine screening for a smear showing mild dyskaryosis. A very small number of smears are reported to show abnormal gland cells or borderline nuclear changes in gland cells.
Treatment of CIN
It should be remembered that CIN within the cervical glands can extend up to 5 mm into the cervical stroma. However, its main disadvantage is that it is not easy to adapt the excision to the exact area of the anomaly.
Invasi v e carcinoma of the cervix
Cancer of the cervix may not be clinically apparent to a practitioner until it has become very large. Carcinoma of the cervix can spread by direct infiltration and via the lymphatic vessels.
Malignant disease of the body of the uterus
In advanced cervical cancer, radiotherapy can be used in a palliative setting to reduce vaginal bleeding and discharge and help local control of the disease. Anterior exenteration consists of removing the uterus, vagina and bladder, with the implantation of the ureters in an artificial bladder made from an ileal loop.
E pidemio lo g y
Response rates are typically 60%, and chemotherapy can be used in the neoadjuvant setting before surgery rather than after surgery. External beam radiation may be used in early pregnancy; followed by abortion of the dead fetus and then local cesium irradiation can be performed.
P a tholo gy
I\Tomen using oral contraceptives or progestogens have up to a 50 percent reduction in the incidence of endometrial cancer and the protection lasts for many years after these drugs are discontinued. Increasing evidence suggests that it is simplistic to view excess estrogen as the main factor in the development of endometrial cancer.
Clinical presentation
The cause of endometrial carcinoma is unknown, although a number of factors that increase the risk of endometrial cancer are listed in Table 12.2. In the postmenopausal period, most circulating estrogen is derived from aromatization of peripheral androgens.
Diagnosi s
It is curious that the incidence of a tumor believed to be related to estrogen should increase so rapidly at a time when endogenous levels of estrogens are declining. III The carcinoma has spread outside the uterus, but not outside the actual pelvis. IV The carcinoma has spread outside the uterus.
Staging
Ultrasound also allows imaging of the ovaries, as a number of patients with postmenopausal bleeding will have ovarian pathology.
Prognosis
Disease prognosis is related to stage, which now includes disease extent, myometrial invasion, and lymph node involvement. Other factors such as age and body morphology are also important: the higher the age, the more likely the patient will succumb to the disease.
Mixed mesoderma l tu mou rs
Leiomyosa rco ma
The cause of cervical cancer is unknown, but HPV infection appears to play a role. Radiotherapy is used for older and less fit patients, regardless of the size of the tumor.
Carcinoma of the ovary and Fallopian tube
CANCER OF THE OVARY
Incessant ovul ation' theo ry
Sub fert ility treatment
Genetic factors
Familial ovarian cancer
Famili a l ovar ian c ancer
Management of women with a family history of ovarian cancer
Classification of ovarian tumours
Primary ovarian tumors are divided into epithelial type (implying a surface epithelial origin), germline gonadal type (also known as germline stromal type or germline mesenchymal type and derived from mesenchymal elements of the germline) and germline type.
Simplified histological classification of ovarian tumours
Pathology of epithelial tumours
S erous ca rcinoma
Muc inous carcinoma
E ndom e t ri oid carcinoma
Clear cell carcino ma (mes onephroid)
Because there is a very strong association between clear cell tumors of the ovary and ovarian endometriosis, and because clear cell and endometrioid tumors often coexist, it has been suggested that the clear cell tumor may be a variant of the tumor endometrioid.
Borderline epithelial tumours
Natural history
Clinical staging
Tumor in stage Ia or Ib but tumor on the surface of one or both ovaries or with a ruptured capsule or. Tumor in stage IIa or lIb but tumor on the surface of one or both ovaries or with a ruptured capsule or.
Markers fo r epitheli al tumours
Screening
Surgery
Surgery for epithelial ovarian cancer
If a young woman has had an ovarian cystectomy and complete removal of the disease seems likely, there is probably little to be gained from further surgery, but the risk of recurrence (36 percent) is greater than in a young woman . after oophorectomy (15 percent) or pelvic clearance (2.5 percent). If in doubt, a second laparotomy should be performed to thoroughly examine the abdomen and remove the remainder of the affected ovary.
Selecting p atients for postoperative treatment
If the tumor is later found to be poorly differentiated or if the lavages are positive, a second operation will be necessary to clear the pelvis. When bulky disease remains after initial surgery, a second laparotomy may be performed on those women who respond after two to four courses of chemotherapy.
Radiotherapy
However, in a young nulliparous woman with a unilateral tumor and without ascites, unilateral salpingo-oophorectomy may be warranted after careful examination to rule out metastatic disease and curettage of the uterine cavity to rule out a synchronous endometrial tumor. This has led to the use of initial chemotherapy in women where it is unlikely that the disease can be removed surgically.
Chemotherapy
A large European study of this approach suggests that median survival in this poor-prognosis group can be increased by 6 months and that survival at 3 years can be improved from 10 percent to 20 percent (Van der Berg et al. ., 1995). Confirmation of malignancy is by cytology or guided biopsy, and surgery follows if the tumor responds.
Chemotherapy for epithelial ovarian cancer
Until the advent of the S-hydroxytryptamine (SHT) antagonists (ganesetron and ondansetron), severe nausea and vomiting, sometimes lasting several days, was a serious problem. Paclitaxel is derived from the bark of the Pacific yew tree (Taxus brevifalia) and has a mechanism of action that is unique among cytotoxic drugs.
Results - epithelial tumours
Paclitaxel (Taxol) is given in combination with cisplatin or carboplatin as first-line treatment, but can be used alone when the disease recurs. Nausea and vomiting are very mild, but body hair loss is usually complete regardless of dose and schedule.
Results of treatment of epithelial tumours
Permanent kidney damage will occur unless cisplatin is given with adequate hydration with intravenous fluids. Carboplatin is as effective as cisplatin in the treatment of ovarian cancer and is the most commonly used first-line drug, either alone or in combination with paclitaxel.
Borderline epithelial tumours
The lack of renal toxicity means that there is no need to hydrate carboplatin intravenously. Other forms of toxicity, such as myalgia and arthralgia, are dose dependent but never serious.
Invasive epithelial ovarian cancer
It is usually given as a 4-hour infusion following a premedication regimen with dexamethasone 20 mg, diphenhydramine SO mg, and ranitidine or cimetidine to prevent hypersensitivity reactions. Sensory neuropathy and neutropenia are more common at higher doses, and 24-hour infusions result in a higher incidence of grade 4 neutropenia.
Non-epithelial tumours
Sex cord stromal tumours
Germ cell tumours
Yolk sac (endodermal sinus) tumor is the second most common malignant germ cell tumor of the ovary, accounting for 10-15 percent overall and reaching a higher proportion in children. It can appear as an acute abdomen due to tumor rupture after necrosis and hemorrhage.
Treatment of non-epithelial tumours
Mature teratomas are benign; the most common is the cystic teratoma or dermoid cyst found at all ages, but especially in the third and fourth decades. Immature teratomas consist of a wide variety of tissues and comprise approximately 1 percent of all ovarian teratomas.
CANCER OF THE FALLOPIAN TUBE
A very thorough sampling of all dysgerinomas should be undertaken by the histopathologist to rule out the presence of these more malignant germ cell elements, as this indicates a worse prognosis. Blood levels of f3-hCG and AFP should be evaluated, even when the tumor appears to be a direct immature teratoma.
Staging Pathology
Clinical presentation and management
Results
Additional read ing
Chapter 14
Conditions affecting the vulva and vagina
VULVA
Anatomy
Benign conditions of the vulva
Information on treatments used to date is important, as many of these women will have already started using a variety of topical preparations, some of which may be potentially harmful. Depression may be a result of the vulvar condition rather than the cause, but it will still require treatment.
Examinatio n
Even when it seems that no specific therapy can be offered, many patients are helped by the knowledge that there is no serious underlying pathology and by a supportive attitude. The duration of the complaint, details of its onset and any triggering factors must be determined.
Symptoms of benign vulval conditions
After washing, the vulva should be carefully and gently dried - if necessary, you can use a hair dryer set to a low temperature. Strong topical steroids such as 0.1% diflucortolone valerate or 2.5% hydrocortisone can be used two to three times a day for several weeks.
Non-neoplastic disorders of the vulva
A sedative at night, such as hydroxyhydrochloride, can be helpful in breaking the cycle of nocturnal itching and scratching. Even if the patient is not pathologically depressed, she can benefit greatly from sympathetic support and understanding, and time should be set aside for this when necessary.
Classification of vulval disorders
The most common general diseases that cause itching of the vulva are diabetes, uremia and liver failure. In lichen planus, the lesion on the vulva is characteristically a purple-white papule with a shiny surface and regular outline.
Vulval ul c ers
Squamous cell hyperplasia is a term used when there is histological evidence of hyperplasia without any clinical evidence of the cause. There is a variant of this condition that is erosive and can lead to pain, bleeding and itching.
Causes of benign vulval u lcers
There is practically no place for vulvectomy for this condition, as the morbidity is not justified given the high recurrence rate. Although these are discussed elsewhere (Chapter 15), vaginal infections are the most common cause of vulvar itching, especially in younger women.
Benign tumours
In diabetes, the vulva, in addition to itching, is swollen and dark red in color. In allergic dermatitis, the skin is usually red and swollen and may later thicken.
Premalignant conditions
Similarly, the histological appearance of Paget's disease is similar to the lesion seen in the breast. In one-third of cases of Paget's disease, there is an associated invasive cancer, often an adenocarcinoma of the underlying apocrine glands, and these have a particularly poor prognosis.
Natural history o f VIN
The histological features and terminology of VIN are analogous to those of cervical intraepithelial neoplasia (CIN) and vaginal intraepithelial neoplasia (VAIN).
Treatment 01 VIN
This may be applied twice or three times a day for up to six months as it can cause the skin to thin. When assessing the results of treatment, the duration of follow-up should be taken into account.
Conclusions
Uncertainty regarding the malignant potential, the multifocal nature of the disorder, and the discomfort and disability resulting from therapy suggest that recommendations should be cautious and conservative in order to avoid worsening the treatment of the disease. An alternative approach used to be to vaporize the abnormal epithelium with a carbon dioxide laser.
P age t's diseas e
Spontaneous regression of VIN III in women with the variant known as Bowenoid papulosis is well described. The documented progression of untreated cases of VIN III to invasive cancer underscores the potential importance of these lesions.
Invasive disease of the vulva
Despite the apparent limitations of this classification, it provides a reasonable guideline for prognosis. The major drawback was reliance on clinical palpation of the inguinal nodes, which is notoriously inaccurate.
Diagnosis and assessm ent
Drainage to both groins occurs from midline structures—the perineum and clitoris—but some contralateral spread may occur from other parts of the vulva. Numbness and paresthesia over the thigh are common due to the division of small cutaneous branches of the femoral nerve.
VAGINA
Modifications of this en bloc excision have been designed to allow primary closure and to reduce the significant morbidity. Many studies have since testified to the reduced morbidity of this method without loss of effectiveness.
Vaginal intraepithelial neoplasia
Natural h istory of VAIN
Vaginal cancer
Natu ral histo ry
C lini cal stagi n g
Di a gnosis a nd assessment
High-resolution MRI has become the most important part of the pre-treatment evaluation of invasive vaginal cancer. Careful examination under anesthesia combined with colposcopy will detect coexisting VAIN and help determine the location of the lesion.
Treatment and resu lts
Chapter 15
Principles of management of sexually transmissible infections
Ideally, therefore, full screening for chlamydia, gonorrhea, vaginal infections, and serological tests for syphilis, hepatitis B, HIV, and hepatitis C should be performed if indicated. If facilities for such a screen are not available, the patient should be referred to a genitourinary medicine (GUM) clinic.
Lower genital tract infections
To break the chain of infection and prevent re-infection, it is essential that the patient avoid intercourse until she is sure that her partner(s) have been screened and received appropriate treatment.
Physio logical discha r ge
Va ginal candidia s is
Sexual acquisition is rarely important, although the physical trauma of intercourse may be sufficient to trigger an attack in a predisposed individual. The classic manifestation is itching and pain in the vagina and vulva, with a mushy, white discharge that may smell of yeast, but in some cases there may be itching and redness with a thin, watery discharge.
Factors predisposing to vaginal candidiasis
This is an epithelial cell covered with small bacteria, so the edge of the cell is obscured. Longer courses of treatment are necessary when there are predisposing factors that cannot be eliminated, such as steroid therapy.
B acterial vagin osis
If this appears to be the case, it is important to consider other diagnoses, especially herpes simplex, which causes local ulceration and pain, and dermatological conditions such as eczema and lichen sclerosus and atrophitis. If recurrences are common it is worth doing a full blood count to check for anemia and check thyroid function, but usually these are normal.
Trichomoniasis
Vagi nal discharge in children
O th er conditions affecting the vagina
B artholi n 's abscess
Infe station s
Key Points: vaginal infections
Upper genital tract infections
In Scandinavian countries, national screening programs have reduced the incidence of chlamydial infection with concomitant reductions in the incidence of PID and ectopic pregnancy. Microimmunofluorescence can be used to detect serum antibodies that are not present in all infected individuals.
Gonorrhoea
It is essential that sexual partners are fully screened for STIs and prescribed treatment for chlamydia before resuming intercourse. It is essential that sexual partners are fully screened for sexually transmitted diseases and prescribed treatment for gonorrhea before resuming intercourse.
Cervicitis
Pelvic inflammatory disease
Subsequent scarring can lead to the fimbriae being pulled into the ends of the fallopian tubes, causing the ends of the tubes to stick and seal. In early salpingitis, however, the inflammation may not be visible from the serosal surface of the tubes.
Key Points: pelvic inflammatory disease
If there is doubt about the possibility of pregnancy, a urine pregnancy test should be carried out. Disseminated infection with gonorrhea occurs rarely (more often in women than men) but presents as a septic arthritis usually affecting the small joints of the hand or wrist, with a sparse papular rash.
Other causes of endometritis
Laparoscopy should be performed if the clinical diagnosis is uncertain, drainage of an abscess may be required, or there is no improvement after 24-48 hours of intravenous antibiotic treatment in a systemically ill woman. If there is any history of pelvic pain, the IUD should be removed and antibiotic treatment with penicillin should be started.
Genital ulcer disease
It can be detected on cervical cytology and, if there are no clinical features suggestive of PID, careful monitoring is required. If not detected, actinomycosis can progress to extensive pelvic involvement with an inflammatory mass and fixation of the pelvic organs.
Herpes simplex virus
Classification of genital ulcers
It is important to counsel such patients that herpes is likely, even if the initial smear is negative. If people with a history of herpes take shots every day, herpes can usually be detected on occasion.
No n-h erpes genital ulcers
Syphilis
Neurosyphilis can manifest within five years of infection as meningovascular syphilis, which manifests as a stroke. Only intravenous penicillin or high doses of procaine penicillin (2.4 MU per day) combined with probenecid (500 mg four times daily) produce acceptable levels of penicillin in the cerebrospinal fluid to treat neurosyphilis.
Tropical genital ulcer disease
In the early stages there is often a small superficial ulcer that can slowly increase in size, but often goes unnoticed. Granuloma inguinale is an infection caused by Klebsiella granulomatis (formerly known as Calymmatobacterium granulomatis).
Key Points: genital ulcers
The sores may last for several months and the glands may fester through the skin. It is usually a slowly progressing infection that starts with individual papules on the skin or vulva, which may enlarge and form 'fleshy red' painful ulcers.
Other viral infections Human papillomavirus
The majority of genital warts are caused by HPV types 6 and 11 - viruses that have little oncogenic potential. It is important to clarify that most visible genital warts are not caused by oncogenic virus strains and that the risk of cervical cancer is not greatly increased.
Key Points: genital warts
Healing can be followed by ulcers, so patients should be carefully instructed in its use. If cervical cytology has not been performed within three years, it should be done, but there is no need to advocate annual Pap smears or any other increased surveillance.
Molluscum contagiosum
HPV types 16 and 18 can cause flat warts and are linked to the development of cervical carcinoma. The majority of squamous cell carcinomas of the cervix contain DNA sequences from oncogenic HPV strains.
HIV infection
It is a particularly devastating disease because of the stigma of sexual transmission and the risk of vertical transmission to children. Even for children who are not infected, the death of one or both parents threatens their development and survival in many parts of the world.
Common manifestations of AIDS
This may include co-trimoxazole to prevent pneumonia caused by Pneumocystis carinii (PCP) and, in severely immunocompromised individuals with CD4 counts below 0.005/l, azithromycin to prevent disseminated Mycobacterium avium intracellular complex (MAC) infection and ganciclovir to prevent cytomegalovirus (CMV) infections.
Virology
Diagno s is
Transmissi o n
G y naecological manifestations
Although all HIV-infected women are encouraged to use condoms to prevent transmission to others, they should also be advised to use a more reliable form of contraception if they do not wish to become pregnant. Currently, providing fertility treatment to HIV-infected women is controversial, but is offered by some gynecologists.
New develo p ments
If an HIV-infected woman plans to become pregnant, the means to reduce the risk of vertical transmission should be discussed with her, as well as the consequences for the child of potentially losing his or her mother in infancy. If the partner is HIV negative, the couple should be assisted in performing artificial insemination by providing information and syringes or pipettes.
Commen t
Urinary tract infection
Chapter 16
CLINICAL CONDITIONS
Common symptoms associated with incontinence
