1

A. N. Rybalka, V. A. Zabolotnov, I. K. Kamilova,

A. N. Sulima, S. S. Anikin, V. V. Litvinov, I. M. Shlapak,

S. E. Regushevsky, D. A. Beglitce, Z. S. Rumyanceva,

I. A. Khomulenko, N. S. Demidova, O. P. Miklin, G. N. Bagrova

OBSTETRICS AND

GYNECOLOGY

Textbook

in 2 volumes

Edited by Professor A. N. Rybalka

Volume 2

GYNECOLOGY

Simferopol

2018

2

3

N. Rybalka, V. A. Zabolotnov, I. K. Kamilova, A. N. Sulima,

S. S. Anikin, V. V. Litvinov, I. M. Shlapak,

S. E. Regushevsky, D. A. Beglitce, Z. S. Rumyanceva, I. A. Khomulenko,

N. S. Demidova, O. P. Miklin, G. N. Bagrova

OBSTETRICS AND

GYNECOLOGY

Textbook

in 2 volumes

Edited by Professor A. N. Rybalka

Simferopol

2018

4

УДК 618.2/7

ББК

R 98

Rybalka A. N., Zabolotnov V. A., Kamilova I. K. at al.

R 98 Obstetrics and gynecology. Textbook - in 2 vol. Vol. 2 Gynecology. –

Simferopol, 2018. – 704 p., 134 pic., 20 +ав.

ISBN 978-966-2913-33-0

Annotation

The manual on obstetrics and gynecology is designated for English-speaking

students of the 5-6 courses of medical higher schools. Short lectures on the main

topics of obstetrics and gynecology are presented in the manual. The book acquaints

the reader with up-todate notions in etiology, pathogenesis, diagnosis and treatment

of gynecological diseases. The book is intended as a handbook on obstetrics and

gynecology for the English-speaking students.

© A. N. Rybalka, V. A. Zabolotnov, I. K. Kamilova, A. N. Sulima,

S. S. Anikin, V. V. Litvinov, I. M. Shlapak, S. E. Regushevsky,

D. A. Beglitce, Z. S. Rumyanceva, I. A. Khomulenko, N. S. Demidova,

O. P. Miklin, G. N. Bagrova, 2018

5

Volume 2

GYNECOLOGY

Recommended by the Scientific Council of the Midical Academy named after

S. I. Georfievsky V. I. Vernadsky Crimean Federal University as “Obstetrics and

gynecology” textbook in 2 volumes in English for students, internus and doctors of

higher medical schools, who study the academic discipline in English 27. 12. 2016

(Protocol №14)

6

Authors:

A. N. Rybalka – DM, Professor, Academician, Head of the Department of

Obstetrics, Gynecology and Perinatology.

V. A. Zabolotnov – DM, Professor, Head of the Department of Obstetrics and

Gynecology.

I. K. Kamilova – PhD, Associate Professor of the Department of Obstetrics

and Gynecology.

A. N. Sulima – DM, Professor of the Department of Obstetrics, Gynecology

and Perinatology.

S. S. Anikin – PhD, Associate Professor of the Department of Obstetrics,

Gynecology and Perinatology.

V. V. Litvinov – PhD, Chief Physician of the Human Reproduction Clinic

“Altra Vita” (LLC “ECO Center”), Moscow.

I. M. Shlapak – DM, Professor of the Department of Obstetrics, Gynecology

and Perinatology, Chief Physician of the Crimean Republican

Clinical Perinatal Center.

S. E. Regushevsky – PhD, Associate Professor of the Department of Obstetrics,

Gynecology and Perinatology, Chief Obstetrician and

Gynecologist of the Ministry of Health of the Crimea, Deputy

Chief Republican of Crimean Republication Clinical Perinatal

Center.

D. A. Beglitce – PhD, Associate Professor of the Department of Obstetrics,

Gynecology and Perinatology, Chief Physician of Clinical

Maternity №1.

Z. S. Rumyanceva – PhD, Associate Professor of the Department of Obstetrics

and Gynecology №1.

I. A. Khomulenko – PhD, Associate Professor of the Department of Obstetrics,

Gynecology and Perinatology.

N. S. Demidova – PhD, Associate Professor of the Department of Obstetrics,

Gynecology and Perinatology.

O. P. Miklin – PhD, Associate Professor of the Department of Obstetrics

and Gynecology №1.

G. N. Bagrova – PhD, Associate Professor of the Department of Obstetrics,

Gynecology and Perinatology.

7

CONVENTS

INTRODUCTION. ....................................................................................................... 7

Gynecology as a science. Historical Perspective. Deontological ethic in

gynecological practice .............................................................................................. 7

CHAPTER 1. Anatomical and Physiological changes in women in different

periods of the life. Puberty ......................................................................................... 11

Puberty stages in girls. ............................................................................................. 15

Menstruation ............................................................................................................. 19

Menopause. ............................................................................................................... 20

CHAPTER 2. Examination of Gynecological Patients ............................................... 23

Clinical breast examination. ..................................................................................... 31

Inspection of external genitalia. ............................................................................... 47

Vaginal smears ......................................................................................................... 56

Tests for evaluation of vaginal ecology ............................................................ 56

Tests for evaluation of endocrine status ............................................................ 61

Tests for evaluation of abnormal (precancerous and cancerous) conditions .... 70

Invasive methods of examination sounding of the

uterus ...................................................................................................................... 172

Histological investigations. Cervical biopsy. ......................................................... 174

CHAPTER 3. Congenital anomalies and displacements of the female genitalia .... 186

CHAPTER 4. Inflammaory diseases of the

female genitalia ......................................................................................................... 203

Sexually transmitted pelvic inflammatory diseases. .............................................. 236

CHAPTER 5. Neurohumoral control of the

menstrual cycle .......................................................................................................... 253

CHAPTER 6. Menstrual disorders ............................................................................ 270

CHAPTER 7. Neuroendocrinal syndromes in

gynecology ............................................................................................................... 299

8

CHAPTER 8. The infertile couple ............................................................................ 322

CHAPTER 9. Contraception ..................................................................................... 332

CHAPTER 10. Typical operations in gynecology .................................................... 354

CHAPTER 11. Acute abdomen in gynecologic practice .......................................... 435

CHAPTER 12. Injuries of the female genital tract.................................................... 452

CHAPTER 13. Myoma of the uterus. Endometriosis. Sarcoma of the uterus .......... 470

CHAPTER 14. Breast diseases .................................................................................. 500

CHAPTER 15. Premalignant diseases of the vulva and vagina. Cancer and

sarcoma of the vulva and vagina .............................................................................. 519

CHAPTER 16. Background processen and premalignant lesions of cervix.

Cervical cancer ......................................................................................................... 545

CHAPTER 17. Premalignant diseases of the endometrium. Cancer of the uterus.

Sarcoma of the uterus ................................................................................................ 573

CHAPTER 18. Cysts of the ovary. Ovarian tumors ................................................. 589

CHAPTER 19. Cancer of the fallopian tubes ........................................................... 605

CHAPTER 20. Trophoblastic diseases .................................................................... 609

CHAPTER 21. Gynecological diseases in childhood and adolescence .................... 617

CHAPTER 22. Female dispensary – prophylactic medical examination of

gynecological patients .............................................................................................. 635

CHAPTER 23. Hygienic regimen in female ............................................................. 640

CHAPTER 24. Urinary tract diseases in female ....................................................... 647

CHAPTER 25. Appendices ....................................................................................... 681

Appendix 1. Tests 1. ............................................................................................... 681

9

PART II. GYNAECOLOGY

INTRODUCTION

Gynecology as a science. Historical Perspective

Gynaecology (British) or gynecology (North American) literally means

'the science of women', - “the science of womankind” (Oxford Dictionary);“the

medical specialty concerned with diseases of the female genital tract as well as

endocrinology and reproductive physiology of the female”(Stedman

Dictionary). Almost all modern gynecologists are also obstetricians.

Gynecology is a typically consultant specialty. In most countries, women must

see a general practitioner first. If their condition requires knowledge or

equipment unavailable to the general practitioner, they are referred to a

gynecologist. However, in many countries law and many health insurance

plans allow gynecologists to provide primary care and some women select

that option.

Clinical history and examination generally accepted in medicine are the

main tools of diagnosis in gynecological practice. Gynecological examination

is a special one as it is quite intimate and it involves special equipment.

Various taboos associated with the study of female genitalia, for a long time

hampered the development of the science of gynecology. This drawing of 1822

by Jacques-Pierre Maigreira (Fig.1) shows a "compromise" procedure in

which the doctor kneels in front of a woman, but cannot see her genitals.

Modern gynecology no longer uses this position

Historical Perspective (see also Volume I). Down to the sixteenth

century gynecology was almost exclusively in the hands of midwives, who

were trained for it as for a trade. Only in rare cases was a surgeon called in.

Almost all the achievements of ancient times seemed to be forgotten, and only

10

after anatomical studies had been resumed and surgery had made some

progress those things began to improve.

The most important accounts of the condition of ancient gynecology are

found in famous Indian Ayurvedic books, which mean “the Science of Life”, in

the Hippocratic writings, one of the books named “About female diseases”. In

ayurvedic books there is some information about displacements of uterus,

condylomas of vulva, amenorrhea. Important information about

inflammatory processes of the uterus and vagina (diagnosis and treatment of

endometritis and vaginitis) are found in the Hippocratic writings, as well as

material about swellings of the female genitalia, some types of surgical

treatment of uterus tumors (removing of the tumor with tongs, knife and red-

hot iron).

The first scientific background of gynecological science appeared in the

16th century, in writings of Kuper, Vesalius, Bartoline, Fallopio and others.

(Fig. 2). The detailed description of female anatomy was done at this period of

time. Mercado, the professor of the university in Toledo (Spain) wrote one of

the oldest books on gynecology in the 16th century. Much was done to enlarge

and enrich the study of this branch of medicine by the works of Jacques

Guillemeau (1560 to about 1609), Scipione Mereurio (1595), Ambroise Paré

(1517–1590), Renie Graaf (1641–1673).

Fig. 1. A compromise" procedure of gynecological examination.

11

Fig.2. A - Gabriello Fallopio, 1523–1562; B - Ambroise Paré, 1517– 1590.

The gynecology was a part of surgery, it wasn’t an independent science

over a long period of time. Historically, gynecology has been one of the few

medical practices dominated by female practitioners. From Agnodice in

ancient Greece to the 18th century in Europe, the care of mothers and delivery

of infants has been regarded, both by the patients and by the specialists of

medical profession, as a profession carried out by women.

In the 18th century, a gap between surgeons and midwives arose as

medical men began to assert that their modern scientific processes were

better for mothers and infants than the midwives. A number of excellent full-

length studies of these historical changes have been written. The powerful

progress of natural science, medicine, physiology and anatomy became the

basis for development of gynecology in many countries of the world. In the

40th of the 18th century special gynecological clinics were opened in some

countries of Europe (Russia, England, France, and Germany). Up to this time

gynecology had been only a part of obstetrics and surgery. Since this time

gynecology has become the independent science studying female reproductive

system, its physiology and pathology. French scientist J. Astruc was a pioneer

of study of the septic endometritis, he detailed clinical features and supposed

12

the pyaemia to be a reason of fever, sweats, emaciation, weight loss.

F. Osiander (1759–1822) proposed to perform the amputation of the uterus

cervix in case of cancer and invented a novel device – special forceps for this

operation. The introduction of scientific gynecology in different countries was

important at that time. The science of gynecology has long inhibited the

shame associated with the examination of female genitalia. This 1822 drawing

by Jacques-Pierre Maygnier shows a "compromise" procedure, in which the

physician is kneeling before the woman but cannot see her genitalia. Modern

gynecology has overcome these inhibitions. J. Simpson, J.-L. Baudelocque,

K. Schroeder, V. A. Krasovsky, J. Pean, A. Hegar, I. Semmelveis, D. Lister,

V. Stroganov, A. Neisser, V. Snegirev, A. Gubarev, D. Ott are famous due to

their important contribution to the science.

Fig. 3. Professor V. F. Snegirev, 1847-1916

Deontological ethics in gynecological practice

The study of ethics has been defined as the way of understanding and

examining the moral life, and as the study of conduct and moral judgment

standards. Thus, the study of ethics is the study of morality, careful and

systematic reflection and analysis of moral decisions and behaviour. Since

ethics deals with all aspects of human behaviour and decision-making, it is a

13

very large complex field of study with many branches. Medical ethics

(deontological ethics) is the branch of ethics that deals with moral issues in

medical practice. The Hippocratic oath is referred to the one of the oldest

codes of medical ethics. It was Hippocrat who suggested the most important

ethical principle “do no harm” (“non nocere”) in this code.

In recent times medical ethics has been greatly influenced by the

development in human rights. It is closely related to law. But ethics and law

are not identical. As for the laws, they differ from one country to another

while ethics is applicable across national boundaries. At the same time,

medical ethics vary from one country to another depending on the

development in medical science and technology, social values, cultural wealth

and moral traditions. Although these differences may seem significant, the

similarities are far greater. Physicians throughout the world have much in

common. The fundamental values of medical ethics such as compassion,

competence, autonomy, beneficence, do no harm, confidentiality, honesty,

respect for a patient and respect for the law are common for all physicians all

over the world.

Physicians caring for patients should follow these fundamental ethical

principles.

Autonomy.

Physician’s autonomy, or self-determination is the core value of

medicine. Any physician traditionally enjoyed a high degree of clinical

autonomy in deciding how to treat a patient. On the other hand, physicians in

general (the medical profession) have been free to determine the standards of

medical education and medical practice. Both of these ways of exercising

physician autonomy have been moderated in many countries by the

government and other authorities imposing controls on physicians.

At the same time, there has been a widespread acceptance of patient

autonomy, which means, the patients should be the ultimate decision-makers

in matters that affect them. Physicians must respect a patient's right to make

14

decisions regarding medical care. Competent, informed patients have the

right to choose treatment options and refuse any unwanted medical

interventions.

Decisions for Competent Patients

One of the most important ethical principles of ethical delivery of care is

informed decision making. Informed, competent patients have the power to

choose consent to, or refuse medically feasible options for care, even when the

result will be disability or death.

Decision-Making for Incompetent Patients

Patients may be incompetent to make decisions for themselves.

Examples include young children, individuals affected by certain neurological

or psychiatric conditions, and those, who are temporary unconscious or

comatose. The World Medical Association Declaration on the Rights of the

patients states the physician’s duty in this matter as follows:

If the patient is unconscious or otherwise unable to express the will,

informed consent must be obtained from a legally entitled representative

where legally relevant. If a legally entitled representative is not available, but

a medical intervention is urgently needed, consent of the patient may be

presumed, unless it is obvious and beyond any doubt on the basis of the

patient’s previous firm expression or conviction that she/he would refuse

consent to the intervention in that situation.

Refusal of Therapy

Most patients accept treatment recommended by their physician.

However, some patients may refuse treatment that the physician believes to

be highly beneficial (e. g., amputation of a myomatous uterus). In such

circumstances it is appropriate for the physician to try to persuade the patient

to accept beneficial treatment, although the physician should refrain from

badgering the patient or misrepresenting the facts. The physician should

check that the patient is fully informed of the consequences of the decision

and has the capacity to make informed decisions. In the end, the physician

15

must respect a competent, informed patient's right to make decisions about

medical care, even if the physician believes the decision is unwise.

Compassion, defined as understanding and concern for another

person’s distress, is essential for the practice in medicine, especially in

gynaecology. In order to deal with the patient’s problems, the physician must

identify the symptoms that patient is experiencing and their underlying

causes and must want to help the patient achieve relief. Patients respond

better to treatment if they perceive that physician appreciates their concerns

and is treating them rather than just their illness.

Competence is defined as the totality of scientific knowledge and

practical skills of a physician. The lack of competence can result in death or

serious morbidity for patients.

Beneficence.

Fundamental in the doctor-patient relationship is the principle of

beneficence. It is the core ethical principle of the Hippocratic writings:

“Declare the past, diagnose the present, foretell the future; practice in such a

way. As for disease, make a habit of two things, help or at least “do no harm”.

Physicians must do their best acting in the interests of their patients. Patients

are vulnerable because of illness and lack of medical expertise. Therefore,

they rely on physicians. Physicians must put the interests of their patients

above their own interests or those of the third parties, such as insurers or

managed care organizations. If patients lack decision-making capacity, they

need to be protected from making decisions that are contrary to their

interests.

Do no harm.

The related principle directs physicians to “do no harm” to patients.

Physicians must refrain from providing ineffective treatment or acting with

malice towards patients. This principle, however, offers little useful guidance

to physicians, as many beneficial therapies also have serious risks. The

pertinent ethical issue is whether the benefits outweigh the burdens.

16

Confidentiality.

Physicians must maintain the confidentiality of medical information.

Confidentiality respects patient autonomy and encourages patients to seek

care and be candid. A physician will preserve absolute confidentiality on all he

knows about his patient even after the patient has died. The World Medical

Association Declaration on the Rights of the Patient summarized the patient‘s

right to confidentiality as follows:

All identifiable information about a patient’s health status, medical

condition, diagnosis, prognosis and treatment and all other information of a

personal kind, must be kept confidential, even after death.

Confidential information can only be disclosed if the patient gives consent or

if expressly provided for in the law. Information can be disclosed to other

healthcare providers only on a strictly “need to know” basis unless the patient

has given explicit consent.

All identifiable patient data must be protected. The protection of the

data must be appropriate to the manner of its storage. Human substances

from which identifiable data can be derived must be likewise protected.

Many of the most prominent issues in medical ethics relate to special

gynaecological conditions, such as contraception, assisted reproduction,

prenatal genetic screening, abortion, severely compromised neonates, etc.

Any information of these conditions is confidential.

The world medical association declaration of Geneva

At the time of being admitted as a member of the medical profession:

I solemnly pledge myself to consecrate my life to the service of humanity;

I will give to my teachers the respect and gratitude, which is their due;

I will practise my profession with conscience and dignity; The health of my

patient will be my first consideration;

I will respect the secrets, which are confided in me, even after the patient has

died;

17

I will maintain by all the means in my power, the honour and the noble

traditions of the medical profession;

My colleagues will be my sisters and brothers;

I will not permit considerations of age, disease or disability, creed, ethnic

origin, gender, nationality, political affiliation, race, sexual orientation, or

social standing to intervene between my duty and my patient;

I will maintain the utmost respect for human life from its beginning even

under threat and I will not use my medical knowledge contrary to the laws of

humanity;

I make these promises solemnly, freely and upon my honour.

18

Chapter 1. ANATOMICAL AND PHYSIOLOGICAL

CHANGES IN WOMEN IN DIFFERENT PERIODS OF

LIFE

PUBERTY

Puberty is an exciting but perplexing stage of life that both girls and

boys go through. In girls, it is a time of physical transition between childhood

and womanhood. Rapid physical change goes hand in hand with

psychological change.

One of the changes is the first menstrual period, which occurs at this

time. The changes of puberty are usually complete by the age of eighteen, by

that time the girl is a full-grown woman.

A girl-child starts becoming a woman at the age from 9 to 14, when the

pituitary gland and the hypothalamus in her brain send a signal to her

ovaries. This signal instructs the ovaries to increase production of the female

sex hormones. It is due to this increased hormonal production that causes the

changes of puberty for the period from two to six years. Some girls experience

puberty early others experience it late. Usually they enter puberty about the

same age as their mother or any of their father’s close female relatives.

Outward Changes of Puberty

Physical change is to be expected mostly during puberty. Secondary

sexual characteristics and other changes that develop or occur at this stage

include:

Development of breasts (thelarche);

Growth of pubic hair (pubarche);

Changes in body shape;

Increased height (accelerated growth);

Increased weight;

Growth of external genitalia;

19

Increased sweating;

Pimples;

Vaginal discharge;

The first menstrual period (menarche).

Development of breasts: The area around the nipples grows first,

followed by the actual breasts. Breast development continues approximately

until the age of 18. The growing girl often worries because one breast develops

faster than the other. She needs to be reassured that this happens to many

other girls and the pace of development will soon even out her figure.

Growth of pubic hair: Hair begins to grow in new places during puberty.

Pubic hair begins to grow in a triangular patch in the pubic area, lightly at

first. This is followed by hair growth under the arms. Hair on the legs and

sometimes hair on the arms begins to darken. Some girls are worried by

excessive hair on their limbs and upper lip and may request cosmetic

attention.

Changes in body shape: The hips and thighs widen and the pelvis

expands. The shape of the girl’s body becomes more curvaceous, she prepares

to carry a baby during future pregnancies.

Increased height: Girls enter puberty earlier than boys, and thus enter

their 'growth spurt' before boys. The growth spurt is one of the first signs of

puberty. A girl may grow as much as four inches taller in a single year. After

this, growth slows down considerably. Most girls completely stop growing

about one to three years after the first period, while some gain an inch or so

up to the age of 21. A girl’s feet grow at a fast pace, reaching their full adult

size much before the rest of the body.

Increased weight: A girl tends to be hungrier and have a better appetite

during puberty than she had earlier. Her body needs more calories as it is

growing very quickly. There is an increase in weight as well.

20

Growth of external genitalia: The genitals, which are not conspicuous in

a child, grow and become more evident during puberty. The female external

genitals include the vulva, labia and clitoris.

Increased sweating: Girls now tend to perspire more than they did as

children. Body odor also develops, sometimes necessitating the use of a

deodorant or anti-per- spirant. Daily bathing and frequent change of clothes,

particularly in hot weather, helps to reduce the unpleasant effects of excessive

sweating.

Pimples: One of the difficult changes a young girl may have to endure is

the crop of pimples on her face. Puberty causes her skin to break out because

the oil glands are now more active. The best way of dealing with pimples is to

keep the area clean and to prevent the pores from clogging. This is

particularly important in cities with their high levels of pollution.

Vaginal discharge: Six months to a year before the first period, a girl

usually notices a clear, white vaginal discharge. This is normal, and might

turn yellow on contact with underwear. It is important to change underwear

regularly.

The first period: Shortly after the breasts and pubic hair begin to grow,

the first period occurs (menarche). Girls must be forewarned about menstrual

bleeding, as the first period can otherwise come as a frightening shock. They

need to be taught to use sanitary towels and proper hygiene. Sanitary towels

should be changed at least three to four times a day. This is also the right time

to explain the menstrual cycle to a young girl. Menstrual irregularities in

puberty include a number of conditions, some of which require medical

attention.

Invisible Changes of Puberty

Growth of internal sex organs: The uterus and vagina, which are the

female sex organs within the body, grow during puberty. The uterus increases

in size and sheds its lining in a monthly discharge called the menstrual

period. The vagina grows longer and its walls stretch and become more

21

elastic. Girls going through puberty should be taught about work and

anatomy of the female reproductive system.

Puberty does not begin at the same age for every girl. It can occur

normally at any time in the age from 9 to 14. However, a doctor should be

consulted under certain circumstances, to make sure there is nothing wrong:

- Puberty begins before the age of 9. This is called precocious puberty;

- Pubic hair and breasts (secondary sexual characteristics) have not

begun to appear by the age of 13. This is referred to as delayed puberty;

- The first period has not occurred by the age of 16 (primary

amenorrhea), or the menstruation has stopped for a period of six

months or more (secondary amenorrhea).

Puberty has been divided into five Sexual Maturity Rating (SMR) stages

by two doctors, W. Marshall and J. M. Tanner. These ratings are often

referred to as Tanner Stages one through five. Staging is based on pubic

hair growth, on genital development, and female breast development. Staging

helps determine whether development is normal for a given age. Both sexes

also grow armpit hair and develop pimples. Males develop muscle mass, a

deeper voice, and facial hair. Females redistribute body fat. Along with the

maturing of the sex organs, there is a pronounced growth spurt averaging 8–

10 centimeters and culminating in full adult stature.

Puberty stages in girls

Stage 1. Age Range: Usually 8-11

In Stage 1 there are no outside signs of development, but a girl's ovaries

are enlarging and hormone production is beginning.

Stage 2. Age Range: Usually 8-14. Average: 11-12

The first sign is typically the beginning of breast growth, including

"breast buds." A girl may also grow considerable height and weight. The first

signs of pubic hair start out fine and straight, rather than curly. (Fig. 4)

Stage 3. Age Range: Usually 9-15. Average: 12-13

22

Breast growth continues, and pubic hair coarsens and becomes darker,

but there still isn't a lot of it. The body is still growing, and vagina is enlarging

and may begin to produce a clear or whitish discharge, which is a normal self-

cleansing process. (Fig.5). Some girls get their first menstrual periods late in

this stage.

Fig. 4. Illustration of the Tanner scale for females:

23

I - no glandular tissue: areola follows

the skin contours of the chest

(prepubertal)

no pubic hair at all

(prepubertal)

II - breast bud forms, with small area

of surrounding glandular tissue; areola

begins to widen

small amount of long,

downy hair with slight

pigmentation on the labia

majora

III - breast begins to become more

elevated, and extends beyond the

borders of the areola, which continues

to widen but remains in contour with

surrounding breast

hair becomes more coarse

and curly, and begins to

extend laterally

IV - increased breast size and

elevation; areola and papilla form a

secondary mound projecting from the

contour of the surrounding breast

adult–like hair quality,

extending across pubis but

sparing medial thighs

V - breast reaches final adult size;

areola returns to contour of the

surrounding breast, with a projecting

central papilla.

Stage 4. Age Range: Usually 10-16. Average: 13-14

Pubic hair growth takes on the triangular shape of adulthood, but

doesn't quite cover the entire area. Underarm hair is likely to appear in this

stage, as is menarche. Ovulation (release of egg cells) begins in some girls, but

typically not in a regular monthly routine until Stage 5.

Stage 5. Age Range: Usually 12-19. Average: 15

This is the final stage of development, when a girl is physically an adult.

Breast and pubic hair growth is complete, and full height (stature) is usually

attained by this age range. Menstrual periods are well established, but within

24

the first 1,5-2 years after menarche most menstrual cycles are anovulatory. An

ovulatory menstrual cycle is formed in 1-2 years after menarche and ovulation

occurs monthly. Irregular menstrual patterns are also common within 24

months of menarche.

Fig. 5. The pre-pubertal uterus compare with the adults

To evaluate the rating of sexual maturity special table is used now-a-

days (Table 1)

25

Table 1

Female Sexual Maturity Rating (SMR)

Stage 1 2 3 4 5

Age range 8 -10 yrs 10.5-12.9

yrs

11.3 – 13.5

yrs

11.8 – 14.0

yrs

13.3 –

15.5 yrs

Breast External

development

is not yet

visible.

Breast and

papilla

elevated as

small

mound, or

breast

bud,

areolar

diameter

increased

Breast and

areola

enlarged,

no

contour

separation

Areola and

papilla form

secondary

mound

projecting

from the

contour of

the

surrounding

breast

Adult

size and

contour.

Areola

returns

to part of

general

breast

contour,

nipple

projects

Pubic

Hair

- // - Hair is

sparse,

lightly

pigmented

and

straight,

located on

medial

border of

labia

majora

Hair is

darker,

more

coarse and

beginning

to curl,

increased

in amount

and begins

to extend

laterally

Hair is

coarse and

curly as in

the adult,

hair extends

across the

pubis but

spares the

medial

thighs

Adult

hair –

coarse

and

curly,

spreads

to medial

surface

of thighs

Menarche

(10.8 –

14.5 yrs)

- 10% 30% 90% 100%

Acne Mean age

of onset –

13.2 years

26

MENSTRUATION

The menstrual cycle is the scientific term for the physiological changes that

can occur in fertile women for the purposes of sexual reproduction and

fertilization. The menstrual cycle means a monthly cycle of changes in the

hypothalamus, pituitary gland, in the ovaries and endometrium, aimed at

maturing the eggs for fertilization and preparing the endometrium for the

implantation of a fertilized egg. The menstrual cycle is also described based

on its length (number of days between onset of menstrual bleeding in one

cycle and the onset of bleeding of the next cycle). If fertilization will not

happen, the cycle would completed with menstruation (aka periods,

menstrual flow, etc). Menstruation is the periodic bleeding from the vagina.

Menstruations begin during puberty, in the age from 9 to 14 and ends at

menopause (usually in the age from 45 to 50). For a regular menstrual cycle,

the median age of menarche is 12.77 years. The median duration of a

menstrual cycle is 28 days with most cycle lengths between 25 to 30 days.

Patients, who experience menstrual cycles that occur at intervals less than 21

days are termed polymenorrheic, while patients who experience prolonged

menstrual cycles greater than 35 days, are termed oligomenorrheic. The

typical volume of blood lost during menstruation is approximately 30 mL.

Any amount greater than 70-80 mL is considered abnormal. The duration of

the period (menses) varies in women. Normally, it should last from 3 to 5

days. A woman typically will have about 500 menstrual cycles in her lifetime.

Since it is a cycle, there is no beginning or end, and the changes that

occur are generally gradual. It is convenient, however, to call the first day of

menstruation "day one" of the cycle, because the flow of menstrual blood is

the most apparent of the changes that occur. It is also convenient to divide the

cycle into phases based on changes that occur in the ovary and in the

endometrium.

27

However, a normal cycle can range from 18 to 40 days. And the first day

of the menstrual cycle, when the bleeding begins, is the first day of the period.

MENOPAUSE

Menopause is the cessation of menstruation, in women over the age of

45, for at least 6 to 12 months. Menopause is accompanied with some physical

and psychological changes. It occurs over a few years. Ovarian failure also

takes place during this time. Needless to say, once a woman stops

experiencing the menstrual cycle, her child-bearing years are over.

Today, women’s health and longevity have improved significantly. Even

as recently as a century ago, a large percentage of women did not live up to

menopause. Improved nutrition and medical care have contributed to the

longer life of women. Nowadays, women are encouraged to live in good health

and happiness after their fertile years are over. Menopause might mean the

end of fertility but there is no valid reason why a woman should not be well

and comfortable in the years or decades ahead.

Menopause is a physiological change in the Hypothalamic-Pituitary-

Ovarian Axis (HPOA) according to the age of the woman. In order to

understand the context in which the physiological changes of the menopausal

transition are happening, it is necessary to consider the definitions and stages

associated with reproductive aging. The premenopause is typically defined as

the phase of a woman’s life from the menarche (onset of menstruation) until

the beginning of the perimenopausal stage. The perimenopause comprises

the time from a woman’s mature reproductive state at the point when she

begins to experience variability in the length of her cycle or characteristic

symptoms of the menopausal transition, to the year following her final

menstrual period (FMP). It is only following this 12-month period of

amenorrhea that a diagnosis of menopause can be made. The terms

28

“menopause” and “postmenopause” are often used interchangeably to

describe the phase of a woman’s life from this point

The age of menopause varies. In India, which has a warm climate,

women reach menopause in the age of 45 to 50. In colder climates, women

experience menopause a few years later. In the USA, for instance, the average

age of menopause is 50 to 52 years. In Russian Federation the average age of

menopause is 45–55 years. Apart from climate, the age of menopause also

depends on hereditary factors.

Psychological Features of Menopause

The frequency of the menstruation reduces gradually as a woman

approaches perimenopause. In rare cases menstruation ceases abruptly. Some

women get their periods at frequent intervals with scanty or prolonged flow.

This is because of limited follicle maturation as the remaining follicles in the

ovaries become less sensitive to gonadotropin stimulation.

There are some common psychological features of menopause. These

include increased moodiness, irritability and greater anxiety and fearfulness.

Some women undergo depression and experience insomnia (inability to

sleep). Others report a decreased libido. The vagina becomes narrow closer to

menopause. The uterus also decreases in size and the endometrial tissue

becomes sparse. The vaginal part of the cervix becomes smaller as the muscle

atrophies. The pelvic tissues and ligaments that support the vagina and uterus

lose their tone and become weaker. This predisposes to prolapse of the uterus.

If there are fibroids in the uterus, they become smaller, but do not disappear.

The fat in the breasts gradually reduces. Nipples become smaller. In general,

the breasts become softer, less full and lose the form they had in the child-

bearing years.

All these psychological symptoms form part of the menopausal

syndrome, which follows reduced estrogen in the body. Menopause, like

puberty, is another time when women require a lot of reassurance.

Menopausal women also have to cope with a changing self-image. Emotional

29

disturbances and insecurity only worsen the uncomfortable symptoms of

menopause (see also chapter “Neuro-endocrinal syndromes in gynecology”).

Self test

1. The changes of puberty are complete in the age of

A. 16-18

B. 13-14

C. 9-14

D. 20

2. The first period is named

A. menarche

B. menopause

C. menstruation

3. Girls usually notice vaginal discharge

A. six months to a year before the first period

B. one month before the menarche

C. after the appearing of the first period

4. The average blood loss in periods is

A. 35 ml

B. 20-25 ml

C. 50 ml

D. 0. 5 % of body weight

5. The first day of the menstrual cycle is

A. the first day of the period

B. the first day after the finishing of blood loss

C. the first day of increased basal temperature

6. What hormone is responsible for the release of the egg

(ovulation)?

A. the follicle stimulating hormone

30

B. the luteinizing hormone

C. the somatotropic hormone

D. the adrenocorticotropic hormone

7. The age of menopause is

A. over the age of 45

B. over the age of 65

C. over the age of 35

8. The uterus in menopause

A. decreases in size

B. increases in size

C. is without changes

9. Precociuos puberty means

A. puberty before the age of 9

B. puberty before the age of 14

C. puberty before the age of 18

31

Chapter 2. EXAMINATION OF GYNECOLOGIC

PATIENTS

Examination of gynecologic patients includes history taking, physical

examination, and examination with the help of additional techniques.

This is the scheme of questioning:

1. Biographical details;

2. Chief complaints;

3. Anamnesis or medical history;

4. Physical examination: a) general examination, b) special gynecologic

examination;

5. Additional methods of examination.

BIOGRAPHICAL DETAILS

First is the identification of a patient: name and surname, age of the

patient, home address, occupation, family status, sex, education, nationality,

and so on.

CHIEF COMPLAINTS

The most typical and frequent complaints of gynecologic patients

include pains, leucorrhoea, bleeding and menstrual disorders, infertility and

dysfunction of the adjacent organs. Pain is the most frequent complaint

associated with gynecologic diseases. It may be caused by spastic uterine

contractions, and contractions of the uterine tubes, compression of nerve

endings and plexuses of tumors and infiltrates of the inflammations. In all

cases the nature, intensity, localization, irradiation of pain must be

established. In cases of abnormal bleeding, its relation to the periods

(premenstrual, intermenstrual or postmenopausal), or to coital experience

32

must be defined. Its frequency and duration, and information about

amenorrhea, if any, the type of contraceptive used (whether hormonal or

intrauterine device), the quantum of flow and whether it is associated with

clots and pain, are important.

The periods may be profuse or prolonged (menorrhagia), or frequent

(polimenorrhea), or irregular with bleeding between the periods

(metrorrhagia).

Leucorrhoea or abnormal vaginal discharge: the quantum (profuse or

scanty), color (white, yellowish, blood-stained, brownish), nature (curdy or

frothy or mucoid), odor (offensive, urinary or ammoniac), its relation to the

menstrual cycle (intermenstrual or premenstrual) and associated symptoms

such as pruritus and burning micturition should be ascertained. An ulcerated

lesion in the genital tract (cancer, polyp) will result in an irregular blood-

stained discharge. If the growth is infected and covered over with slough, the

discharge is likely to be offensive. In rectovaginal fistula the discharge may be

fecal.

MEDICAL HISTORY (ANAMNESIS)

It is important to obtain the detailed history before a gynecological

examination. Incomplete history may lead to a wrong diagnosis.

HISTORY OF LIFE.

At the beginning one should question the history (anamnesis) of life,

including development in childhood, living conditions. For example, the

nature of nutrition, whether sufficient and adequate, which is of importance,

especially during puberty. Insufficient, excessive or inadequate nutrition may

lead to an incorrect genital system formation, as well as to menstrual

reproductive disorders. One should inquire about the woman’s living

conditions and the way in which her household and rest are organized.

33

Excessive physical work at home may trigger off a number of diseases.

Heavy lifting soon after the delivery and hard work in advanced age may

result in genital prolapse. The patient’s working conditions and occupational

hazards (dusty working environment, chemicals, vibration, noise and others)

may affect the course of some diseases.

HEREDITY.

In the course of questioning the examiner should determine whether

any relatives of the patient have suffered or suffer from mental and endocrine

diseases, alcoholism, cancer, blood and metabolic diseases. A family history of

tuberculosis, diabetes or pelvic malignancy should alert the gynecologist to

any early evidence of these conditions in the patient during the check-up.

HISTORY OF PREVIOUS DISEASES.

The history of systemic diseases should be taken in the chronological

order.

Chronic tonsillitis, epidemic parotitis and measles occurring during

puberty may have an influence on the establishment of menstrual function

and be responsible for underdevelopment of the female genital organs.

Information about any major previous illness such as tuberculosis,

appendicitis or surgery involving the abdominal or pelvic viscera should be

recorded in detail. The indication, findings at surgery, details of the procedure

and pathology report on the tissue (resected organ) would be useful. Previous

surgery especially on the abdominal organs may be responsible for

inflammation of the uterus adnexa , adhesions and ectopic pregnancy. It is

important to find out whether the patient has been taking any drugs, such as

cortisone, hypotensors, antituberculous agents or sex steroids recently.

Of particular significance is a history of blood transfusions. To obtain

the necessary information, one should inquire if the patient has ever been

34

subjected to blood transfusion, what necessitated the transfusion, and

whether it was followed by any abnormal response.

Allergy History should also be taken; it should be ascertained whether

the patient has ever had allergic reactions to any foods or drugs. This

information is essential at prescribing any medical therapy which should be

done with taking into consideration the patient’s drug tolerance.

MENSTRUAL HISTORY.

The following factors are of particular importance:

- age of menarche, regularity and length of cycle;

- date of last normal period;

- premenstrual symptoms, for example, mastalgia, tension,

headache, weight gain;

- duration of flow;

- whether menstruation is associated with pain, and facts relating

to it, for example, the site of pain, time of onset and subsidence,

accompanying nausea or vomiting;

- amount of flow, judged by the number of pads or tampons used

per day.

If the person is menopausal, the age of menopause and associated

menopausal symptoms, if any, should be ascertained.

MARITAL HISTORY. This would include facts relating to the age of

marriage, duration of the marriage, frequency of coitus and whether it is

associated with dyspareunia or not, the type of contraceptive used, its

duration and side effects, if any. Information about patient’s husband must

include: his age, occupation, blood group, Rhesus factor, his health condition

and pernicious habits (alcohol, smoking, drugs).

35

SECRETORY FUNCTION.

The patient should be questioned about the presence of leucorrhoea, its

nature (color, odor, consistence, amount), periodicity of its appearance.

GYNECOLOGIC DISEASES.

If the present disease is not the first gynecologic complaint, the patient

should be questioned about the course of the previous disease as well as the

nature and outcome of the treatment.

OBSTETRIC HISTORY.

The obstetric history should include the following information:

a) the number of pregnancies: normal or complicated by (reason);

the end of each (delivery or abortion);

b) deliveries: premature or full term (and date);

c) nature of delivery: spontaneous , instrumental, cesarean

section;complications, if any;

d) the condition of the baby at birth: live birth, fetal or neonatal

death;

e) weight of the baby at birth;

f) postpartum complications;

g) duration of breast feeding;

h) resumption of menses after the delivery;

i) the number of abortions, the date of every abortion, the period

of gestation at each termination, whether abortion was

spontaneous or induced (what method of induction) and

postabortal complications, if any;

j) the date of the last pregnancy and delivery or abortion.

For the description of the obstetric anamnesis the unified systems are

used in the most different countries. And they are understandable to any

practitioner. 3 systems used to designate OB history in females.

36

TPAL terminology is a system used to describe obstetrical history.

T — term births

P — preterm births (prior to 37 weeks gestation)

A — abortions

L — living children

TPAL numbers should be separated by hyphens.

Example: A pregnant woman who carried one pregnancy to term with

a surviving infant; carried one pregnancy to 35 weeks with surviving infant;

carried one pregnancy to 11 weeks as an spontaneous miscarriage; and has

two living children would have a TPAL annotation of T1, P1, A1, L2. This could

also be written as 1-1-1-2.

GPA Terminology

GPA is the abbreviation for gravida, para, abortus.

G - gravida (number of pregnancies)

3 types of “gravid” condition are distinguished:

- Nulligravida = 0 pregnancies.

- Primigravida = 1 pregnancy.

- Multigravida = 2+ pregnancies.

P - para (number of births, live or stillborn)

3 types of "para" conditions are distinguished:

- Nullipara = 0 births.

- Primipara = 1 birth.

- Multipara = 1+ births.

A or Ab - abortus (abortions). Number of terminated pregnancies,

including:

- Spontontaneous and missed abortions.

- Ectopic pregnancy.

- Elective abortion.

If using GPA to report pregnancy history, the G P and A should be

separated by (commas/dashes). Accompanied by Arabic numbers, G, P, and A

37

(or Ab) describe the patient’s obstetric history. Roman numerals are not used.

Alternatively, spell out the terms in lower case.

For example, when recording the history of a woman who has had two

pregnancies (both of which resulted in live births), it would be noted as G2P2.

The obstetric history of a woman who has had four pregnancies, one of which

was a miscarriage before 20 weeks, would be noted as G4P3A1.

That of a woman who has had one pregnancy of twins with successful

outcomes would be noted as G1P1. When one or more of the numbers is 0, the

preferred form is to write out the terms: gravida 2, para 0, abortus 2.

GTPAL system

Very often, GPA terminology is combined with TPAL terminology aka

GTPAL system (or TPALM when GTPAL is followed by number of multiple

pregnancies). In this case, G separated by comma, TPAL by hyphens: e.g. G,T-

P-A-L.

For example, gravidity and parity of a woman who has given birth at

term once and has had one miscarriage at 12 weeks would be recorded as G2

T1 P0 A1 L1. This notation is not standardized and can lead to

misinterpretations.

38

PHYSICAL EXAMINATION

GENERAL EXAMINATION

This should include, assessment of height, weight, nutrition status, skin

condition (color, turgor, cicatrices, scratches, ulcers, hemorrhages). Tongue,

its status: color, fur. Blood pressure and pulse rates, and temperature must be

recorded. Attention should be paid to the patient’s condition (mild, moderate,

severe). Сonstitution should be ascertained (asthenic, normosthenic,

hypersthenic). Infantile, intersexual types of constitution are also found in

gynecologic patients.

The chest examination should include the heart, lungs and breast. The

breasts are examined (inspection, palpation) for any abnormality: skin

retractions, masses (mobile, fixed), erythema, axillary or supraclavicular node

enlargement (see below).

Examination of the respiratory, cardio-vascular, gastro-intestinal and

urinary systems involves inspection, percussion, palpation and auscultation.

Detection of systemic diseases helps to specify the etiology of the gynecologic

diseases. Thus, in the presence of pulmonary or any other tuberculosis,

adnexal tuberculosis may be suspected.

Examination of abdominal organs not infrequently helps to reveal a

gynecologic disease. Abdominal examination is done with the patient in a

dorsal recumbent position with the knees slightly flexed as it promotes the

abdominal relaxation. The inspection reveals whether the abdomen moves

freely on respiration, it also indicates enlargement or prominence, scars from

previous surgery and skin changes which have followed earlier pregnancies.

Superficial palpation of the abdomen helps to ascertain the muscular

tension of the abdominal wall, diffuse or local tenderness or pain. Deep

palpation allows to determine the presence of tumors and infiltrates, their

39

localization, size, consistence, mobility and tenderness in palpation. The

surface of the tumor may be smooth or tuberous.

Abdominal percussion helps to identify the presence of meteorism (high

thympanitis) and fluid in the abdominal cavity.

SPECIAL GYNECOLOGIC EXAMINATION.

It involves a complex of methods for the examining of the genital system

in women. The basic methods include:

clinical breast examination;

inspection of external genitalia;

speculum examination;

vaginal examination: manual and/or bimanual

(vaginoabdominal).

Clinical breast examination

The reproductive system is typically described as including the organs

needed for sex and reproduction. Mammary glands are part of the

reproductive system, a hormone dependent organ, a target for the action of

sex hormones and other hormones of the endocrine system. Breasts do feed

infants once they're born. Breasts are influenced by hormonal changes during

the development of the reproductive system and during and after pregnancy.

(Fig.6)

Prolactin - produced by: anterior pituitary. The target organ: breasts

(female) . Action (females): stimulates secretion of milk (lactogenesis);

estrogen and progesterone from placenta have an inhibiting effect on milk

production until after placenta is expelled at birth; suckling of newborn

stimulates prolactin secretion to maintain milk production.

Oxitocin - produced by: posterior pituitary. The target Organs: uterus and

breasts (female). Action females: uterus: stimulates contractions during birth

and stimulates postpartum contractions to compress uterine vessels and

40

control bleeding. Stimulates let-down, or milk-ejection reflex, during

breastfeeding.

Estrogens - produced by ovaries under the influence of FSH and LH during

menstrual cycle. They are responsible for:

- development of breasts

- development of the uterus and vagina

- broadening of the pelvis

- growth of pubic and axillary hair

- increase in adipose (fat) tissue

Fig.6. Female reproductive system.

Since the mammary glands are part of the reproductive system, examination

and palpation of mammary glands by gynecologist is necessary, as are other

methods of special gynecological examination. Breast examination by a

specialist in medical treatment (clinical breast exam) is an important part of

routine physical examinations.

The clinical breast examination (CBE) is a widely used practice as a screening

tool for early detection and prevention of breast cancer; it has become a

41

standard part of the annual preventive well-woman examination. A

significant number of cancers would have been missed if CBE had not been

performed. Currently, there are many recommendations regarding use and

frequency of the clinical breast exam among various organizations, but no

consensus.

The most commonly used recommendations of the American Cancer Society

(2015):

Women 20-39 should have a physical examination of the breast (CBE) at

least every three years, performed by health care professional such as a

physician, physician assistant, nurse or nurse practitioner. Women 20-

39 should also perform monthly breast self-exam (BSE).

Women 40 and older should have CBE every year, performed by a health

care professional, such as a physician, physician assistant, nurse or nurse

practitioner. CBE can often be performed in the same visit as a

mammogram. Monthly BSE should also be performed.

Women 40 years of age should receive a screening mammogram every

year. The National Cancer Institute recommends mammography every

one to two years for women between 40-50 years of age. Beginning at age

50, screening mammography should be performed every year.

The goal of the breast examination is to determine if the breasts are

normal or abnormal. If abnormal, any or all of the following may be

indicated: surgical consultation, reexamination at a different time of the

menstrual cycle, mammograms, and possibly ultrasound.

It may be recommended to perform clinical breast exam during any visit

to gynecologist, regardless of the cause and frequency of visits, for prevention

and early diagnosis of breast cancer for those, who have strong family history

of breast cancer. Finding a breast cancer tumor when it is smaller improves

the chances of saving a breast by avoiding a mastectomy, and may reduce the

need for chemotherapy.

42

CBE procedure

I. Preparation

For a proper breast examination :

1. Patient should be undressed down to the waist.

2. A mobile bright light with an assistant is necessary to focus the

light from one area to another as the examination is being conducted.

II. Introduction (WIIPPPE)

For a breast examination the introduction is vital. The patient must feel

at ease with you and know why you are carrying out each step.

Wash your hands (and try to ensure your hands are warm)

Introduce yourself (name and position)

Identity of patient (confirm name and date of birth)

Permission (consent and explain examination: “I’m going to

examine your breasts now. This will involve inspecting and pressing them

quite firmly. Is that OK?”)

o Note that any intimate examination (including the breast exam)

should be done with a chaperone present, particularly if the

doctor is male

Pain?

o Inform the patient they should let you know if you cause them any

discomfort

Position

o Initially sitting on the edge of the couch for inspection. Then lying

flat (with one arm above head) to palpate

Privacy

o Provide a cover such as a blanket or a hospital gown (with the

opening at the front) and ensure the curtain or door is firmly

closed

Exposure

43

o You need to be able to compare both breasts visually and then

palpate both breasts in turn. Most women will not have any issue

with such exposure provided you are relaxed and explain fully.

III. Inspection

Begin by asking the patient to point to the area of concern, and always

explain what you are doing to avoid any embarrassment

Asymmetry

o Look for any asymmetry in the size of the breasts and in the breast

contour

o The size and shape of the breasts in healthy women varies

and having one breast larger than the other is common (Fig.8)

Skin change

o Look for lumps and associated skin changes including signs

of inflammation, ulceration and skin retraction which may be

caused by an underlying cancer (Fig.9).

o Dimpling known as “orange peel” (“peau d’orange ”) may be

visible. This arises due to obstruction of lymphatics (which can be

caused by tumour cells, infection, or treatment with radiotherapy)

resulting in skin oedema with multiple small indentations caused

by the hair follicles of the breast (Fig.10)

o Colour changes which may be a sign of imminent ulceration

Scars

o Indicating previous surgery

Nipple skin change

o Scaling and flaking around the nipples is commonly due to

primary dermatitis and will often be present elsewhere on the

body

o Unilateral eczematous skin changes on the nipple may

indicate Paget’s disease which is caused by carcinoma cells

migrating along ducts to the nipple

44

Nipple inversion, deviation and colour

o Benign nipple inversion is bilateral and slit-like and is typical of

duct ectasia

o Nipple retraction due to malignant disease is asymmetrical and

distorting and can pull the nipple away from its central position

leading to nipple deviation

o If an inverted nipple is seen, it is important to ask the patient if it

is normal for her or she can evert it

o Unless it is longstanding, formal investigation is essential to rule

out the possibility of carcinoma

o The ability to evert a newly inverted nipple is suggestive of benign

breast disease

Fig.8. Enlargement and asymmetry of breasts

Fig.9. Retraction (dimpling) of the skin noticeable

when raising the ipsilateral arm

45

Fig.10. Breast edema giving the skin an “orange peel” (peau d’orange)

appearance

Evaluation of masses

Some movements can be used to accentuate any subtle masses. The

examiner should demonstrate these movements and ask the patient to copy.

Watch the breast closely as the patient moves.

o Ask the patient to raise her arms above their head so that skin

tethering becomes more apparent

o Ask patient to press her hands against her hips in order to tense

her pectoral muscles to accentuate chest wall tethering.

o Ask patient to make some other maneuvers to observe breasts.

(Fig.11.)

Fig.11. A - Patient standing with arms down. B - Patient standing with arms

elevated. C – Pushing on hips to tense pectoral muscles. D - Patient standing

with palms pressed together in front of the forehead, contracting the pectoral

muscles.

46

Observing the breasts while the patient sits up may increase your ability

to detect asymmetry or other surface abnormalities, particularly if the person

has large breasts. (Fig.12).

Fig.12. The patient sits, bending forward so breast hangs free

IV. Palpation

There are 3 specific components of the clinical breast palpation that

influence the accuracy of the examination. These are the amount of time

spent on the examination, the search pattern utilized, and the finger

technique in palpation.

Time spent on clinical breast examination is one of the best predictors

of sensitivity. Spending 2 minutes on the breast examination improves

sensitivity.

The second critical aspect of the clinical breast examination technique is

the search pattern used to identify abnormalities. Use a systematic search

pattern that ensures that all areas of the breast tissue are clearly examined.

This will increase the effectiveness of clinical breast research. In this case,

keep in mind that about 50% of the breast tissue is located in the upper outer

quadrant of the gland, about 20% are located under the nipple and areola

nipple. (Fig.12.)

47

Fig. 13. Distribution of breast tissue across chest wall. Most breast

tissue is seen in upper outer quadrant.

In systematic search pattern (with the patient supine during the

examination, and her hands above her head), the area for examination should

extend from the clavicle, medially to the midsternum, laterally to the

midaxillary line, and to the inferior portion of the breast. In addition, the

examination should include the axillary tail of breast tissue and the axilla to

search for palpable lymphadenopathy.

The third critical aspect of the clinical breast examination is the finger

technique (see below).

Ask the patient to lie on the couch to palpate the breasts. Have the

patient remove their arms from the sleeves of the gown - though keep both

breasts covered by laying the garment on top of their chest. Alternatively, the

patient may put on the gown so that it opens in the front, which may make

exposing one breast at a time a bit easier.

Patient should be lying flat on the table - It may help to have them place

hand on side to be examined behind their head, allowing easier access to

breast and axilla.

Uncover only the breast that you are going to examine.

48

For the lateral examination of the breast, the patient places the

ipsilateral arm on the forehead. For medial examination, the patient's elbow

should be aligned with the shoulder. (Fig.14, 15).

Fig.14. Position of patient and direction of palpation for the CBE. The top

figure shows the lateral portion of the breast, and the bottom picture shows

the medial portion of the breast. Arrows indicate the vertical strip pattern of

examination.

Figure 15. Position of patient for the CBE.

49

With patient in supine position, observe again the breast, looking for

evidence of skin or nipple dimpling/retraction, discoloration, obvious masses

or asymmetry.(Fig. 16)

Fig.16. Clinical breast exam findings

Boundaries of the breast for palpation

Consider the main area of breast tissue as a rectangle bordered by

the clavicle superiorly, the bra-strap line inferiorly, the midsternum medially

and the midaxillary line laterally. The tail of the breast extends beyond the

midaxillary line into the axilla and must also be examined carefully.

Methods for systematic palpation of the breast (the search patterns)

Wedge or radial spoke pattern (1)

o Imagine that the breast is broken into a series of wedge-type slices, with

the nipple at the center.

o Start at the nipple, working outwards toward the periphery of the slice

that you're examining. Move your hands a few centimeters along each

time.

o When you are clearly no longer over the breast, move to the next slice

o There is a "tail" of breast tissue that extends from the lateral aspect of

the structure towards the axilla. Make sure that you palpate this

region as well.

50

Vertical strip pattern (2)

o To use this technique, start in the mid-axillary line at the bra-strap line,

and palpate by moving your fingers in a vertical strip upwards until you

reach the apex of the axilla.

o Then move your gingers medially and palpate downwards in a vertical

strip to the bra-strap line, moving your fingers medially again and

palpate up to clavicle.

o Continue palpating in a linear pattern until the sternum is reached and

all breast tissue has been palpated.

o Make sure that you palpate the “tail” of the breast as described above.

Circular pattern (3)

o Start at the nipple.

o Work along in circular fashion, moving in a spiral towards the

periphery.

o Make sure that you palpate the "tail" of the breast as described in

above.(Fig. 17)

Fig.17. Breast palpation techniques

There is conflicting evidence for the effectiveness of each method. The

most important point as a clinician is that you are confident in your palpation

that you have examined all the important areas. As such, use the method you

are most confident with.

51

Finger techniques

Three-finger technique

Palpate the breast using the pads of the middle 3 fingers of one hand (Fig.18)

Fig.18. Three –fingers for palpation of breast

Two hands can be used in women with larger breasts in order to fix the area

you wish to palpate

If a lump is found, use two hands to assess its characteristics:

o Side

o Site

o Size (measured in mm)

o Consistency (Soft; firm; hard)

o Margins (discrete vs diffuse)

o Surface (smooth vs irregular)

o Mobility

o Skin fixation or tethering

A tethered lesion is suggestive of locally advanced cancer and occurs

when the fibrous ligaments that separate the lobules of breast tissue are

shortened

These ligaments are anchored to the skin so that shortening them

puckers the skin and pulls it inwards although the lesion is mobile and can be

moved independently of the skin.

52

A fixed lesion has spread into the skin itself so that the mass cannot be

moved independently of the skin and implies more advanced local disease.

Documentation

Any abnormality found on examination must be documented, and

include the size of the mass in centimeters, its location (often described by

hours on a clock-face) and characteristics (soft, firm, hard, tender, mobile or

fixed). If a mass or other abnormality is identified, it's location can be

described as being in one of 4 quadrants (left upper, left lower, right upper,

right lower) of the breast. Alternatively, it can be described relative to it's

position, imagining a clock face were superimposed on the breast.(Fig. 19.).

Fig. 19. Description of the location of pathological formation.

In patients with large or pendulous breasts it may be necessary to use

maneuvers to flatten the breast tissue against the chest wall to optimize the

examinationю To flatten the lateral part of the breast, ask the patient roll onto

her contralateral hip, with her shoulders in a supine position, and place her

ipsilateral forearm on her forehead. To flatten the medial part, ask the patient

to lie flat on her back and move her elbow up until it is level with her

shoulder. (Fig.15)

53

Nipple discharge

Nipple discharge is a common symptom and may be clear, cloudy, or

blood-stained. It is most often due to duct ectasia, but can also be the result of

lactation, a duct papilloma, or carcinoma. If the patient is complaining of

discharge, ask them to try to express some discharge if they are comfortable

to. On no condition try to express it yourself unless the patient is totally agree

do so! Try to evaluate, is discharge originating from a single duct or multiple

ducts? Note its color.

Palpation for axillary and supraclavicular lymphadenopathy

Following direct palpation of the breast, the axillary region should be

palpated. This is because the axillary lymph nodes are usually the first site of

spread in the setting of breast cancer. While this is of greatest importance

when you identify a concerning mass in the breast itself, include the axilla in

all of breast exams. To examine, proceed as follows:

o It may help to have the patient lower their arm so it is next to their side,

as when the hand is behind their head, the axillary skin is taught and

perhaps more difficult to palpate thru.

o Gently move the arm 20-30 cm away from the patient's body, so that

you can gain access to the axillary region.

o Direct the finger tips of the examining hand (it's a bit easier to use your

L hand when examining the R breast, and vice versa) toward the top of

the axilla.

o Then push the palmar aspect of the hand towards the chest wall. You

are trying to identify any abnormal nodules/lumps that could represent

axillary adenopathy. In addition, you may be able to trap the nodes

between your hand and the chest wall, which can then be better

characterized.

o Most women will not have palpable axillary lymph nodes. If you do feel

discrete masses, make note of: firmness, quantity and degree of

54

mobility. In general, malignancy is associated with: firmness, increased

quantity, adherence to each other and/or the chest wall.

o Recognize that adenopathy may not be due to breast disease. For

example, infections of the hand can cause acute, painful axillary

adenopathy. Similarly, systemic diseases (e.g. lymphoma, sarcoidosis)

may also cause lymph node enlargement. Thus, as with all other aspects

of the exam, history and findings in other regions are of great

importance.(Fig.20)

Fig.20.Axillary lymph node examination

Finally, examine the supraclavicular fossa.

Examine from in front of the patient, place your fingers in the supraclavicular

fossae and move them in small circles to try and identify any enlarged lymph

nodes as illustrated in fig. 21.

Fig.21. Palpation of the supraclavicular areas with the patient sitting.

55

Completing the examination

o Thank the patient, help them back into comfortable posture and wash

your hands

o Give the patient some privacy to re-dress.

o In an exam situation you should finish by addressing the examiner,

stethoscope behind your back, not looking back at the patient and

presenting your findings slowly and concisely. In clinical practice the

patient should be given privacy to redress before discussing the findings

of the examination with them.

All patients with signs of breast cancer, and those presenting with

breast symptoms in whom cancer cannot be excluded by examination, must

be formally assessed with ‘triple assessment’

The three elements are:

o Clinical examination

o Imaging (ultrasound or mammography)

o Pathological analysis (core biopsy or fine needle aspirate)

Ultrasound is usually the imaging modality of choice in women under

35 years of age, whereas mammography is preferred for women over 35 years.

If there is any abnormality detected in the examination, or imaging, then

biopsies are taken. This can be in the form of Fine Needle Aspiration Cytology

(FNAC) or a core (Tru-Cut) biopsy. If neither of these provide a reliable

answer then an open surgical biopsy may be required.

Inspection of external genitalia

The first step is to establish whether the vulva is healthy. Routine

evaluation of the vulvar area includes basic developmental assessment,

symmetry, hair quality and growth distribution, skin abnormalities, swelling,

ulcerations, growths such as external genital warts (EGW) or tumors, rashes,

lacerations, piercings, bruising, and discharge. Evaluation of signs of

56

inflammation, leukoplakia, if any, perineal relaxation, presence of tears, scars

due to previous deliveries should be made. The patient is asked to strain to

see whether there is a cystocele of the uterus. Discharge of any kind from the

urethral meatus (bloody or purulent), the vaginal or hymenal orifices and the

opening of ducts of Bartholin must be noted. (Fig.22). Sexual maturity rating

should be made according to the stage of pubertal age (Tanner scale).

Speculum examination

It should be done prior to manual examination. This is carried out

mainly to view the cervix and the vagina and to determine whether they are

healthy or not. The walls of the vagina are inspected for discharge,

estrogenization (presence or absence of atrophy), erythema, and lesions. The

cervix should be examined for contour, amount of erosion, shape of the os

(patulous, scarred, parous, nonparous), discharge, lacerations, polyps,

neoplasias, and lesions (eg, warts). It is necessary also to evaluate the color of

the vaginal and cervical mucosal coat, for example, in a pregnant woman, the

cervix may appear to have a purple tone (cyanotic).

Speculum examination (CE) is also necessary for the obtaining of

smears for cytology and biopsy of the cervix.

There are several different types of vaginal specula: Sims’s, Cuscos’s,

Otto’s, Fergusson’s and Graves’ are well known and each is available in three

sizes. (Fig 23, 24, 25) For this examination most clinicians prefer Sims’s

57

specula (or spoon-shaped specula). Most often, disposable specula are

currently used. Metallic specula are sterilized according to the rules of

metallic instrument preparation. When introducing the blade of Sims’s

speculum, the labia are gently separated and the speculum is inserted

obliquely and carefully passed along the posterior vaginal wall up to the

posterior fornix of the vagina, pressing the single blade against the posterior

vaginal wall will bring the cervix and the anterior vaginal wall into the view.

(Fig. 26).

Cuscos’s speculum (bivalve speculum) is inserted with the blades closed,

and after the blades have met the cervix or vaginal vault, they are opened to

retract the anterior and posterior vaginal walls thus exposing the cervix fully

for examination. The blades can be fixed in position by tightening a screw.

Since it is a self-retaining speculum, the physician is then free to do any tests:

to collect smears, to obtain material for culture with a platinum loop, to do a

biopsy of the cervix, etc.

58

Fig. 24. Sim’s speculum

After exposing the cervix it is inspected for the shape, cicatrices, ulcers,

polyps, fistulas. A conical-shaped cervix with a point-like os is a characteristic

of nulliparous woman. Cicatricial deformation points to intrapartum

ruptures. Hypertrophy of the cervix may indicate its chronic inflammation. A

slit-like form of the external os is seen in parous women.

59

As the speculum is being withdrawn gradually, the vaginal walls are

examined carefully. Instead of the pink thick mucosa, one may find it bluish

in pregnancy, congested or covered with discharge in vaginitis, or ulcerated

due to pathological lesions.

Vaginal examination

It is divided into manual, bimanual vaginal (vagino-abdominal), and

rectovaginal examination (rectal).

Manual examination

The labia are gently separated and one or two lubricated fingers (index

and middle finger) of the gloved right hand are carefully introduced into the

vagina. During examination one should palpate the area of glands of

Bartholin and the urethra, and determine the state of pelvic floor muscles.

The next step is the palpation of the cervix. The cervix is felt as the

fingers are passed into the vaginal vault. The length, consistency, mobility,

tenderness, opening of the cervical canal should be determined by palpation

of the cervix. If the uterus is anteverted, the anterior lip is the first to be felt,

and if it is retroverted, the posterior lip is palpated first. In nulliparous

women the cervix is conical and the external os is circular. But in multiparous

women it may be enlarged or hypertrophied and external os is often slit

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transversely. The cervix lightly outlined with the fingers to identify the size,

position, consistency, texture and dilation of the orifice. It is normally smooth

and firm. In pregnant women the cervix is soft. Its surface around the

external orifice may feel velvety in cases of erosion. In cases of pelvic

inflammation and fallopian gestation there is tenderness when the cervix is

moved. The patient is then asked to strain to see whether there is any descent

of the uterus.

Bimanual examination

In bimanual examination (examination with both hands) the internal

(dominant) hand is introduced into the vagina and is placed over the anterior

surface of the cervix. The non-dominant hand outside is placed over the

patient’s lower abdomen and firm pressure is applied to displace the lower

abdomen and pelvic organs towards the fingers in the vagina to meet the

uterus. The patient is requested to breath through the mouth to avoid

marking the abdominal wall tense. Then two internal fingers, which are

placed in the anterior vaginal fornix against the anterior

lip of the cervix press the uterus upwards while the external hand placed

over the lower abdomen pushes it downwards. The uterine outline between

the two hands can be clearly noted. (Fig. 27).

Fig. 27.Bimanual exam

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If the uterus is retroverted, the internal fingers are inserted into the

posterior fornix to push up the uterus and thus feel it more easily bimanually.

When the uterus is felt, one can determine its:

• position,

• size,

• shape,

• consistency,

• contour,

• surface characteristics (smooth vs nodular)

• tenderness

• mobility.

Normally it is in the midline in the upper half of the pelvis with the

external os in the same plane as the ischial spine. The uterine fundus is

directed forwards and is said to be anteverted. It is normally pear-shaped,

firm and smooth. Normal or abnormal size can be made out only with some

experience as in the relationship of the size of the cervix to that of the corpus.

For palpation of the adnexa the fingers in the vagina are placed in the

lateral fornix and the external hand is pressed down over the vaginal fingers

in the attempt to outline the uterine adnexa. Normally, the healthy tubes are

not palpable but the ovaries may be felt when prolapsed, cystic or enlarged. In

acute pelvic inflammatory diseases (PID) the fornices may be tender and in

chronic cases a thickened tube or a fixed, tender, retort-shaped pyosalpinx

may be felt on one or both sides of the uterus. The pouch of Douglas may be

felt through the posterior fornix, one may find the body of the uterus when it

is retroverted, an adnexal inflammatory swelling, pelvic hematocele, pelvic

abscess, the lower pole of an ovarian tumor. If the rectum is overfilled, one

may feel the fecal masses and lack of experience may lead to a wrong

diagnosis.

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Bimanual recto-vaginal examination

The rectovaginal exam is a diagnostic tool that helps gynecologist to

more fully examine the internal pelvic anatomy and check the vaginal and

rectal areas for abnormalities. The recto-vaginal exam is not a particularly

accurate screening exam and is usually reserved for women who either have

rectal or pelvic pain or are experiencing symptoms related to the

genitourinary tract (such as pain, urinary urgency, abnormal bleeding). It is

used to determine whether the tumor or other formation is originated from

genital organs or from the rectum. As for procedure, the index finger is

inserted into the vagina, and at the same time, the middle finger is inserted

into the rectum. (Fig. 28).

By putting one finger inside the vagina and another into the rectum, a

provider can:

• evaluate the back side of the uterus and the wall between the vagina and

rectum;

• check on the tone and alignment of the pelvic organs: ovaries, Fallopian

tubes, and ligaments of the uterus;

• determine if the uterus is retroverted (tilted);

• more thoroughly investigate complaints of pelvic or rectal pain;

• feel for rectal growths, check for blood in the stool, and look for other

early signs of colon cancer, especially in women over the age of 40.

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Fig.28. Bimanual recto-vaginal examination

Bimanual recto-abdominal examination

It is not an obligatory part of routine gynecologic examination of a

patient. It is reserved for those who are virgin, for patient in pubertal age, for

patient who cannot tolerate a vaginal exam, also for cases, when vaginal exam

is impossible. (Fig.29). Hematocolpos, congenital abnormalities of internal

genitals are also indications for recto-abdominal palpation

Fig.29. Bimanual recto-abdominal examination

64

Vaginal smears

I.Tests for evaluation of vaginal ecology

Investigation of vaginal smears is used to assess the vaginal ecology, for

the diagnosis of the inflammatory diseases and the identification of the types

of infectious agents. Routine investigations of vaginal smear include:

• pH test;

• vaginal microscopy;

• vaginal discharge culture and sensitivity.

The pH of the vaginal secretions. The vaginal microbiota of

healthy women consists typically of a diversity of anaerobic and aerobic

microorganisms. Lactobacilli are the most prevalent and often numerically

dominant microorganisms and are relevant as a barrier to infection. The

capacity of lactobacilli to adhere and compete for adhesion sites in the vaginal

epithelium and the capacity to produce antimicrobial compounds (hydrogen

peroxide, lactic acid, bacteriocin-like substances), are important in the

impairment of colonization by pathogens. The dominance of lactobacilli

results in a normal pH of the vaginal fluid. The dominance of lactobacillus

leads to a normal pH of the vaginal environment, whereas a decrease in their

number leads to a change of the pH of vaginal secret and is the basis for the

vaginal population to be filled with pathogenic microorganisms,and

development of infectious and inflammatory processes. Vaginal secretions

should be collected from the lateral vaginal walls using a swab or small loop

and pH should be elucidated using litmus paper.(Fig. 30). The normal pH is 4-

4.5.(Fig31) .

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Fig.30. Litmus paper strips for evaluation of pH of smears

Fig.31. The pH scale.

Whiff test. Additionally, whiff test is widly useful now-a-days. Several drops of

a potassium hydroxide (KOH) solution are added to a sample of the vaginal

discharge. A strong fishy odor from the mix means bacterial vaginosis (vaginal

dysbiosis) is present. The odor results from the liberation of amines and

organic acids produced from the alkalization of anaerobic bacteria. A positive

whiff test is suggestive of bacterial vaginosis.

Vaginal microscopy. Microscopy involves use of the:

• wet mount(wet smear, wet prep, vaginal smear, vaginalysis, or

hanging drop),

• KOH slide,

• Gram staining smears.

Vaginal microscopy is an important laboratory tool for evaluation of the

vaginal health. It include: microscopy for white blood cells (WBC),

bacterioscopy for determination of vaginal flora.

66

Wet mount observes living vaginal organisms in order to study the

ecology of the lower genital tract in women. It acts as an accessory tool to the

patient history, inspection of the vulvar and vaginal mucosa, and pH

determination in order to arrive at a presumptive etiologic diagnosis. A smear

should not be obtained after vaginal examination and therapeutic procedures

involving the intravaginal administration of drugs. Thus, it is done whit the

specula examination, before manual palpation and other procedures. A

specimen of the vaginal discharge should be collected from the wall of the

vagina using a cotton swab or sterile platinum loop. It is then placed on a

glass slide, mixed with a drop of saline and immediately examined under a

microscope. Alternatively, the vaginal discharge can be put into a 2-mL test

tube containing saline solution and then placed on a slide. The slide is

examined microscopically using low power (10×) and high dry power (400×).

This test can be carried out by any doctor. The microscopic appearance of the

discharge, in addition to a test of vaginal acidity (pH) will distinguish one type

of vaginitis from another. Microscopic examination of a wet-mount

preparation can also detect “clue cells,” which are vaginal epithelial cells that

are coated with the coccobacilli. When a skilled examiner performs the search

for clue cells, examination of wet-mount preparations can have a sensitivity of

60 percent and a specificity of up to 98 percent for the detection of bacterial

dysbiosis. The examination may also detect fungal hyphae, increased

numbers of polymorphonuclear cells (seen in trichomoniasis) or round

parabasal cells (seen in atrophic vaginitis).

The presence or absence of a large number of leukocytes (WBC) should be

noted. A few may be normal, but more than 10 per high-power field is abnormal

(Fig.32).

67

Fig.32. Normal flora.

Depending on the nature of smears, four degrees of vaginal colonization

are recognized:

• grade I colonization: it is characterized by the presence of squamous

epithelium and vaginal bacilli (normal flora); the reaction is acid;

• grade II colonization: in this case the number of vaginal bacilli is

smaller than in grade 1 colonization; epithelial cells, individual cocci

and leucocytes are observed; the reaction is acid ( grade I and grade II

colonization are considered normal);

• grade III colonization: there are few vaginal bacilli with other types of

bacteria being predominant; leucocytes are present in large numbers;

the reaction is weakly alkaline;

• grade IY colonization: there are no vaginal bacilli, but there are many

pathogenic microbes, including even gonococci and trichomonads; large

number of white blood cells are present; the reaction is alkaline (grade

III and grade IV colonization suggests abnormality).

KOH slide is another component of wet mount. An additional swab

should be taken and some discharge placed on a slide and mixed with a drop of

10% solution of potassium hydroxide (KOH) and covered with a cover slip. The

slide may be warmed briefly (heating promotes cell lysis) and should be

looked at promptly. The KOH kills bacteria and cells from the vagina, leaving

68

only yeast for a yeast infection. The slide should then be examined carefully for

the presence of budding yeast or hyphae. This is useful for detecting candidal

hyphae, mycelial tangles and spores. The test is positive in 50 to 70 percent of

women with candidal infection. During preparation of the KOH slide, a whiff

test can be performed. The whiff test is positive if a “fishy” or amine odor is

detected when KOH is added to the vaginal discharge.

Gram staining smears. The Gram stain involves applying a sample

from an infected area or a sample of bacteria grown in culture onto a glass

slide. The slide is then treated with a special stain and examined under a

microscope by a trained laboratorian. This method is used to distinguish and

classify bacterial species into two large groups (gram-positive and gram-

negative). Gram positive bacteria stain violet. Alternatively, Gram negative

bacteria stain red. The color and shape of the bacteria help classify which

general types of bacteria are present.

Vaginal discharge culture and sensitivity. It is bacteriological

investigation of vaginal discharge to evaluate culture and sensitivity to

antibiotics. It is aka high vaginal swab (HVS). It helps to evaluate culture for

yeasts; culture for bacterial pathogens, if indicated by microscopy or clinical

information. Bacteriological study helps to reveal sexually transmitted

diseases (STD). The material for bacteriological study is taken from the

urethra, cervical canal, and the upper third of the vagina (from posterior

fornix of the vagina). The discharge is transferred with a sterile applicator to a

dry sterile test tube or special container (Fig. 33.) and sent immediately to

the laboratory or is inoculated on to a sterile agar. Cultures should never

substitute for a careful history, physical examination, and microscopic

examination of the wet prep. Depending on the results of a vaginal culture

without microscopic examination of the secretions will result in frequent

errors in treatment. Nevertheless, cervical cultures may be especially helpful

in some cases.

69

Fig.33. Container for HVS.

II. Tests for evaluation of endocrine status

Endocrine status is assessed by such a functional diagnosis parameters

as the cytologic pattern of a vaginal smear, the “pupil” symptom, “fern”

symptom (arborization of cervical mucus), a viscosity and stretch ability of

cervical mucus, and rectal (basal) temperature, as well as by findings of

endometrial biopsy, hormonal levels in the blood plasma and urine and by

hormone assays.

Cytologic pattern of a vaginal smear. To study the cytologic

pattern of vaginal smears, the discharge from one of the lateral fornices is

spread in a thin layer on a glass slide, air-dried, fixed in an alcohol-ether

mixture, and then stained with hematoxylin-eosin. The effect of estrogens on

the stratified squamous epithelium is expressed in epithelial cornification,

degree of which is directly correlated with estrogen concentrations. The

predominance in a smear of cornified cells testifies to a high content of

estrogen (hyperestrogenism). When estrogen levels are moderate, the so-

called intermediate cells are sloughed from the vaginal wall. In patients with

low concentrations of estrogens (hypoestrogenism associated with ovarian

hypofunction or menopause) basal cells from deeper layers are shed and

prevail in a smear. (Fig 34)

70

Fig. 34.Types of epithelial cells of vagina.

Depending on the ratio between the types of epithelial cells, four types

of vaginal smears are distinguished:

type I: a smear consists of basal cells (small round or oval in shape with a

relatively large nucleus) and leucocytes. This type is typical of very

pronounced estrogen deficiency. It is observed in postmenopausal women

and in young women with ovarian hypofunction and amenorrhea;

type II: a smear contains basal and intermediate cells, with the

predominance of basal cells and leucocytes. It occurs in considerable estrogen

deficiency (ovarian hypofunction, post menopause);

type III: intermediate cells are the most predominant in a smear. It is a

characteristic of moderate estrogen deficiency;

type IV: a smear is composed of cornified cells. It is observed in sufficient

estrogen saturation. (Fig. 35 a,b,c,d)

Types III and IV are noted in normal menstrual cycle (depending on the

phase of the cycle).

71

Fig.35. Types of vaginal cytology depending on the types of epithelial

cells: a – type I; b - type II;

c – type III; d – type IV.

The cytologic pattern may also be quantitated, which involves the

determination of the percentage ratio of surface cells with pyknotic nuclei to

the total number of surface cells (caryopyknotic index, ripening index).

The Karyopyknotic Index (KPI). The karyopyknotic index expresses the

percentile relationship of superficial squamous cells with pyknotic nuclei to

all mature squamous cells (with vesiculae nuclei). Usually, 200 to 400

consecutive cells in three or four different fields on the smear are evaluated.

The smear is taken from the lateral fornix of the vagina as cells here respond

72

to cyclical changes in hormone that occurs in the menstrual cycle. The KPI

correlated significantly with the plasma estradiol. The peak of KI usually

coincides with the time of ovulation.

Examples: KPI > 25% - in proliferative phase of endometrial cycle

KPI < 3-5% -very low, corre3spond to secretory phase

KPI : 50-85% - typical for day of ovulation

KPI > 10% in pregnancy – progesterone deficiency

The Eosinophilic Index (EI). The eosinophilic index expresses the

percentile relationship of mature squamous cells with eosinophilic cytoplasm

to all mature squamous cells, regardless of the status of the nucleus. In a

normal menstruating woman, the peak of EI coincides with the peak of KI

and may reach 50% to 75% at the time of ovulation.

The Maturation Index (MI) expresses the maturation of the squamous

epithelium as a percentile relationship of parabasal cells to intermediate cells

to superficial cells. MI is determined by the count of 100-200 cells in 5-8- eye

shots (field of vision), and expressed in per cents. MI is designated as a

formula, where the amount of basal cells is written down on the left, in the

middle – intermediate, on the right – cornified cells. 0 designates the absence

of some types of cells.

In a normal menstruating woman at the time of ovulation, an MI of

0:35:65 would indicate that the smear contained no parabasal cells, 35% of

intermediate cells, and 65% of superficial cells.

MI Examples.

MI = 100/0/0: there are only basal cells in the smear, no intermediate

and cornified, means significant atrophy.

MI=70/30/0: there is 70% of basal and 30% of intermediate cells in the

smear, no cornified, means moderate atrophy.

MI= 0/80/20: no basal cells in the smear, there is predominance of

intermediate cells (80%), and about 20% of cornified cells, means moderate

proliferation.

73

MI=0/20/80: no basal cells, there is about 20% of intermediate and

80% of cornified cells in the smear, means significant proliferation.

MI shows the functional activity of ovaries, it helps to determine the

changes of ovarian function depending on hormonal therapy.

Cervical mucus reveals a number of rheologically related properties

including viscosity, stretchability, flow elasticity or retraction, plasticity and

tack. Rheology is the study of the flow and deformation of matter. In the case

of the cervical mucus, however, this term is extended to include various

biophysical properties and also some viscoelastic characteristics of molecular

physics.

“Pupil” symptom. The “pupil” symptom consists in the following. In

the follicular phase the cervical glands produce a mucous secretion, the

largest amount of which is accumulated by the mid-cycle. The external os of

the cervix is dilated by this secretion as a result and resembles a pupil, which

can be seen during speculum examination. This symptom is observed from

day 10 to day 17 of the cycle, being most pronounced on day 14-15. In women

with estrogen deficiency this symptom is either weak or absent, whereas in

patients with excessive estrogen production it may persist for longer time.

The less degree of dilatation of external os due to accumulation of mucus is

designated as +, moderate ++, maximal (0. 25-0. 3 cm) +++.

Crystallization of cervical mucus (syn.: “fern” symptom,

arborization symptom). Of all the properties of mucus “crystallization”, i. e.

arborization or fern phenomenon, is undoubtedly one of the most sensitive to

changes in the level of sex hormones. Thus “ferning” is widely used for the

detection of ovulation and for assessing corpus luteum function, in the early

diagnosis of pregnancy and even of a threatened abortion, and in monitoring

the induction of ovulation. The arborization is not specific to cervical mucus;

it can be seen in other mucous secretions and in most body fluids as well. It

occurs in all solutions containing proteins or other organic compounds and

electrolytes, particularly sodium chloride. Although not specific in other body

74

fluids, arborization in cervical mucus is distinctly dependent upon the action

of estrogen and bears a close relationship to the two rheological properties

described above, viscosity and spinnbarkeit. The extent of crystallization of

the mucus bears a direct relationship to sperm receptivity.

The fern pattern appears during the early proliferative phase, usually at

about the 5th or 6th day of the 28-day cycle increasing proportionally with the

degree of estrogenic activity. It reaches a maximum at ovulation and 24-72

hours later it begins to be replaced by a cellular pattern characteristic of

progestational activity. The fern pattern usually disappears completely by the

22nd day of the cycle. Pregnancy and the administration of progesterone both

produce the same qualitative picture as seen in the luteal phase of the normal

cycle. Maximal arborization is likely to be found at the time of maximal

spinnbarkeit and will usually precede the shift in basal body temperature by

24-48 hours. The peaks of arborization and spinnbarkeit also coincide with

maximal receptivity to sperm and greater sperm penetrability.

The test, easily performed in the office or clinic, is carried out as follows:

after the cervix is exposed and gently swabbed clean, a sample of endocervical

mucus is obtained with a dry sterile plastic cannula or glass pipet and is

spread on a clean glass slide. If the secretion is spread too thinly or if blood is

present, arborization does not occur, even when adequate estrogen levels

exist. The slide is air-dried for at least 10 to 20 minutes (drying must be

absolutely complete) and then is read under both low- and high-power

magnification on the microscope. If true arborization with crystallization is

present, it is indicative of a predominant estrogen effect, and the test is

positive If a cellular pattern without crystallization and arborization is seen,

the test is negative and indicates either little or no estrogen effect or, more

commonly, suppression of estrogen activity by progesterone. As an indirect

quantification of the extent and intensity of estrogen effect, the cervical

ferning can be graded according to the branching of the ferning pattern upon

crystallization: grade 1 for primary branching, grade 2 for secondary

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branching, grade 3 for tertiary branching, and grade 4 for quaternary

branching, the maximum observable. (Fig.36).

Fig.36. Crystallization of cervical mucus (“fern” symptom)

a- on the 10th day of menstrual cycle; b- on the14th day of cycle;

c- on the15th day of cycle; d- on the 22nd day of menstrual cycle.

Diagnostic use. Ovulation and the production of progesterone by the

corpus luteum normally result in a shift from the positive fern test

characteristic of the preovulatory phase to a negative test typical of the latter

half of the menstrual cycle. Therefore this simple office procedure can be

employed as an index of ovulation and normal corpus luteum function.

Because both low estrogen levels and chronic endocervicitis may lead to a

continually negative test throughout the cycle, at least two tests must be done,

one during each half of the cycle for a valid conclusion to be reached.

Stretchability of cervical mucus. Stretchability (syn.:

spinnbarkeit) pertains to the capacity of liquid to be drawn into threads. This

characteristic also varies in cervical mucus during the menstrual cycle. There

is a gradual increase in spinnbarkeit from the end of menstruation until

a b

c d

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ovulation, when it is at its peak. Following ovulation little or no spinnbarkeit

can be demonstrated. The German term 'spinnbarkeit' is more widely used

than the English equivalent expression “fibrosity, thread ability or elasticity”.

Although this rheological property is one of the easiest to measure objectively,

it is also one of the least accurate, yet it has considerable application both

diagnostically and therapeutically. Most investigators use the simple

technique of drawing the mucus away from a slide with a cover slip and

measuring the length of the mucus thread, which can also be determined by

the length to which the mucus thread can be drawn when the jaws of forceps

are opened. This phenomenon is attributable to the presence of the long

molecules in the mucus and is probably dependent upon branching of

molecular chains and other strong intermolecular forces. (Fig.37)

Stretchability gradually increases during the proliferative phase of the

cycle reaching a maximum of 15-10 cm immediately before or coincident with

the ovulatory phase and the thermal shift of the basal body temperature chart.

As with the arborization phenomenon (see below), after ovulation there is a

subsequent decrease in the spinnbarkeit, signifying the advent of a

progesterone effect.

Its assessment is frequently used as an optimal time for intercourse or

for artificial insemination. The evaluation of stretchability is also useful as a

biological parameter of an estrogenic effect on the endocervical glands. It is

also being used for detection of the fertile period.

Fig.37. Stretchability of cervical mucus (spinnbarkeit).

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Basal body (rectal) temperature (BBT). The basal body (rectal)

temperature is measured in the morning before getting up. In the normal

cycle the rectal temperature fluctuates throughout the cycle: in the follicular

phase the basal body temperature is 36. 2 - 36. 7°C, in the luteal phase it

increases by 0. 4-0. 5°C, declining again with the onset of menstruation. (Fig.

38).

Fig.38. Basal body temperature chart.

The basal body temperature fluctuations depend on the

estrogen/progesterone ratio. Normally, the biphasic chart indicates the

ovulation (ovulatory or biphasic menstrual cycle). In the absence of ovulation

the temperature chart will be monotonous, monophasic (anovulatory

menstrual cycle).

The presence of the ovulatory and luteal phases is confirmed by a

histological examination of the endometrium, namely its secretory

transformation. The curettage of the uterine cavity (scrapping of the

endometrium) should be performed in the second half of the menstrual cycle.

The absence or insufficiency of the secretory transformation of endometrium

suggests luteal dysfunction.

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The endocrine status of the patient is also evaluated by hormonal

concentrations in the blood serum and urine. To specify the level of the

impairment (hypothalamus, pituitary gland, ovaries, adrenal cortex) and the

cause of endocrine lesion, various functional tests may be employed

(progesterone, releasing hormones, LH, FSH, HCG, ACTH, synthetic

progestins, glucocorticoids etc).

III. Tests for evaluation of abnormal

(precancerous and cancerous) conditions

Cytological examination (the Papanicolaou test). The

Papanicolaou test, also known as the Pap test or the Pap smear, was

developed in the 1940s by Georgios Papanikolaou. It is a cytology-based

screening, the main purpose of screening with the Pap test is to detect

abnormal cells that may develop into cancer if left untreated. The Pap test can

also find noncancerous conditions, such as infections and inflammation. It

can also find cancer cells. In regularly screened populations, however, the Pap

test identifies most abnormal cells before they become cancer. A Pap smear is

a microscopic examination of cells taken from the uterine cervix. A Pap smear

can detect certain viral infections such as human papillomavirus (HPV),

which is known to cause cervical cancer. Early treatment

of precancerous changes detected on the Pap smear can stop

cervical cancer before it fully develops. A woman may have cervical cancer

and not know it because she may not have any symptoms.

The test itself involves collection of a sample of cells from a woman's cervix

during a routine pelvic exam. Exfoliating cells from the transformation zone

of the cervix are taken for microscopic examination to reveal the presence of

malignant or precancerous lesions. The transformation zone is an area of

actively maturing epithelium, between two kinds of cells of the cervix:

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rectangular columnar cells and flat, scale-like squamous cells. Columnar cells

are constantly changing into squamous cells in an area of the cervix called the

transformation (transitional) zone. And it is the most common place on the

cervix for abnormal cells to develop. These abnormal cells can be detected on

a Pap smear. The location of the transformation zone varies among women.

In teenage girls, the transformation zone is on the immature cervix's outer

surface (vaginal portion of the cervix) and is more susceptible to infection

than in adult women. In older women, the transformation zone may be higher

in the cervical canal.

There are two techniques of taking and making Pap-test: Pap-smear and

Liquid-Based Pap-Test (E-Prep)

Pap-smear technique: the cells, taken form transformation zone, are

placed directly on a glass slide and stained with a substance known as

Papanicolau stain. The stained cells are then examined under a microscope to

look for pre-malignant (before-cancer) or malignant (cancer) changes.

Liquid-Based Pap-Test - sample cells are placed into a vial of liquid

preservative that is then used in the cytology lab to produce a slide for

microscopic evaluation of the cells. (Fig.39)

In both cases a “broom” device or a brush/spatula combination is used to

collect the cells. To obtain the specimen, a cervical broom or cervical spatula

is applied to the surface of the cervix and turned in a single direction to

achieve an adequate sample for cytology, making sure to rotate it at least 360

º for the spatula and 5 rotations for the broom. If the spatula is used, a

cytobrush is additionally needed and must be inserted into the cervix so that

the outermost bristles are still visible at the external os. The brush is then

rotated one half turn in a single direction to achieve an adequate cytology

sample (see image below).

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Fig.39. Pap-testing: 1- taking cells for examination; 2- placing of smear

on glass for further staining and examination; 3-placing of smear into

container with special liquid for

Liquid-based pap-test

To get adequate results, special preparation of the patient for testing is

necessary, which includes:

• avoidance of day of menstruation for Pap-testing;

• avoidance of vaginal intercourse, douching, use of tampons, use of

medicinal vaginal cream or contraceptive cream for 24-48 hrs prior to

cervical screening.

• ideally, pre-existing cervicitis should be treated prior to cervical

screening.

The smears show normal or abnormal cells. The abnormal cells are

identified by their big nuclei, chromatin network and nuclear-cell ratio. All

women over 25 years of age should be annually screened.

Depending on the type of cells seen (Fig.40), the Pap smears are

classified by Bethesda system:

• Squamous cell abnormalities (SIL)

• Atypical squamous cells of undetermined significance (ASC-US)

• Atypical squamous cells – cannot exclude HSIL (ASC-H)

• Low-grade squamous intraepithelial lesion (LGSIL or LSIL)

• High-grade squamous intraepithelial lesion (HGSIL or HSIL)

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• Squamous cell carcinoma

• Glandular epithelial cell abnormalities

• Atypical glandular cells (AGC), specify endocervical, endometrial, or not

otherwise specified (NOS)

• Atypical endocervical cells, favor neoplastic, specify endocervical or

NOS

• Endocervical adenocarcinoma in situ (AIS)

• Adenocarcinoma

• Other

Endocervical and endometrial abnormalities can also be detected, as can a

number of infectious processes, including yeast, herpes simplex

virus and trichomoniasis. However it is not very sensitive at detecting these

infections, so absence of detection on a Pap does not mean absence of the

infection.

The past decade has witnessed several changes in the realm of cervical cancer

screening, prevention, and management. These include the increased use of liquid-

based preparations.

In 2014, the Bethesda system received some changes:

• reporting of benign-appearing endometrial cells is now recommended for

women aged 45 years;

• terms such as “LSIL, cannot exclude HSIL” or “LSIL-H” have been proposed;

• an interpretation of atypical squamous cells (ASC) cannot rule out HSIL (ASC-

H) may be made in addition to an LSIL interpretation. This would indicate that

definite LSIL is present as well as some cells that suggest the possibility of

HSIL. In general, follow-up guidelines for these interpretations are for

colposcopy and biopsy; however, in patients (such as young women) who have

samples for which the guidelines differ between LSIL.

• and ASC-H, the addition of the ASC-H interpretation should lead to

colposcopic evaluation.

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Fig.40. Changing of cervical cells over time and becoming abnormal. LSIL

and HSIL are two types of abnormal changes to cervical squamous cells.

However, in case of negative results, smears need to be repeated every

1-3 years.

When abnormal cells are detected on the Pap-test, further diagnostic

procedures are indicated. These tests include: colposcopy, cervical

biopsy, colposcopic biopsy, endocervical curettage, cone biopsy, LEEP (Loop

Electro-Surgical Excision Procedure). Subsequent cervical cancer may be

prevented through the diagnosis and treatment of these cervical cancer

precursors.

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Additional methods of examination

Endoscopic methods

Endoscopy is the examination of body cavities using an optical device

equipped with an illuminating device. At present, the method has ceased to be

of a purely diagnostic nature; various endoscopic operations have already

been developed and put into practice. In gynecology, endoscopy is used to

examine the cervix (colposcopy), the uterine cavity (hysteroscopy), and the

pelvic organs (laparoscopy), as well as for operations on them.

Colposcopy - examination of the vagina and vaginal part of the cervix

using a binocular or monocular loupe equipped with a lighting device (an

increase in the study area is 30 times or more).

Hysteroscopy - examination of the inner surface of the uterus in

order to detect pathological changes in the endometrium;

Laparoscopy (peritoneoscopy) - is examination of abdominal

cavity with the help of an optical instrument inserted into the abdominal

cavity; as well as a method of minimally invasive surgery.

Culdoscopy - is the examination of the pelvic organs with the help of

an optical instrument inserted into the abdominal cavity through the

posterior vaginal fornix (aka cul-de-sac, rectouterine pouch, the pouch of

Douglas).

Colposcopy

A colposcopy is an examination of the vagina and cervix using a lighted

magnifying instrument called a colposcope (special microscope), to examine

cervical and vaginal tissues in real time (in vivo). The colposcope (Fig. 41)

magnifies the image many times, thus allows the health care provider to see

the tissues on the cervix and vaginal walls more clearly and determine

anomalies. (Fig.42). A colposcope is placed in the vagina and used to

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microscopic examination of the area of the cervix where an abnormality is

suspected.

Fig.41. Colposcope.

Fig.42. Colposcopy

Comparatively with Pap-test, which is a screening method, colposcopy

is the diagnostic test to evaluate patients with an abnormal cervical

cytological smear or abnormal-appearing cervix. The most common

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indication of referral for colposcopy is positive screening tests (e.g., positive

cytology, positive on visual inspection etc.).

The simple colposcopy and extended colposcopy are used in clinical

practice.

The key ingredients of colposcopic examination are the observation of

features of the cervical epithelium after application of normal saline, 3-5%

dilute acetic acid, and Lugol’s iodine solution in successive steps.

The simple colposcopy is the examination of the cervix after removal of

the discharge from its surface without the use of medications. It is the first

phase of the survey, which is performed at the beginning of the study, and

allows identifying anomalies of cells, their location and the degree of change,

if any. (Fig.43). When a white area is observed on the cervix prior to the

application of acetic acid, it is called leukoplakia. (Fig.44).These areas

represent hyperkeratosis and can be associated with infection by HPV,

chronic trauma or scarring. It is generally recommended that biopsy of at

least one representative area of leukoplakia be performed during a

colposcopic examination.

Extended colposcopy is the examination of the cervix after application

of 3% acetic acid solution or 2% Lugol solution (Schiller's test), hematoxylin,

adrenaline on its vaginal part.

Acetic acid is applied to the cervix using a cotton wool ball or with a

spray. The action is manifested 30-60 sec after the application of the solution

and lasts 4 minutes. 3-5% solution of acetic acid causes a short-term swelling

of the epithelium, swelling of the cells of the Malpighian layer of cervical

epithelium, a reduction in the subepithelial vessels and a decrease in blood

supply. Abnormal areas, such as cervical intraepithelial neoplasia (CIN), will

tend to turn white (acetowhite). (Fig.45, Fig. 46). The characteristics of

acetowhite changes, if any, on the cervix following the application of dilute

acetic acid are useful in colposcopic interpretation and in directing biopsies.

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The colposcopic diagnosis of cervical neoplasia depends on the

recognition of four main features: intensity (colour tone) of acetowhitening,

margins and surface contour of acetowhite areas, vascular features and colour

changes after iodine application. The occurrence of abnormal features in a

localised area in the transformation zone increases the probability of

diagnosis of a neoplastic lesion. Low-grade CIN is often seen as thin, smooth

acetowhite lesions with well-demarcated, but irregular, feathery or digitating

or angular margins. High-grade CIN are associated with thick, dense, dull,

opaque or greyish-white acetowhite areas with well-demarcated, regular

margins. Abnormal vascular features such as punctation and mosaics are

significant if these are seen confined to acetowhite areas. Other

abnormalities, such as cervical condyloma, endometriosis are also identified

in colposcopy (Fig.47 – Fig.53).

The Schiller’ test is based on the ability of normal epithelium to change

the coloration under the influence of iodine on dark brown, depending on the

content of glycogen epithelium in cells. (Fig.54). Areas containing glycogen

turn brown or black; areas lacking glycogen remain colourless or pale or turn

mustard or saffron yellow. Normally, uniform brown coloration is noted.

Yodnegative sites indicate a sharp decrease in glycogen in the cells of the

integumentary epithelium of the cervix. CIN lesions do not contain glycogen

and thus do not stain with iodine and remain mustard or saffron yellow areas.

To identify cell changes iodine cannot be used alone because immature

epithelium does not turn brown. Inflammation creates a lighter yellow-

stained area. Columnar epithelium is usually being stained with orange spots

by iodine. Iodine is not relevant in women with low estrogen levels in vaginal

epithelium, as in breastfeeding or after menopause, when the epithelium

contains little or no glycogen.

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Fig.43. Normal cervix as seen through a colposcope without the application of

vinegar. The red color around the os is produced by columnar cells and the

lighter pink on the remainder of the cervix result from normal squamous

cells. The presence of visible columnar cells outside the internal os is called

ectropion and is a normal finding in young women and women on estrogen-

containing contraception. The junction between the two cell types and colors

is the squamocolumnar junction.

Fig.44. Leukoplakia (hyperkeratosis) – a.

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Fig.45. A colposcopic picture of a woman with low-grade squamous

intraepithelial lesion cytology.

Fig 46. Acetowhiate areas on the cervical surface

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Fig.47.Cervix with circumorificial, mild to dense acetowhite lesion with fine

mosaic (arrow)

Fig.48. Dense, well defined acetowhite area with regular margins and coarse

mosaic

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Fig.49. Punctation (1) within a field of intraepithelial neoplasia. This

widespread and variable field of punctuated vessels indicates the presence of

various degrees of high- and low-grade cervical intraepithelial neoplasia

(CIN). Capillaries toward the center of the field are more spaced, indicating a

higher degree of CIN than in the capillaries at the periphery, which are more

closely spaced and indicate a lesser degree of abnormality.

Fig.50. Cervical cancer (indicated by the yellow arrows) is seen on both the

anterior and posterior lips of the cervix. The epithelial surface is elevated,

friable and yellowish in color. Atypical blood vessels are noted, the hallmark

of invasive cervical cancer.

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Fig. 51. Cervical condyloma (indicated by the arrow) detected during

colposcopy. The long villous-like projections are a common morphologic

appearance of HPV-induced lesions.

Fig.52. Cancer precursor (indicated by the arrow)seen by colposcopy. The

opaque white epithelium and coarsely dilated mosaic blood vessels are

diagnostic of CIN 3(photo courtesy of Daron Ferris, MD).

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Fig 53. Cervical endometriosis

Fig.54. The Shiller’ test: unpainted areas indicate pathology, are take material

for biopsy. Schiller’s test does not allow to answer the question about what

process was going on.

Chromocolposcopy is another aspect of colposcopy method. It is the use

of special filters for during colposcopy examination. The filters help the

physician examine tiny blood vessels (capillaries) in the area of the

squamocolumnar junction (SCJ). Blue or green filtered light can cause

abnormal capillaries to become more obvious, usually inside an acetowhite

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area. Normal capillaries are slender and spaced out evenly. In contrast,

abnormal capillaries can appear as red spots (thickened capillaries seen on

end) or can produce a pattern resembling hexagonal floor tiles. The worse the

cervical disease, the thicker and more widely spaced out are the capillaries.

The abnormal capillary pattern ranges from mild, as with pre-cancer

(dysplasia), to severe, as with established cancer.

Colpomicroscopy (microscopic colposcopy) - colposcopy under high

magnification (160-280 times) with the help of a contact lens and with

preliminary staining of the study area. The peculiarities of the structure of

nuclei and cytoplasm of cells of surface layers of epithelium may be examined

with microscopic colposcopy.

Biopsy should be directed whenever in doubt. Using a special scoring

system and terminology, colposcopic index may guide colposcopic

interpretation and diagnosis.

The latest version of the international terminology, which is used in this

book, was formulated by the International Federation for Cervical Pathology

and Colposcopy (IFCPC) with the International Society for the Study of

Vulvar Disease (ISSVD) in Rio de Janeiro, Brazil, in 2011. (Table 2).

Table 2.

2011 IFCPC Colposcopic terminology

2011 IFCPC Colposcopic terminology

General assessment • Adequate/inadequate PGA (for example bleeding, scars,inflammation)

• Squamocolumnar junction visibility: Completely visible, partially visible, not visible

• Transformation zone(TZ) types 1,2,3

Normal colposcopic findings

Original squamous epithelium:

• Mature

• Atrophic

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Cylindrical epithelium

• Ectopy

Metaplastic squamous epithelium

• Nabothian cysts

• Crypt (gland) openings

• Deciduosis in pregnancy

Abnormal colposkopic findings

General principles

Location of the lesion: Inside or outside the T-zone. Location of the lesion by clock position

Size of the lesion:Number of cervical quadrants the lesion covers. Size of the lesion in percentage of cervix.

Grade 1 (Minor)

Thin aceto-white epithelium, irregular, geographic border

Fine mosaic, fine punctuation

Grade 2 (Major)

Dense aceto-white epithelium, rapid apperance of acetowhitening, Cuffed crypt (gland) openings

Coarse mosaic, coarse punctuation, sharp border, inner border sign, ridge sign?

Non specific

Leukoplacia, erosion, iodine/Lugol´s staining (brown/yellow)

Suspicious for invasion

Atypical vessel. Additional signs: Fragile vessles, irregular surface, exophytic lesion, necrosis, ulceration (necrotic tumor)

Miscellaneous finding

Congenital transformation zone, condyloma, polyp, (ectocervical/endocervical), inflammation

Stenosis, congenital anomaly, post treatment consequence, endometriosis

Strander/Swede colposcopic score

• Five variables equivalent to 1-5 above has a value of 0,1 or 2

• At full deflection, the maximum is 10 point

• 1-4 points speak against CIN2+, while 8-10 points indicates for

CIN2+ (CIN3, cancer in situ)

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Strander/Swede colposcopic score (Table 3) is a newer and international

approved scoring system, easy to use and helpful to systematize colposcopic

findings and knowing where to take biopsies.

Table 3

Strander/Swede colposcopic score

Score 0 1 2

Uptake of

asetic acid

None or

transparent

Shady, milky (not

transparent not

opaque)

Stearin-like (distinct, opaque

white)

Margins Diffuse Sharp, but

irregular, jagged,

“geographic”

satelittes

Sharp end even, difference in

surface level

Vessels Fine,

regular

Absent Coarse or atypical vessels

Size < 5mm 5-15 mm or 2

quadrants

> 15 mm or spanning, 3-4

quadrants or endocervically

undefined

Iodine

absorbtion

Brown Faintly or patchy

yellow

Distinct yellow

Factors affecting the outcome of colposcopy:

qualification of a doctor conducting colposcopy

bleeding

severe inflammation

marked atrophy of an ectocervix

Colposcopy harms include pain, cost, psychological impact, and possible

impact of subsequent cervical procedures on obstetrical outcomes.

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Contraindications. No absolute contraindications to the performance of

a colposcopic examination exist, although special precautions may be

required in special circumstances, such as a pregnant patient who harbors a

placenta previa. The patient's ability to tolerate a standard speculum

examination is the only true limiting factor. Pregnancy by itself is not a

contraindication. Active cervicitis and vulvovaginitis should be treated before

undertaking the examination, because inflamed tissues can alter the ability to

obtain an accurate assessment, and it can make the discomfort of the

examination markedly worse.

When any lesion is identified, at least 2 biopsy specimens should be

taken to improve the accuracy of colposcopy. A biopsy should be performed

on specimens taken of the most severe area found on colposcopic examination

to confirm or rule out malignant lesions.

Hysteroscopy

Hysteroscopy is forms of minimally invasive surgeries, which allows

visualizing the internal surface of the uterus with the cervical canal to exam or

treat it. The equipment is a tiny telescope (hysteroscope), which is inserted

through the cervix into the uterus. The hysteroscope allows the surgeon to

visualize the inside of the uterine cavity on a video monitor. The inside of the

cervical canal, openings of the Fallopian tubes are visualized too.

Hysteroscopy is one of the most informative and effective methods of

diagnosis and treatment in modern practice. It helps to determine

intrauterine pathology, to make topical diagnostics and perform some

surgical intervention. Hysteroscopy has allowed not only to increase the

efficiency of diagnosis and treatment of a number of intrauterine and

endocervical problems, but also to significantly reduce surgical aggression in

modern practices. Since hysteroscopy examines the endometrium only, it is

not appropriate for examination or diagnosis of problems or conditions that

occur within the muscular layer or serous coat of the uterus. It also does not

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allow for direct examination of the Fallopian tubes, because of makes

visualization of the openings to the Fallopian tubes, but not tubes in whole.

The procedure can be performed as an aid in the diagnosis of problems

with the uterus, or it may be combined with simple surgical techniques for

treatment purposes. Thus, diagnostic and operative hysteroscopy are

distinguished.

Diagnostic hysteroscopy - is a procedure performed to evaluate the

endometrial cavity. Two systems of diagnostic hysteroscopy exist: panoramic

(also known as direct optical) and contact (also known as contact

microhysteroscopy). The most often used a panoramic technique. In this case

the uterine cavity is distended by a medium (which could either be fluid or

carbon dioxide), to achieve adequate visualisation of the uterine cavity.

Carbon dioxide is mostly used for diagnostic hysteroscopy, because the

bleeding that appears during operative hysteroscopy obscures visibility.

Carbon dioxide is a safe distension media when used at pressures below the

mean arterial pressure (MAP) of approximately 100 mmHg and flow rates

less than 100 mL per min. The advantages of CO2 include high solubility in

blood, high image clarity, and ubiquity in all operating rooms equipped for

laparoscopy. Its use for hysteroscopy is limited to diagnostic cases and has

significant disadvantages: the combination of intrauterine blood and

CO2 creates bubbles that can dramatically reduce the viewable area and limit

the diagnostic survey. 0.9% sodium chloride solution and lactated Ringer

solution are isotonic, conductive, low-viscosity fluids that are used for

diagnostic hysteroscopy and operative procedures. 0.9% sodium chloride

solution and lactated Ringer's solution are isotonic, conductive, low-viscous

liquids, which are used for diagnostic hysteroscopy and for limited

operational procedures. 5% mannitol, 3% sorbitol and 1.5% glycine are

hypotonic, non-conductive liquid with low viscosity, they improve

visualization in bleeding. They can be used in both diagnostic and operative

hysteroscopy.

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Contact hysteroscopy is a related procedure in which no distending

media is used and the hysteroscope is passed directly into the uterus and put

in gentle contact with the endometrial lining to obtain maximum

magnification. Only tissue that is in direct contact with the distal tip can be

inspected and evaluated.

Indications for diagnostic hysteroscopy:

abnormal premenopausal or postmenopausal uterine bleeding

confirmation of abnormal test findings (thickened endometrial lining

on sonography)

evaluation of the effectiveness of a hormone therapy

control of the uterine cavity after previous operations on the uterus

suspected Müllerian anomalies

suspected submucosal leiomyoma

suspected adenomyosis

suspected intrauterine synechiae

suspected the remnants of a fertilized ovum in the uterus after

miscarriage/abortion

suspected foreign body in the uterine cavity (IUD/fragments of IUD,

etc)

endometrial polyps

suspected perforation of a uterine wall.

Contraindications for diagnostic hysteroscopy:

Few contraindications to hysteroscopy exist. Severe medical

comorbidities may be a contraindication and should be assessed for each

individual’s needs and tolerances. Contraindications to hysteroscopy include

the following:

viable intrauterine pregnancy

female genital tract cancer, including cervical or uterine cancer

active pelvic infection

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inexperienced surgeon

Treatment of pelvic infections is mandatory prior to hysteroscopy and

can decrease the chance of propagating gynecologic infections that can lead to

pelvic pain, tubal factor infertility, and even death.

Preoperative preparation includes:

general clinical examination, including gynecological exam and imagine

studies, is made with spеcial attention to inflammation, anemia, the

circulation and the lungs.

CBC

urinalysis

HVS should be taken for microscopy for white blood cells, epithelial

cells, yeasts, bacterial vaginosis and Trichomonas vaginalis, and

bacteriology culture for bacterial pathogens and sensitivity to antibiotic

agents. electrocardiography

chest x-ray

blood sugar level

other tests by indications

the rectum and the bladder should be empty before operation.

Diagnostic hysteroscopy should be performed in the proliferative phase

of the menstrual cycle after cessation of menstrual flow. The procedure is

typically performed at day 5-7 of menstrual cycle. Examinations during the

secretory phase should be avoided to allow for optimal views of the cavity

since secretory endometrium can mimic intrauterine pathology. However,

there are exceptions when it is necessary to assess the state of the

endometrium in the secretory phase of the cycle. In such cases, the procedure

is performed 3-5 days before menstruation. In patients with perimenopause,

in postmenopausal patients, as well as in emergency cases, with bleeding, the

time of hysteroscopy does not matter. Some patients with anovulatory cycles

sometimes need in pharmacological preparation of endometrium for

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Hysteroscopy. In such cases pharmacologic thinning of the endometrium can

be done with a course of progestins, oral contraceptives, danazol, or GnRH

agonists. However, endometrial preparation is more typically performed prior

to operative hysteroscopy.

Fig. 55. A diagnostic hysteroscopy

Technique. The procedure may be done in specially equipped out-patient

office or in the hospital, under the local or general anesthesia. A patient

should be placed in the dorsal lithotomy position. A 10% povidone-iodine

vaginal and perineum preparation is preferred for hysteroscopic procedures.

After a bimanual examination, sim’s specula are used to bring the cervix into

view. The cervix should be cleaned with an antiseptic solution (10% povidone-

iodine or 4% chlorhexidine gluconate solution). A single-toothed tenaculum is

then applied to the anterior lip of the cervix. A small amount of local

anesthetic can be used prior to applying the tenaculum. If necessary,

administer the paracervical block with the cervix under gentle traction. In

order to achieve an adequate paracervical block for the nonpregnant female,

10-20 ml of anesthetic should be injected 10 mm deep at the 4 o'clock and 8

o’clock position in the cervicovaginal junction with a 25-gauge spinal needle.

The cervical canal should be dilated before insertion of hysteroscope into the

cervix. Special dilators usually used or patient may be given medication

(misoprostol, a synthetic prostaglandin e1 analogue) that is inserted into the

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cervix for cervical ripening to improve the likelihood of successful cervical

dilation and decrease intraoperative pain with few adverse events. Then

equipment for distention media is activated and the flow of the medium can

be started. The hysteroscope is introduced to the external cervical os and

advanced into the endocervical canal. The flow of media should function to

"wedge" a path to uterine entry. The walls of the cervical canal, the uterine

internal surface, walls should be examined accurately during the

procedure.(fig.55, fig.56.). If hysteroscopy is being performed to evaluate

endometrial polyps or other intrauterine pathology, tissue samples can be

obtained with hysteroscopic forceps.

Fig.56. Hysteroscopic picture of a normal uterine cavity

Operative hysteroscopy is a minimally invasive gynecological operation in

which an endoscopic optical lens is inserted through the cervix into the

endometrial cavity to direct treatment of various types of intrauterine

pathology. Operative hysteroscopy is can be combined with diagnostic one,

where after accurate examination of the uterine cavity and determination of

pathology, the surgical treatment may be done. This procedure is performed

in the operating room under IV sedation administered by an anesthesiologist

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(IV infusion of Tramadol, opioid pain medication).Transcervical instillation of

5 mL of 2% mepivacaine lowers pain scores and decreases the rate of

vasovagal reactions for women undergoing diagnostic hysteroscopy followed

by endometrial biopsy. Regional anesthesia (paracervical block), is also used.

General anesthesia may be indicated for more extensive procedures or for

patients who have lower pain tolerance and/or anxiety. General endotracheal

anesthesia is required for more complex or lengthy procedures or when

concurrent laparoscopy is expected. Thus, operative hysteroscopy may be

done under local, regional, or general anesthesia.

Operative hysterectomy is done to:

Take a tissue sample (biopsy)

Remove polyps or fibroid tumors

Prevent bleeding by destroying tissue using electric current, freezing,

heat, or chemicals

During operative hysteroscopy, equipment similar to the diagnostic

procedure (for example, a hysteroscope, light source, stretching means,

camera and gynecological instruments) is used, as well as special equipment,

need for surgical intervention with hysteroscopy. Equipment unique to

operative hysteroscopy includes:

an operative bridge that contains ports for hysteroscopic

instruments (ie, shears, graspers, and biopsy forceps),

the input and output channels that allow for continuous laminar

flow and irrigation,

the automated system that provides real-time fluid deficit

calculations and can control the pressure at which distension

medium is instilled,

the hysteroscopic morcellators

etc.

High-viscosity fluids are more preferred in operative hysteroscopy to limit

image distortion due to intrauterine bleeding. Currently, the only high-

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viscosity fluid option is Dextran 70. Dextran 70 is void of electrolytes and is

therefore nonconductive. Intraoperative fluid management is an important

aspect of hysteroscopy. Infusion pressure can be generated by elevating the

fluid bag or by using an automated pressure infuser or blood pressure cuff.

Pressure devices may increase fluid absorption and should be kept less than

the patients MAP, especially during prolonged cases. In cases in which

visualization is not optimal, the intrauterine distending pressure may be

increased 5-10 mmHg above the mean arterial pressure for short periods of

time.

Indications for operative hysteroscopy:

abnormal uterine bleeding (AUB) or heavy menstrual bleeding

(transcervical resection of endometrium is made to prevent

bleedings).Fig.57.

submucous leiomyoma (hysteroscopic removal of submucosal fibroids if

they are less than 3 cm. in diameter); Fig. 58.

uterine polyps (polips can cause AUB, infertility, also are dangerous due

to risk for malignant transformation); Fig. 59.

uterine septum (it is noted to be a major etiology of recurrent pregnancy

loss (RPL) and resection significantly improves live birth rates); Fig.60.

intrauterine adhesions (aka Asherman syndrome, which can lead to

AUB, infertility, or RPL, and hysteroscopic resection is the standard

treatment of symptomatic intrauterine adhesions);Fig.61, Fig. 62.

tubal infertility (hysteroscopic proximal tube cannulation can be

performed to open blocked tubes with operative hysteroscopy);Fig.63.

foreign bodies in the uterus (removal of a retained intrauterine

contraceptive device, or parts of device, as well as other foreign

bodies);Fig.64.

sterilization (it is hysteroscopic alternatives to laparoscopic or mini-

laparotomy sterilization techniques).

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Operative hysteroscopy can be performed in all of these situations with

minimal or no anesthesia and minimal surgical risk.

Contraindications:

pregnancy,

cervicitis,

active pelvic infection,

known cervical or endometrial cancer,

surgeon inexperience.

Comorbidities that may be exacerbated by intravascular volume expansion

are a relative contraindication

Technique. Operative hysteroscopy is best performed in the proliferative

phase of the menstrual cycle after menstrual flow has stopped when the

endometrium is thin. The initial steps of procedure are similar to those for

diagnostic hysteroscopy. A paracervical or intracervical block may be used

additional anesthesia. The cervix is then progressively dilated to the required

diameter (depending on the operative hysteroscope being used) with the

surgeon’s preference of cervical dilators (ie, Hegar, Hank, or Pratt).

Then the flow of distension medium is started and flushed through the

hysteroscope. The scope is then introduced to the external cervical os and

advanced into the dilated cervical canal. As the hysteroscope is slowly

advanced into the uterine cavity, continuous gentle counter-traction is

applied with the tenaculum. Once the distal tip of the hysteroscope appears in

the uterine cavity, the distension medium is allowed to expand the

intrauterine space. Uterine cavity should be accurately described, any

pathology should be noted at this time. Pathology may be treated as described

above.

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106

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Hysteroscopy complications. The most common complication that has been

reported is accidental perforation of the uterus. Uterine perforations occur

most frequently during adhesiolysis, but can also occur during insertion of the

hysteroscope. Perforations are generally diagnosed by direct visualization, but

should also be suspected in cases of unexplained rapid increase in the fluid

deficit, uncontrolled hemorrhage, and hemodynamic instability. Observation

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in intensive care unit should consist of monitoring vital signs, urine output,

and, in some cases, hematocrit. Perforations through the posterior or lateral

uterus or by sharp or electrocautery instruments should prompt laparoscopy

because of the potential for injury to the pelvic viscera or vasculature. A

cystoscopy should be performed to evaluate for bladder injury if an anterior

perforation is noted.

Fluid overload and electrolyte imbalance may happen as a result of

prolonged duration of a hysteroscopy, myomectomy, uterine septum

resection, extensive lysis of adhesions. Electrolyte free distension media can

cause rapid and profound hyponatremia if absorbed in large quantities. For

this reason, fluid deficits should be carefully managed, and intrauterine

pressures should be kept below the mean arterial pressure. Once the fluid

deficit reaches 750 mL, the surgeon should plan for completion of the

procedure. The operation is terminated when deficits reach 1500 mL for

nonelectrolyte fluids and 2500 mL for isotonic fluids.

Bleeding may arise during or after hysteroscopy. The surgeon should first

ensure that the noted bleeding is not a result of uterine perforation. Mild

bleeding is typically self-limited and generally does not require intervention.

If bleeding occurs, electrocautery may be used to coagulate small vessels. If

these conservative approaches fail to control heavy bleeding or if there is

bleeding from larger vessels, an intrauterine balloon can be inserted into the

cavity and inflated to tamponade the hemorrhage.

Other possible (but rare) complications include infection, medical

complications resulting from reactions to drugs or anesthetic agents,

gas embolism from the gas that is injected to distend the uterine cavity during

the procedure.

Laparoscopy

Laparoscopy is a method of investigation, by which organs of pelvic and

abdominal cavities are examined by an optical instrument inserted into the

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abdominal cavity through an opening in the anterior abdominal wall.

Synonyms are: endoscopy, pelviscopy, peritoneoscopy, ventroscopy, aka

keyhole surgery). The term originated the mid 19th century term from Greek

“lapara” (flank), plus - scopy. With the help of laparoscopy, a number of

gynecological surgeries can be performed: sterilization (tubal coagulation,

tantalum brace or seam imposition), dissection and coagulation of adhesions

in the small pelvis, coagulation of the endometrioid nodes, puncture of the

retention formations of the ovaries, coagulation of ovarian tissue in patients

with ovarian apoplexy.

The advantages of the method are that it is a minimally invasive type of

surgical intervention that allows manipulation through several small (5-10

mm) incisions. With its help, almost without blood loss, doctors perform

surgical treatment of diseases of the pelvic organs, in particular the uterus,

fallopian tubes and ovaries. Laparoscopy provides a much better overview of

the abdominal organs in comparison with traditional surgical methods

(laparotomy) due to the optical enlargement of the organs under

examination; allow visualizing all the floors of the abdominal cavity and

retroperitoneal space and performing surgical treatment if necessary.

(Fig.65). Other benefit of laparoscopy is that simultaneously with direct

viewing of the organs of abdominal cavity it enables the surgeon to take a

small sample of tissue for histological study (biopsy), if necessary. It

increases the accuracy of the diagnostic procedure many times over. Also

makes possible to perform needed surgical operation after immediate

histological examination of samples of tissue, making more invasive surgery

(laparotomy) unnecessary. So, with the help of small incision the diagnostic

inspection of abdominal cavity, biopsy, and surgical treatment, based on

histological study, may be performed. And the total duration of this procedure

is usually calculated in minutes. Other advantages of minimally invasive

laparoscopic procedures are also:

much smaller scars

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decreased blood loss

less post-operative discomfort since the incisions are much smaller

shorter hospital stays

quicker recovery times and earlier return to full activities

there may be less internal scarring when the procedures are performed

in a minimally invasive fashion compared to standard open surgery.

Fig.65. The technique of laparoscopic surgery: carbon dioxide gas inflates the

abdominal cavity to help with procedure; telescope and instruments allow the

surgeon to examine the abdomen.

As laparoscopy may be done to diagnose a pathological condition or to

perform certain surgical procedures, diagnostic (exploratory) and operative

laparoscopic procedures are distinguished. Diagnostic laparoscopy is applied

to find the cause of the symptoms such as pelvic pain, infertility problems or

other gynecological conditions that cannot be confirmed with clinical

examination or an ultrasound scan. Operative laparoscopy is used to treat a

disease that has already been diagnosed. As mentioned above, if an

abnormal condition is detected during the diagnostic procedure, operative

laparoscopy or hysteroscopy can often be performed to correct it at the same

time, avoiding the need for second surgery.

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Today, laparoscopy is one of the most widely used methods of diagnosis

and treatment, which is widely used practically all over the world. Due to its

characteristics laparoscopy has evolved from a limited gynecologic surgical

procedure used only for diagnosis and tubal ligations to a major surgical tool

used for a multitude of gynecologic and nongynecologic indications.

Laparoscopy is performed according to planned or emergency

indications

Indications for planned laparoscopy:

tubal and peritoneal infertility,

ovarian tumors,

leiomyoma,

genital endometriosis,

Mullerian anomalies,

sterilization,

lower abdominal pains of unclear etiology.

Indications for emergency laparoscopy:

ectopic pregnancy,

ovarian apoplexy,

rupture of ovarian cyst or tumor-like formation,

pelvic inflammatory diseases,

torsion of the pedicle of an ovarian tumor or a subserous

myomatous node,

differential diagnosis of acute gynecological and surgical

pathology.

Absolute and relative contraindications for laparoscopy are

diatinquished.

Absolute contraindications:

hemorrhage shock

uncorrected coagulopathy

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diseases in which a patient cannot be located in the Trendelenburg

position (brain trauma, cerebral vascular disease

acute and chronic renal-hepatic insufficiency

Acute intestinal obstruction associated with a massive (>4 cm)

bowel dilatation, which may obscure the laparoscopic view and

increase the likelihood of bowel injury

Trauma with hemodynamic instability or a clear indication of

bowel injuries, such as presence of bile or evisceration

Relative contraindications

multivalent allergy;

presence of anterior abdominal wall infection (cellulitis or soft-

tissue infection),

ICU patients who are too ill to tolerate pneumoperitoneum or

general anesthesia;

recent laparotomy (within 4-6 weeks) or extensive adhesions

secondary to previous abdominal surgery

aortoiliac aneurysmal disease (may be associated with

increased risk of vascular rupture)

pregnancy (may be associated with injury to gravid uterus or

fetal distress)

cardiopulmonary compromise

morbid obesity

Preparation for laparoscopy. The preparation for surgery starts before

the patient even arrives in the preoperative area, and includes a discussion of

informed consent and home bowel preparation. Many patients with comorbid

medical conditions undergo a review of their treatment strategy with their

primary care physicians. Although commonly termed “medical clearance,”

this process really provides an opportunity to optimize the patient’s medical

management prior to scheduled surgery. The implementation of a method to

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prevent venous thromboembolism begins based on the procedure and the

patient’s risk factors. Preoperative antibiotic prophylaxis typically commences

before arrival in the surgical theater, with the goal of having therapeutic levels

of the medication in the skin prior to incision. Proper skin preparation and

sterile draping of the patient is also necessary to decrease infectious mortality,

as has been done for almost a century. Obtaining a detailed list of current

medications is essential in a preoperative assessment. It is important to pay

attention to any supplements or herbal medications, because these may affect

coagulation and wound healing. Medications that affect blood clotting, such

as ibuprofen, ginko biloba, clopidogrel, and others, should be discontinued 7

days to 10 days before surgery. Angiotensin-converting enzyme inhibitors and

angiotensin II antagonists should be discontinued at least 10 hours before

general anesthesia is administered to reduce intraoperative hypotension.

Although it is advisable to stop aspirin prior to surgery, a daily low-dose pill

may be considered safe to continue into the perioperative period for patients

with a strong cardiovascular history; the risks and benefits of anticoagulation

should be balanced with the potential for increased blood loss. Elastic

compression stockings applied to legs can improve venous return but may not

be sufficient. For patients with moderate to high risk of developing deep

venous thrombosis (morbid obesity, operative duration >30 min, history of

previous deep venous thrombosis [DVT] or pulmonary embolism [PE],

certain cancers with increased association of DVT) should receive prophylaxis

with fractionated or unfractionated heparin.

CBC, urinalysis, biochemical tests, such as liver function tests or

electrolytes, blood clotting test, pregnancy test, as well as determination of

the blood group and Rh factor are made as before any surgical intervention.

Electrocardiogram, chest radiograph, other imaging studies may be used if

indicated.

Anesthesia. Laparoscopic surgical procedures are most commonly

performed with general anesthesia and skeletal muscle relaxation. However,

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in rare circumstances, such as in trauma and intensive care unit (ICU)

patients, local anesthesia with intravenous (IV) sedation has been successfully

used.

The laparoscopic procedure. The majority of abdominal laparoscopic

procedures are performed with patients in the supine position, whereas the

lithotomy position is favored for pelvic pathologies (rectal cancer, gynecologic

malignancies, and pelvic conditions). (Fig.66). Then abdomen is cleansed and

draped for the procedure.

The operation begins usually with an intra- or infraumbilical incision

from where the Veress needle is inserted creating the pneumoperitoneum

(Fig.67). The abdominal wall is elevated by manually grasping the skin and

subcutaneous tissue to maximize the distance between the umbilicus and the

retroperitoneal vessels. The Veress needle is placed through the umbilicus

into the peritoneal cavity, avoiding of both the retroperitoneal vessels and the

intestinal tract(Fig.68). A gas, such as carbon dioxide or nitrous oxide or air is

then allowed to flow into the abdomen just below the belly button. This gas

creates a space inside by pushing the abdominal wall and the bowel away

from the organs in the pelvic area and makes it easier to see the reproductive

organs clearly.

The main (10mm) trocar is inserted through the same incision, after

removing the Veress neddle, and the laparoscope is positioned through it.

Types of trocars and placement methods are widely variable. Usually two to

three extra trocars (5mm usually or 10mm) are placed for most operative

gynaecologic laparoscopic surgeries, two lateral and in some cases one

suprapubic (Fig. 69.). The suprapubic port should be placed 3 to 4 cm above

the symphysis pubis to avoid bladder injury. A small trocars are placed

through another incision in order to move the pelvic organs into clear view. A

diagnostic laparoscopy is incomplete without a "second puncture" because,

without this second probe, it is not possible to visualize all the structures

completely.

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During the laparoscopy the entire pelvis is carefully scanned and the

organs inspected systematically - the uterus; the ovaries; and the lining of the

abdomen, called the peritoneum. In addition to looking for diseases affecting

these structures, the doctor also looks for adhesions (bands of scar tissue),

endometriosis and tubercles. In case abnormalities are found, the doctor can

either try to correct them (operative laparoscopy), or take out bits of tissue for

histologic examination (biopsy) with a biopsy forceps. When the surgery is

complete, the gas is removed and one or two stitches inserted to close the

incisions. Videolaparoscopy, in which a video camera is connected to the

laparoscope, so that what the surgeon sees, can be displayed on a TV monitor

very often used today. This kind of laparoscopy can be very useful for

documentation and record-keeping.

Fig.66. Position of the patient

Fig.67.Diagram of a Veress needle.

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Fig.68. Veress needle insertion

Fig. 69. Position of trocars in gynecologic laparoscopy.

Complications. In addition to the traditional risks of surgery such as

infection and generalized bleeding, laparoscopy is a technique that presents

its own unique complications.

1. Gas embolism. Embolization usually is caused by inadvertent placement

of the Veress needle in a major vessel prior to insufflation of the

abdominal cavity with carbon dioxide. Usually the carbon dioxide is

quickly absorbed from the artery, and no serious results have been

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reported secondary to arterial embolization. In these cases, arterial

bleeding would be the major complication. On the other hand,

embolization of carbon dioxide into the venous system may be fatal due

to complete occlusion of the pulmonary artery by a large carbon dioxide

embolism. To avoid this complication, the operator must verify

intraperitoneal placement of the Veress needle prior to insufflation.

Treatment includes immediately stopping insufflation, removing the

needle, placing the patient in the left lateral decubitus position,

administering 100% oxygen, and giving cardiac support.

2. Retroperitoneal major vessel injury. Laceration of major abdominal

blood vessels is one of the least common but most life-threatening

complications in laparoscopy. When placing the Veress needle, the

patient must be in the horizontal position (not Trendelenburg), and the

angle of entry varies depending on patient weight. Open laparoscopy

remains an alternative for avoiding retroperitoneal injury. Immediate

recognition of the injury is paramount to patient survival. If blood flows

from the open Veress needle or if the patient's vital signs rapidly

decompensate after Veress or trocar insertion, prompt action must be

taken: to place a central line and order blood products, make a midline

incision for good exposure and suturing.

3. Abdominal wall vessel injury. The first step to avoiding injury is

knowing the positions of these vessels. When an injury occurs, the

operator must be prepared to control the bleeding promptly. An attempt

can be made to coagulate the vessel with electrocautery. If this approach

does not result in homeostasis, transabdominal sutures have been

advocate.

4. Intestinal or urologic injury. If injury is recognized at the time of

surgery, immediate action must be taken to repair the damage.

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Imaging studies in gynecology

An x-ray (radiograph) is a noninvasive medical test that helps

physicians diagnose and treat medical conditions. Images with X-rays include

the effect of a small dose of ionizing radiation on a specific part of the body to

create images of its internal structure. X-ray wavelengths are shorter than

those of UV rays and typically longer than those of gamma rays. X-ray is one

of the oldest forms of medical imaging. With the development of ultrasound

and endoscopic methods, X-ray diagnostics began to be used much less

frequently. In modern gynecology, X-ray methods of investigation are most

relevant in oncogynecology, urogynecology, and also in a number of cases of

differential diagnosis of gynecological and surgical diseases.

Since the body is made up of various substances with differing densities,

X-rays can be used to reveal the internal structure of the body on film by

highlighting these differences using attenuation, or the absorption of X-ray

photons by the denser substances (like calcium-rich bones). Medical

radiography includes a range of modalities producing many different types of

image.

For detection of the reproductive system diseases, following methods

are used in gynecological practice:

hysterosalpingography (metrosalpingography – MSH);

contrasting peritoneography;

vaginography;

mammography;

arteriography, phlebography, lymphography of the pelvis and

retroperitoneal space.

Pneumopyelviography

Pneumopyelviography (gynecography, pneumogynecography, X-ray

and neovigraphy, etc.) is the second most frequently used radiographic

method in gynecology. As a contrast medium, nitrous oxide, carbon dioxide

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and oxygen can now be used. The first two gases can only be used in a

specialized X-ray room. Their advantage is a rapid (within 30 - 120 min)

resorption in the cavity. In the absence of such a cabinet, it is more

appropriate to use oxygen, which is delayed in the abdominal cavity for 24

hours or more. The advantage of oxygen insufflation is the possibility of long-

term X-ray examination, its bactericidal and analgesic properties. Before the

procedure, 750-1500 ml of gas are administered depending on the length of

the body and the completeness of the woman at 100-200 ml per 1 min under a

pressure of no more than 40 mm Hg. Indications for pneumopyleviography

are obtaining information about the external contours of the internal genitalia

in girls and non-sexually active women, the necessary information for vaginal

examination in the presence of pronounced cicatricial or atrophic changes in

the vagina, adhesions in the small pelvis, etc .; anomalies and malformations

of internal genitalia; ovarian tumors; pseudohermophroditism and primary

amenorrhea; differential diagnosis of tumors of the uterus and appendages,

as well as genital and extragenital neoplasms. A variation of this method of

research is contrasting peritoneography, which is used to diagnose effusion

and adhesions in the abdominal cavity.

Vaginography

Vaginography is performed using a two-channel catheter (Foley type).

The expanded part of it is inserted into the vagina, and the balloon is filled

with an indifferent fluid or gas (air) in an amount of 100-150 ml, as a result of

which the entrance to the vagina is blocked. The main catheter is injected

with 150-250 ml of contrast medium (20-30% for diagnosis of vesicovaginal

fistulas and 40-50% for ureteral-vaginal). If possible, radiography should

preferably be carried out using X-ray television equipment or an ordinary X-

ray image table.

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Hysterosalpingography

Hysterosalpingography ((HSG), is an x-ray examination of

a uterus and fallopian tubes that uses a special form of x-ray called

fluoroscopy and a contrast material.

An x-ray (radiograph) is a noninvasive medical test that helps

physicians diagnose and treat medical conditions. Imaging with x-rays

involves exposing a part of the body to a small dose of ionizing radiation to

produce pictures of the inside of the body. X-rays are the oldest and most

frequently used form of medical imaging. Fluoroscopy is a special x-ray

technique that makes it possible to see internal organs in motion. During a

hysterosalpingogram, the uterus and fallopian tubes are filled with a water-

soluble contrast material and the radiologist is able to use fluoroscopy to view

and assess their anatomy and function. HSG is a real-time form of x-ray

examination

Indications for HSG include detection of:

tubal patency

uterine polyps,

submucosal leiomyomas,

uterine synechiae,

Müllerian anomalies,

hydrosalpinges,

salpingitis isthmica nodosum (SIN),

peritubal adhesions.

Contraindications are:

pregnancy

known contrast allergy

active pelvic infection

recent uterine or tubal surgery

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To minimize the possibility that the patient may be pregnant, a β- hCG

is warranted prior to commencing.

Technique. The procedure should be performed during the proliferative

phase of the patient’s menstrual cycle (days 6-12), when the endometrium is

thinnest. This improves visualisation of the uterine cavity, and also helps to

prevent false-positive intrauterine filling defects and proximal tubal occlusion

due to endometrial thickening. After an antiseptic cleaning of the external

genital area, a vaginal speculum is inserted with the patient in the lithotomy

position; the cervix is cleaned with an aseptic solution. Catheterisation of the

cervix is then performed; the type of device used depends on local practice

preferences: e.g. Foley catheter with balloon inflation, or any one of a range of

available HSG catheters or metal cannulas. Whatever the device, it should be

primed with contrast prior to commencing to avoid the introduction of gas

bubbles which may provide a false positive appearance of a filling defect.

Water soluble iodinated contrast is subsequently injected slowly under

fluoroscopic guidance. Some radiologists use iodinated oil (Lipiodol) as

contrast when the indication is for lack of fertility. Patient feels discomfort

during the procedure, it is related to cervical manipulation, uterine cavity

distention with the instillation of the contrast media, and peritoneal irritation

from dye that has spilled into the pelvis. Endocervical and exocervical topical

application of lidocaine-prilocaine cream 10 minutes before performing

hysterosalpingography helps to reduce pain during cervical manipulation

with tenaculum and cannula and during cervical traction. To decrease uterine

spasm, the media should be warmed to body temperature and injected slowly.

A typical fluoroscopic examination includes preliminary frontal view of the

pelvis, as well as subsequent spot images that demonstrate uterine

endometrial contour, filled fallopian tubes and bilateral intraperitoneal spill

of contrast, to establish tubal patency. For this aim the scout radiograph is

taken prior to the instillation of contrast. Then a series of at least 4 more

images should be captured as the contrast spreads through the genital tract.

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The first image after the scout film documents initial cavity fill and is best for

visualizing small filling defects. The subsequent image should be obtained

when the cavity is fully distended to assess uterine shape. The third and

fourth images after the scout are obtained as the fallopian tubes are filling and

after dye has spilled into the pelvis, respectively.(Fig. 70). Additional images

may be required to better document any pathology that is seen.

Complications from HSG are rare. The most common adverse event

are:

abdominal cramping;

vaginal spotting;

venous extravasation;

contrast reaction (vasovagal reaction with bradycardia and hypotension,

potentially resulting in syncope);

pelvic infection

Hysterosalpingogram results interpretation. Conditions which may be

detected with HSG include:

uterine congenital anomalies (Fig.71);

submucosal uterine fibroids (Fig.72);

uterine malignancy;

adenomyosis;

intrauterine adhesions (Fig.73);

uterine (endometrial) polyps (Fig.74);

obliteration of fallopian tubes (Fig.75, Fig. 76);

tubal polyps;

tubal malignancy;

hydrosalpinx (Fig. 77);

salpingitis isthmica nodosa;

tubal spasm;

salpingectomy.

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Fig.70. Normal HSG

Fig. 72. Uterine fibroid: the radiograph shows a well-defined

filling defect (arrow) in the fundus.

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Fig.73. Uterine adhesions: intrauterine adhesions

(scar tissue) inside the uterus are seen as irregular

dark shadows (white arrows) within the triangular shaped uterine cavity

Fig. 74. Endometrial polyp

Fig. 75. Tubes are closed off at their ends (liquid,

injected into the uterus, accumulated at their ends)

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Fig.76. Proximal tubal occlusion (liquid, injected into the uterus,

cannot enter the fallopian tubes)

Fig. 77. Hydrosalpinx: the radiograph shows dilatation of the ampulla

portion of the right fallopian tube (arrow). The left tube is normal in caliber

Phlebography, arteriography and lymphography are used in

oncogynecologic practice to determine the localization and nature of the

primary process, the extent of its spread. Lymphography can be repeated and

repeated to study the dynamics of the process at various intervals after

treatment. In gynecological practice, these methods are used extremely rarely.

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X-ray studies of the chest, gastrointestinal tract and genitourinary

system are conducted by appropriate specialists, if necessary with the

participation of an obstetrician-gynecologist.

Mammography

A mammogram is an x-ray picture of the breast. An x-ray (radiograph) is a

noninvasive medical test that helps physicians diagnose and treat medical

conditions. Imaging with x-rays involves exposing a part of the body to a

small dose of ionizing radiation to produce pictures of the inside of the body.

X-rays are the oldest and most frequently used form of medical

imaging.(Fig.78)

Fig.78. Mammography

Mammography is specialized medical imaging that uses a low-dose x-

ray system to see inside the breasts. A mammography exam, called a

mammogram, aids in the early detection and diagnosis of breast diseases in

women.

There are 3 recent advances in mammography, widely used in current

clinical practice, they are:

digital mammography,

computer-aided detection

breast tomosynthesis.

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Digital mammography, also called full-field digital mammography

(FFDM), is a mammography system in which the x-ray film is replaced by

electronics that convert x-rays into mammographic pictures of the breast.

These systems are similar to those found in digital cameras and their

efficiency enables better pictures with a lower radiation dose. These images of

the breast are transferred to a computer for review by the radiologist and for

long term storage. Conventional mammography stores the image directly on

film. (Fig.79). Digital mammography is an electronic image stored as a

computer file. The digital image can be enhanced, magnified and or

manipulated for further evaluation much more easily than the film

counterpart.

Computer-aided detection (CAD) systems search digitized

mammographic images for abnormal areas of density, mass,

or calcification that may indicate the presence of cancer. The CAD system

highlights these areas on the images, alerting the radiologist to carefully

assess this area.

Breast tomosynthesis, also called three-dimensional (3-D)

mammography and digital breast tomosynthesis (DBT), is an advanced form

of breast imaging where multiple images of the breast from different angles

are captured and reconstructed ("synthesized") into a three-dimensional

image set. In this way, 3-D breast imaging is similar to computed tomography

(CT) imaging in which a series of thin "slices" are assembled together to

create a 3-D reconstruction of the body. Although the radiation dose for some

breast tomosynthesis systems is slightly higher than the dosage used in

standard mammography, it remains within the safe levels for radiation from

mammograms.

A mammogram allows the doctor to have a closer look for changes in

breast tissue that cannot be felt during a breast exam. Women ages 50 to 74

years should get a mammogram every 2 years. Women younger than age 50

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should talk to a doctor about when to start and how often to have a

mammogram.

Different types of mammograms are distinguished:

Screening mammograms are done for women who have no

symptoms of breast cancer. Usually it includes two x-rays of each

breast. Screening mammograms can detect lumps or tumors that are

not felt in palpation. They can also find microcalcification or tiny

calcium deposits in the chest, which sometimes means that breast

cancer is present. Current recommendations in most countries

recommend screening mammography for women starting at age 40.

Regular mammograms (once a year or once every two years) lead to

early detection of breast cancer, when they are the most curable and

contribute to breast preservation.

Diagnostic mammography is used to evaluate a patient with

abnormal clinical findings—such as a breast lump or nipple discharge—

that have been found by the woman or practitioner. Diagnostic

mammography may also be done after an abnormal screening

mammogram in order to evaluate the area of concern on the screening

exam. This type of mammogram also can be used to find out more

about breast changes found on a screening mammogram, or to view

breast tissue that is hard to see on a screening mammogram. A

diagnostic mammogram takes longer than a screening mammogram

because it involves more x-rays in order to obtain views of the breast

from several angles. The technician can magnify a problem area to make

a more detailed picture, which helps the doctor make a correct

diagnosis.(Fig.80, 81,82, 83)

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A. B.

Fig. 79. A – Digital mammogram. B – Conventional mammograpgy (film)

Fig. 80. Normal mammogram.

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Fig.81. Fibroadenoma

Fig.82.Bilateral cysts associated to duct ectasia, no prior history of

breast disorders

Fig.83. Breast cancer

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It is proved that screening with breast mammography results in improved

breast cancer detection rates. Finding breast cancer as early as possible before

it has grown or spread greatly improves a woman’s chance for a successful

treatment.

Computer tomography

Computer tomography is based on the change (weakening) of the

intensity of X-ray radiation when passing through tissues of various densities.

Computed tomography or CT scan uses a high amount of ionizing

radiation (in the form of X-rays) in conjunction with a computer to create

images of both soft and hard tissues. These images look as though the patient

was sliced like bread (thus, "tomography"- "tomo" means "slice"). The exams

are generally short, most lasting only as long as a breath-hold. Contrast

agents are often used, depending on the tissues needing to be seen. Computed

tomography (CT) has become essential in the diagnostic evaluation of the

female pelvic. CT allows accurate delineation of neoplastic and inflammatory

processes and provides an effective means of guiding percutaneous needle

biopsy of masses and aspiration/drainage of fluid collections.

The most popular is spiral CT that not only acquires sliced images, but

also obtains volume images. CT scanners are now widely available in most

hospital settings and in many outpatient facilities as well. Images are now

acquired with the use of multidetector machines that complete their

acquisitions within seconds, and they can be displayed in multiple planes via

reconstruction of data and images. The spatial resolution is excellent and

different circulatory phases can be obtained allowing better interpretation of

images. CT helps to differentiate blood vessels, lymph nodes, and the

presence of tumors. When using contrast, the method helps identify ureters

and the bladder due to the turbidity of these tissues. Oral and rectal contrast

opacifies the bowel and aids in differentiating these anatomic markers from

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gynecologic structures. A large field of view is presented and total body CT

scanning can be accomplished quickly and easily.

Conventional CT scanners are equipped with a tube that produces a

narrow x-ray beam that passes through the patient and is picked up by a row

of detectors on the other side. The tube and detectors are positioned on the

opposite sides of a ring and rotate around the patient. The tube rotates in a

single direction indefinitely (spiral or helical CT). While the tube is rotating,

the table supporting the patient also moves continuously so that a volume of

tissue rather than an individual slice is scanned. The data are then

reformatted automatically to display the images as axial slices. Thus, the scan

time is much shorter. This spiral CT is not even as fast as the newer multislice

scanners, which acquire images 2 to 3 times faster than a single slice scanner.

The multislice CT may be considered a "turbo-charged" spiral CT. Whereas

conventional and spiral CT use a single row of detectors to pick up the x-ray

beam after it has passed through the patient, the multislice CT has up to 16

active rows of detectors.(Fig. 84)

Fig. 84 CT scan

The disadvantages include radiation exposure and the risks of IV

contrast action. The use of ionizing radiation should always be very deliberate

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and applied in absolute indications, when alternative methods (MRI or

ultrasound) can not be applied or are insufficient.

Positron emission tomography as a functional method, combined with

CT as a morphological method (PET/CT), is an optimum method in

diagnostics and the therapeutic management of relapses of gynecological

tumors, as it makes it possible to find a viable tumor tissue, and – unlike PET

by itself – to exactly specify its localization. It may also be beneficial in finding

the primary source of the disease for disseminated tumors or where duplicity

of the tumor is detected. PET/CT is also used in clinical staging and restaging

of gynecological tumors, particular where the conclusions of the other

imaging techniques are ambiguous.

CT scan can visualize abnormal masses but definitive pathologic

diagnosis is established only with surgical biopsy. CT scan is more expensive

than ultrasound.

Indications for CT in gynecology:

to detect pituitary tumor;

to detect ovarian tumor;

to determine the cancer of genital tract;

to detect the staging of cancer cervix;

to determine myometrial involvement in endometrial cancer;

to detect para-aortic nodes and obtain needle biopsy to determine

retroperitoneal spread of cancer;

to determine the spread of ovarian cancer;

to detect intraabdominal abscess and hematoma;

to diagnose pelvic vein thrombophlebitis;

to evaluate peritoneal adhesions;

to make pelvimetry by 3d CT of non-pregnant women(Fig. 85, Fig. 86).

Summary of optimum use of imaging methods presented in gynecology

presented in Table 4.

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Table 4

Summary of optimum use of imaging methods in

gynecology:

Ultrasonography

(TVUS, TRUS,

TAS)

Magnetic

resonance

image (MRI)

Computer

tomography

(CT)

Positron emission

tiomography/Computer

tomography (PET/CT)

Assessment of

early and

advanced stages

of the disease,

lymph glands,

presence of

metastases.

Navigation in

biopsy

procedures.

Assessment of

early stages of

the disease for

tumors of the

cervix and

uterus, local

spreading of

tumors into

surrounding

organs and

closest lymph

nodes,

detection of

metastatic

lesions.

Diagnostic of

unclear adnexal

lesions.

Endometriosis.

Planning of

radiotherapy.

Diagnostics of

relapse.

Assessment of

advanced

disease,

affected lymph

nodes,

metastases.

Planning of

radiotherapy.

Monitoring

response to

therapy.

Diagnostics of

relapse.

Navigation in

biopsy

procedures and

radiofrequency

ablation (RFA).

Determining relapse.

Staging of

gynecological tumors,

especially detection of

infiltrated nodes and

other metastases.

Complementary

method in the event of

ambiguous conclusions

of other imaging

techniques

(distinguishing

between benignant and

malignant lesions).

Assessment of response

to therapy. Detection of

occult primary tumor

where metastases are

known.

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(TVUS – transvaginal ultrasound examination, TRUS – transrectal

ultrasound examination, TAS – transabdominal ultrasound examination)

Fig.85. A contrast enhanced CT scan showing a mass growing in the left

ovary (white arrow).

Fig. 86. Axial CT scan of the pelvis in a patient with stage IIIB cervical

carcinoma shows a cervical mass (c) with right pelvic sidewall invasion

(arrow)

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When carrying out X-ray studies in gynecological practice, several well-

known basic rules should be followed.

Any X-ray examination is accompanied by irradiation of the body,

including gonads, which is a drawback of these methods. Taking into account

the harmful effect of ionizing radiation on the generative function of a

woman, one should strive to reduce the dose of irradiation with this or that

method. This is achieved by carrying out research at a high technical level

using modern equipment that allows it to be carried out with the maximum

hard radiation and ensuring optimum safety. Highly sensitive films should be

used to reduce exposure, large-frame fluorography and electron-optical

amplifiers.

The main rule - to X-ray studies should be resorted to strict clinical

indications and, if necessary, in cases when other harmless methods

(ultrasonic, endoscopic, hormonal, functional diagnostics tests, etc.) cannot

be used.

Ultrasound examination

An ultrasound scan (US), aka sonography, is a diagnostic technique which

uses high-frequency sound waves to create an image of the internal organs.

During an ultrasound exam, a transducer sends sound waves through the

body. The sound waves come into contact with tissues, body fluids, and bones.

The waves then bounce back, like echoes. The transducer receives these

echoes, which are turned into images. The images can be viewed as pictures

on a video screen. The term "ultrasound" refers to sound waves of a frequency

greater than that which the human ear can appreciate, namely frequencies

greater than 20,000 cycles per second or Hertz (Hz). To obtain images of the

pregnant or nonpregnant pelvis, frequencies of 2 to 10 million Hertz (2 to 10

megahertz [MHz]) are typically required. Real-time imaging is the most

common sonographic technique used in obstetrics and gynecology. Multiple

individual B-mode gray-scale images are obtained and rapidly displayed in

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succession, thereby creating a video of the area of interest over time that can

be used to evaluate its structure and some aspects of its function. Real-time

ultrasound is especially useful for imaging mobile subjects, such as the fetus

or heart, and for quickly viewing an organ from different orientations. For

optimum ultrasonographic visualization, certain mechanical, physical, and

ultrasonographic principles must be understood. The quality of an image

ultimately depends on the degree of resolution. In general, the closer the

transducer tip is to the imaging target, the greater the resolution and,

therefore, the clearer the image.

Basic physics and principle of ultrasound examination. Basic Theory:

Sound waves are simply organized mechanical vibrations traveling through a

medium, which may be a solid, a liquid, or a gas. These waves will travel

through a given medium at a specific speed or velocity, in a predictable

direction, and when they encounter a boundary with a different medium they

will be reflected or transmitted according to simple rules. This is the principle

of physics that underlies ultrasonic examination of internal organs. All sound

waves oscillate at a specific frequency, or number of vibrations or cycles per

second, which we experience as pitch in the familiar range of audible sound.

Human hearing extends to a maximum frequency of about 20,000 cycles per

second (20 KHz), while Ultrasound is the term used to describe sound of

frequencies above 20 000 Hertz (Hz), beyond the range of human hearing.

Frequencies of 1–30 megahertz (MHz) are typical for diagnostic ultrasound.

At frequencies in the megahertz range, sound energy does not travel

efficiently through air or other gasses, but it travels freely through all liquids

and biological tissues. The velocity of sound depends on the density and

compressibility of the medium. The construction of images with ultrasound is

based on the measurement of distances, which relies on this almost constant

propagation velocity. The wavelength of ultrasound influences the resolution

of the images that can be obtained; the higher the frequency, the shorter the

wavelength and the better the resolution. Energy is lost as the wave

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overcomes the natural resistance of the particles in the medium to

displacement, i.e. the viscosity of the medium. The higher the difference of

the acoustic reflection of ultrasound energy between two media, the more

significant is the reflection of the ultrasound. That is why we use coupling gel

between the ultrasound transducer and the skin. By using the gel, we decrease

the impedance and allow the ultrasound to penetrate into the tissue. Thus,

absorption increases with the viscosity of the medium and contributes to the

attenuation of the ultrasound beam. Absorption increases with the frequency

of the ultrasound. Echo is the usual term for the reflected or back-scattered

parts of the emitted ultrasound pulses that reach the transducer. For each

echo, the intensity and time delay are measured at the transducer and

electronically processed to allow calculation of the distance travelled. The

displayed results form the basis of diagnostic ultrasound images. The origin of

echoes reflected from broad boundaries, such as the surface of organs or the

walls of large vessels, is easily identified.

The piezoelectric effect is a basis for ultrasound scanning. Piezoelectric

crystals or materials are able to convert mechanical pressure into electrical

voltage on their surface). Conversely, voltage applied to the opposite sides of a

piezoelectric material causes an alteration in its thickness (the indirect or

reciprocal piezoelectric effect). If the applied electric voltage is alternating, it

induces oscillations which are transmitted as ultrasound waves into the

surrounding medium. The piezoelectric crystal, therefore, serves as a

transducer, which converts electrical energy into mechanical energy and vice

versa. Ultrasound transducers are usually made of thin discs of an artificial

ceramic material such as lead zirconate titanate. The thickness (usually 0.1–1

mm) determines the ultrasound frequency. The basic design of a plain

transducer is shown in Fig. 87. Sound is a vibration transmitted through a

solid, liquid or gas as mechanical pressure waves that carry kinetic energy.

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Fig. 87. Basic design of a single-element transducer.

Thus, the ultrasound probe has piezoelectric crystals in it, which convert

the electric current into sound waves. These sound waves pass through the

woman's abdomen as the clinician moves the transabdominal transducers

over the mother’s abdomen after application of water soluble gel, which acts

as a coupling agent. As these sound waves pass through the internal

structures and hit various body’s structures, they get reflected back which can

be used to identify distance between body parts and their size and shape.

When the sound waves hit a high density structure like bone, they are

reflected back in form of high velocity waves, giving a white appearance on

the screen. However, when these sound waves hit a less dense structure,

reflected waves are of a lower velocity. These waves give a gray or black

appearance on the screen. These reflected waves are picked up by the

piezoelectric crystals inside the transducer and get converted into electric

signals which are then displayed on the screen. (Fig. 88). The term

echogenicity of the tissue refers to the ability to reflect or transmit US waves

in the context of surrounding tissues. Whenever there is an interface of

structures with different echogenicities, a visible difference in contrast will be

apparent on the screen. Based on echogenicity, a structure can be

characterized as hyperechoic (white on the screen, high density structure like

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bone), hypoechoic (gray on the screen) and anechoic (black on the screen, less

dense structure like a fluid).

Fig. 88.The pelvic ultrasound exam, suprapubic view

Ultrasound techniques. The various ultrasound techniques are used

today: A-mode, B-scan, two-dimensional, M-mode or TM-mode, Three- and

four-dimensional techniques, Doppler ultrasound, Sonohysterography, etc.

There are three types of pelvic ultrasound: transabdominal,

transvaginal, and transrectal . Transabdominal (Fig. 89) and transvaginal

ultrasound (Fig.90) are mostly used in gynecological practice. A woman may

have both transabdominal and transvaginal ultrasounds to look at the whole

pelvic area. Transrectal is used for men and in sometimes in oncogynecology.

Transabdominal ultrasound (TAUS) involves scanning through the

lower abdomen. TAUS usually provides an overview of the pelvis rather than

detailed images. The transabdominal assessment is particularly helpful for

the examination of large pelvic masses extending into the abdomen, which are

not always well viewed with transvaginal ultrasound. A small amount of

ultrasound gel is put on the skin of the lower abdomen, with the ultrasound

probe then scanning through this gel.

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Fig. 89. Transabdominal ultrasound, the standard midline sagittal view

Transvaginal ultrasound (TVUS) is an internal ultrasound. It involves

scanning with the ultrasound probe lying in the vagina. Transvaginal

ultrasound usually produces better and clearer images of the female pelvic

organs, because the ultrasound probe lies closer to these structures. The

transvaginal ultrasound probe is thin, about 2cm diameter. The probe is

covered with a disposable protective sheath. A small amount of ultrasound gel

is placed on the end of this probe. The probe is then gently inserted a short

distance into the vagina. All transvaginal examination is made according to

the rules of cleaning and sterilization according to recommended protocols.

Fig. 90. The standard transvaginal sagittal view: it produces a

longitudinal image of the uterus similar to the transabdominal sagittal view,

but rotated 90 degrees counterclockwise

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Indications for pelvic ultrasound in gynecological practice include:

pelvic pain,

dysmenorrhea (painful menses),

amenorrhea (absence of menses),

menorrhagia (excessive menstrual bleeding),

menometrorrhagia (excessive irregular uterine bleeding),

follow-up a previously detected abnormality,

evaluation, monitoring and treatment of infertility patients,

delayed menses, precocious puberty, vaginal bleeding in a prepubertal

child,

postmenopausal bleeding,

abnormal or technically limited manual pelvic examination,

signs or symptoms of pelvic infection,

evaluation of congenital uterine anomalies,

excessive bleeding, pain, or signs of infection after pelvic surgery,

delivery, or abortion,

localization of an intrauterine contraceptive device,

screening for malignancy in patient at increased risk,

urinary incontinence or pelvic organ prolapse,

guidance for interventional or surgical procedures,

etc.

The anatomical structures which the sonographer should be able to

examine correctly are:

The anatomical structures which the sonographer should be able to

examine correctly are:

uterus (Fig. 91) :

o position,

o size,

o shape

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o ultrasound characteristics of endometrium and myometrium (Fig.

92);

ovaries (Fig .93):

o position,

o size,

o shape ultrasound characteristics

o number,

o size and internal echo pattern of follicles (Fig.94,Fig.95);

cervix (Fig.96)

o length,

o the angle between the cervix and uterus body;

fallopian tubes where visible (Fig.97, Fig.98)

broad ligaments

pelvic muscles

pelvic blood vessels

vagina (Fig. 99)

A transvaginal ultrasound is usually performed to view

the endometrium, myometrium and the ovaries.

Fig. 91. Transvaginal scan of a uterus (U) in the proliferative phase. E –

endometrium; C-cervix.

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Fig. 92. Normal appearances of cyclical endometrium. (A) Menstrual

phase showing the endometrium as a thin line; (B) follicular/proliferative

phase showing a trilaminar appearance of the endometrium; (C)

periovulatory phase showing the echogenicity of the basal layer of

endometrium has extended to the midline echo; (D) luteal/secretory phase

showing thickened uniform echogenicity.

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Fig. 93 Ultrasound image of a normal ovary with dominant follicles

Fig. 94. Longitudinal image of ovary displaying enlarged ovary with

multiple large peripheral follicles and free fluid: ovarian hyperstimulation

syndrome

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Fig. 95. Polycystic ovary syndrome US picture

Fig. 96. TVUS of a normal cervix, showing the most commonly used

method of cervical length measurement (double-headed arrow)

147

Fig. 97. Pyosalpinx on US: patient with lower abdominal pain and

increased inflammatory markers

Fig. 98. Eight-week-old embryo in the right fallopian tube

Fig. 99. Normal appearance of the vaginal cuff in US.

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Technique. The ultrasound examination is usually initiated

transabdominally. The bladder does not have to be full; however, if the pelvis

cannot be seen well, it may be necessary to have the patient fill her bladder to

a comfortable capacity. This may be especially important for those women

who are unable to tolerate placement of a transvaginal ultrasound probe.

Often in these cases, the entire examination can be performed

transabdominally. If a specific question remains unanswered, or if an

abnormality is suspected, other approaches, such as a transrectal examination

or even a transperineal examination, may be considered. Transabdominal

scanning is important for evaluating the upper pelvis and abdomen, such as

with large fibroids, ovarian neoplasms that extend into the upper abdomen,

or ovaries lying high in the pelvis. Images only obtained by transvaginal

scanning may not be adequate, or may miss pathology, as distance between

the area under investigation and the vagina increases.

After evaluation of the pelvis transabdominally, the patient is asked to

void because transvaginal sonography is best performed with an empty

bladder. Guiding the probe toward the area of interest, such as an ovary, and

watching how this area moves in relation to the other pelvic organs is helpful

for evaluation of complicated or unclear pelvic anatomy, especially in the

setting of abnormalities. As an example, a pelvic mass (pedunculated fibroid

or solid ovarian mass) may lie between the uterus and normal appearing

ovarian tissue. On a still image, the uterus, mass, and normal ovary may

appear contiguous. With movement of the probe, the specific origin of the

mass can usually be determined.

Visualization of pelvic structures with the transvaginal probe is limited

by the relative positions of the pelvic organs and the presence of any pelvic

masses. The resolution of high-frequency vaginal probes is good up to a depth

of 6 to 8 cm. TVUS can be performed concurrently with an abdominal

examination to better define normal and abnormal anatomy. As an example,

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by applying pressure abdominally, the uterus with any associated fibroids,

and even the intestines, can be moved away from the ovaries, allowing better

visualization. Uterine measurements are most accurately obtained by TVUS.

The average transverse width of the endometrial cavity (ie, inside dimension

of the uterus) is 2.7 cm among nulliparas, 3.0 cm among primiparas, and 3.2

cm among multiparas.

The typical measurement of endometrial thickness includes both the

anterior and posterior endometrial walls. If fluid is present within the

endometrial cavity, the anterior and posterior endometrial echoes can be

measured independently and summed. Immediately after menses, the

endometrium is 1 to 4 mm thick; as the estrogen concentration rises, the

thickness increases to 7 to 10 mm. After ovulation, echogenicity increases

starting in the basal area; by the luteal phase, the entire endometrium is

hyperechogenic with a thickness of 8 to 16 mm. In postmenopausal women, a

thick endometrial lining (defined as >4 mm) can be a marker of endometrial

hyperplasia or malignancy.

Multiple 2 to 5 mm follicles may be seen in the ovaries. A leading follicle

of about 10 mm can be identified at the 9th or 10th cycle day; it grows rapidly

and is 20 to 24 mm in diameter just before ovulation. After ovulation, the

corpus luteum develops and may have a slightly heterogeneous consistency.

The wall typically appears to be thick with low-level internal echoes and

circumferential blood flow. The diameter of a normal follicle or corpus luteum

does not usually exceed 30 mm. A corpus luteum cyst appears as a

homogeneous hypoechogenic thin-walled structure.

Any abnormality noted should be described, as appropriate: size, shape,

location, echogenicity, echo pattern (cystic, solid, complex, septations), and a

differential diagnosis of the most likely causes of the abnormality should be

provided. Additional studies, such as Doppler velocimetry or saline infusion

sonohysterography, may be useful in defining suspected lesions, or three-

150

dimensional sonography, which may be helpful for evaluating the uterine

shape in those patients with infertility.

Doppler effect. The Doppler effect was originally postulated by the

Austrian scientist Christian Doppler in relation to the colors of double stars.

The effect is responsible for changes in the frequency of waves emitted by

moving objects as detected by a stationary observer: the perceived frequency

is higher if the object is moving towards the observer, and lower if it is moving

away. The difference in frequency (Δf) is called the Doppler frequency shift,

Doppler shift or Doppler frequency. The Doppler frequency increases with the

speed of the moving object. With Doppler sonography, one can evaluate

changes in waveform (sound, radar, light), determine the speed and direction

of the object (blood flow).

In medicine, Doppler effects are used mainly to analyze blood flow, to

calculate blood velocity, because the velocity of the ultrasound is known and

the angle of the vessels to the beam direction can be measured, allowing angle

correction. Doppler ultrasound images (Fig.100) can help the physician to see

and evaluate:

blockages to blood flow (such as clots)

narrowing of vessels

tumors and congenital vascular malformations (Fig.101)

character of blood flow to various organs (Fig. 102)

increased vasculature of genital organs, which is sometimes seen in

hyperplasia, tumors, in infections, etc.(Fig. 104)

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Fig. 100. Normal left ovary with the normal Doppler flow

Fig. 101. A complex 12 x 10-cm mass in a premenopausal woman

contained multiple ceptations with solid elements that had marked vasculary

flow. The mass correctly identified as a malignant (stage III papilary

adenocarcinoma).

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Fig. 102. Color Doppler image of the ovarian flow in the luteal phase

of the menstrual cycle

Fig. 103.Myometrial vascularization. (A) - Greyscale ultrasound showing

secretory phase of endometrium (arrows) in a woman with heavy periods.

(B) Color Doppler in the same patient reveals increased myometrial

vascularity.

Sonohysterography allows for a more in-depth investigation of

the uterine cavity. It is a specialized procedure where sterile saline is installed

into the uterine cavity, and an ultrasound is performed at the same time. The

procedure helps to delineate intrauterine pathology such as polyps, fibroids

and uterine malformations.

153

Three-dimensional (3-D) ultrasound (3D US) is a fast-evolving imaging

technique that holds a great potential for use in gynecology. 3D US is more

sensitive and specific than two-dimensional ultrasound (2D US) in defining

and mapping uterine lesions, such as fibroids, adenomyosis, and intrauterine

synechia. In cases of suspected malignancy, 3D US is mainly used in the

initial evaluation of patients. 3D US permits evaluation of the uterus and

ovaries in planes that cannot be imaged directly.

These exams are typically performed to detect:

uterine anomalies (Fig.104)

uterine scars

endometrial polyps, fibroids(Fig.105)

cancer, especially in patients with abnormal uterine bleeding

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3D/4D ultrasound allows visualization of dimensional surface

structures such as a baby’s face. The 4D simply shows a 3D image in motion.

Interventional ultrasound - is defined as any diagnostic or therapeutic

procedure performed under ultrasound guidance for any tissue or organ that

is visualized by ultrasound. Diagnostic procedures: ultrasound-guided

aspiration of fluid or cystic fluid for biochemical or cytological and culture

examinations as well as for cytological or tissue sampling with fine-needle.

(Fig.106, Fig.107, Fig. 108)

Fig.106.Interventional ultrasound

Fig. 107. Cyst aspiration under ultrasound guidance

155

Fig.108. Core biopsy under ultrasound guidance

Magnetic resonance imaging

Magnetic resonance imaging (MRI) is an imaging modality that has been

developed and used since the mid-1970s. It is a test that uses a magnetic field

and pulses of radio wave energy to make pictures of organs and structures

inside the body. The imaging components include a large static magnetic field

and an electromagnetic field produced by radio frequency (RF) waves.

Although once termed nuclear magnetic resonance imaging, MRI uses no

ionizing radiation. The nucleus being studied in this form of imaging is the

naturally occurring hydrogen nucleus, a proton, which is ubiquitous in the

body by virtue of its presence in water. MRI has several advantages over

computed tomography (CT) and ultrasonography. One important feature is

its noninvasiveness.

MRI also gives possibility to obtain a simultaneous display of a large

portion of the body without repositioning the patient. Transverse, sagittal,

coronal, not comparable views may be obtained in a short time. Compared

with MRI, ultrasonographic examination allows more tissue planes to be

observed in real time. But, the window of view is actually relatively small, and

a simultaneous display of a large portion of the body is not possible. This is

another advantage of MRI, widely used in clinical practice.

156

A third advantage of MRI is its excellent tissue-differentiating

capabilities. MRI acquisitions may further alter and differ contrast. These

signals are not influenced by the amount of bladder filling, the size of a

patient, or the amount of gas in the surrounding bowel, but these factors have

an important role in the quality of an ultrasonographic image. With MRI,

excellent tissue differentiation is possible without the use of contrast agents.

Besides, newly developed contrast agents may further augment tissue

contrast and are much safer than the iodinated equivalents used in CT. In

many cases, MRI gives different information about structures in the body

than can be seen with an ultrasound, X-ray, or computed tomography (CT)

scan. MRI shows problems that cannot be seen with other imaging method.

For an MRI test, the area of the body being studied is placed inside a

special machine that contains a strong magnet. Pictures from an MRI scan are

digital images that can be saved and stored on a computer for more study.

The images also can be reviewed remotely, such as in a clinic or an operating

room. Additionally, contrast material may be used during the MRI scan to

show certain structures more clearly. The use of MRI is rapidly expanding in

gynecological oncology, gynecologic surgery. Pelvic MRI has excellent soft

tissue contrast and multiplanar imaging ability to demonstrate either normal

or pathological processes.

MRI is extremely sensitive to blood flow. As with Doppler

ultrasonography, flow direction and speed may be determined. Both arterial

and venous abnormalities can be assessed by MRI. Additionally, biochemical

states of blood can be characterized by MRI because characteristic signals are

derived from oxyhemoglobin, deoxyhemoglobin, methemoglobin, and

hemosiderin in red blood cells in different stages of hematoma formation.

Together, these two capabilities for studying blood allow sensitive MRI

diagnosis of thrombotic diseases.

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In gynecological oncology the rapidly evolving role of MRI includes not

only diagnosis but also disease staging, planning of therapy and monitoring

response to treatment.

Basic physics and principle of MRI. Certain atomic nuclei in molecules

possess nuclear angular momentum, or spin. These spinning charged

particles create a magnetic field or moment. Hydrogen nucleus, the proton, is

currently the only nucleus extensively used for MRI because of its relative

abundance in the human body. In the absence of an external magnetic field,

hydrogen nuclei are randomly oriented within a tissue. When a uniform

external magnetic field is applied to these nuclei, the nuclei tend to align in

the direction of the applied field because this is the lowest energy state. The

aligned nuclei will spin at a frequency that is determined by the strength of

the magnetic field being sensed by the nuclei—that is, the larger the external

magnetic field, the higher the frequency of spinning. The magnetic moments

of multiple similarly aligned nuclei produce a net magnetic moment that is

used to produce the MRI signal. After electromagnetic excitation, nuclei

absorb energy and a higher percentage of the nuclear population exists at a

higher energy state. By transferring this energy from the excited nuclei to

surrounding molecules, the nuclei return to a lower energy state, realigning

with the main magnetic field. The efficiency with which energy is transferred

depends on the molecular structure of the surrounding tissues (i.e.,

transferring of energy in fat would differ from transferring if energy in

muscle). The spinning of the proton induces a voltage which is then translated

into a signal that results in a magnetic resonance image. Computer, getting

information about different energy, builds the corresponding images of

different regions. It is the ability of the MRI to evaluate the variations in the

net magnetization of the nuclei in different tissues, allowing for excellent

tissue contrast, that is, a unique feature of MRI.

MRI scans are usually performed in the sagittal (longitudinal) and axial

(transverse) planes. Scanning in the sagittal plane is called a T1 image, and

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scanning in the axial plane is a T2 image. MRI scanning may also be done in

coronal plane.

Indications

Indications for MRI of the pelvis organs in women include, but are not

limited to:

detection and staging of gynecologic malignancies, including those

originating in the vulva, cervix, uterus, ovaries, and fallopian tubes;

evaluation of pelvic pain or mass, including detection of adenomyosis,

ovarian cysts, torsion, tubo-ovarian abscess and benign solid masses,

obstructed fallopian tubes, endometriomas, and fibroids;

identification of a congenital anomaly of the female pelvic organs;

determination of number, location, and type (solid or hemorrhagic) of

fibroids prior to myomectomy, hysterectomy, or uterine artery

embolization;

assessment of pelvic floor defects associated with urinary or fecal

incontinence;

assessment for recurrence of tumors of the bowel, bladder, or

gynecological organs following a surgical resection or exenteration;

evaluation of complications following pelvic surgery, including abscess,

urinoma, lymphocele, radiation enteritis, and fistula formation;

determination of arterial and venous anatomy and patency;

identification and staging of soft tissue origin sarcomas;

identification of the source of lower abdominal pain in pregnant

women, including appendicitis and ovarian and uterine masses;

assessment of fetal and placental abnormalities;

injury or trauma in the pelvic area;

abnormal X-ray results;

unexplained difficulties urinating or defecating;

infertility;

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irregular vaginal bleeding

Contraindications

Contraindications for pelvic MRI are:

any electrically, magnetically or mechanically activated implant (e.g.

cardiac pacemaker, insulin pomp biostimulator, neurostimulator,

cochlear implant…);

intracranial aneurism clips (unless made of titanium);

pregnancy (risk vs benefit ratio to be assessed);

ferromagnetic surgical clips or staples;

metallic foreign body inside;

metal shrapnel or bullet.

Patient preparation

A satisfactory written consent form must be taken from the patient

before entering the scanner room

Ask the patient to remove all metal object including keys, coins, wallet,

any cards with magnetic strip, jewellery, hearing aid and hairpins

Ask the patient to undress and change into a hospital gown

Contrast injection risk and benefits must be explained to the patient

before the scan

Gadolinium should only be given to the patient if glomerular filtration

rate (GFR) is>30

An intravenous line must be placed with extension tubing extending out

of magnetic bore

Claustrophobic patients may be accompanied into the scanner room e.g.

by staff member or relative with proper safety screening

Offer earplug or headphones possibly with music for extra comfort

Explain the procedure to the patient and answer questions

Note down the weight of the patient

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Fasting for six hours prior to the examination diminishes bowel

peristalsis. At some institutions glucagon is given to decrease bowel motion. It

is also useful to empty the urinary bladder to eliminate deformation by an

enlarged bladder.

MRI machines are intended for certain areas of the body. They can be

closed or open type. Closed MRI’s have been around the longest and make

use of a capsule-like space to take high quality images.(Fig.109) Closed

machine are also known as 3 Tesla MRI. A MRI is measured in Tesla units,

which indicates the power of the electromagnet within the system. Some tests

may require a stronger signal to tell if there are issues occurring internally. A

closed MRI systems power varies from .35 to 1.5 Tesla, which offers a high

level of power.

Fig. 109. Closed MRI – Siemens MAGNETOM Trio 3.0T

As the name indicates an open MRI is an open system that doesn’t use

the tube like design. Instead of an enclosed capsule, the open MRI uses a

magnet top and bottom and is open on all four sides. An Open MRI offers .2

to .3 Tesla that scan between two large metal discs; it doesn’t enclose entire

body of the patient. Open machines are used to exclude an attack of

claustrophobia, while the patient lies in a tubular body with a width of 60 cm.

These decrease the risk of claustrophobia and panic attacks and allow patients

of all shapes and sizes to be able to make use of an MRI to accurately diagnose

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their problems. In some cases, it is the only alternative for patients. However,

because of the shape of the open MRI, it is unable to take images of certain

areas of the body and the images it does take are of lesser quality as the

strength of the open machines is less than that of a closed or wide bore MRI.

For this reason, an open MRI is not always an option. Certain scans must be

taken with a closed machine. (Fig.110).

Fig. 110. Open MRI – Siemens MAGNETOM C 0.35T

Thus, choosing the right system depends on patients quality-of-care

preferences, as explained below, and medical indications:

closed MRI systems are more powerful, but they don’t address patient

comfort and claustrophobia concerns.

low field open MRI systems are less powerful, but they do address

patient comfort and claustrophobia concerns.

Technique. MRI examinations may be performed on outpatients or

inpatients. The examination is preferably carried out from 6 to 14 day cycle.

For an MRI test, the patient is placed in a horizontal position on a movable

table in a special chamber of the imager that integrates several magnetic coils

of the apparatus. Through the latest and scans the required area. Patient on a

movable table will enter into the magnet of the MRI unit and the radiologist

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and technologist will perform the examination while working at a computer

outside of the room. Images will be obtained while patient contracting or

squeezing the pelvic muscles and while the pelvic muscles are relaxed. Patient

may also be asked to bear down or forcibly exhale while keeping your mouth

and nose closed. The entire exam is usually completed within 15 -30 minutes.

Pictures from an MRI scan are digital images that can be saved and stored on

a computer for more study. The images also can be reviewed remotely, such

as in a clinic or an operating room. In some cases, contrast material may be

used during the MRI scan to show certain structures more clearly. Some

patients are assigned an MRI of the pelvis with contrast. The study represents

the intravenous administration of a special extracellular low molecular weight

substances based on the chemical element gadolinium — OmniScan,

Magnevist. These drugs have strong paramagnetic properties, absorption and

emission of electromagnetic waves in the radio frequency range. They rarely

cause allergic reactions and do not lead to anaphylaxis, in contrast to the

iodine radiopaque drugs. After the introduction into the blood under the

influence of the electromagnetic field contrast solution that accumulates and

is distributed in the tissues of the area to which this field is directed, which

gives the opportunity to obtain much more information.

Complications

Complications of MRI scans are very rare. The most frequents risks are:

The strong, static magnetic field will attract magnetic objects (from

small items such as keys and cell phones, to large, heavy items such as

oxygen tanks and floor buffers) and may cause damage to the scanner or

injury to the patient or medical professionals. Careful screening of

people and objects entering the MR environment is critical to ensure

nothing enters the magnet area that may become a projectile.

The magnetic fields that change with time create loud knocking noises

which may harm hearing if adequate ear protection is not used. They

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may also cause peripheral muscle or nerve stimulation that may feel like

a twitching sensation.

The radiofrequency energy used during the MRI scan could lead to

heating of the body. The potential for heating is greater during long

MRI examinations.

The use of gadolinium-based contrast agents (GBCAs) risk of allergic

reactions to the contrast agent.

Some patients may experience claustrophobia. Imaging in an open MRI

scanner may be an option for some patients, practitioner should be able

to prescribe medication to make the experience easier for patient.

To produce good quality images, patients must generally remain very

still throughout the entire MRI procedure. Infants, small children, and

other patients who are unable to lay still may need to be sedated or

anesthetized for the procedure. Sedation and anesthesia carry risks not

specific to the MRI procedure, such as slowed or difficult breathing, and

low blood pressure.

The MR environment presents unique safety hazards for patients with

implants, external devices and accessory medical devices. Examples of

implanted devices include artificial joints, stents, cochlear implants,

and pacemakers. An external device is a device that may touch the

patient like an external insulin pump, a leg brace, or a wound dressing.

An accessory device is a non-implanted medical device (such as a

ventilator, patient monitor) that is used to monitor or support the

patient. The strong, static magnetic field of the MRI scanner will pull on

magnetic materials and may cause unwanted movement of the medical

device; heating of devise may lead to burns, may cause electrically active

medical devices to malfunction and failure of the device function.

The presence of the medical device will degrade the quality of the MR

image, which may lead to an inaccurate clinical diagnosis, resulting in

inappropriate medical treatment.

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Therefore patients with implanted medical devices should not receive

an MRI exam unless the implanted medical device has been positively

identified as MR Safe or MR Conditional. An MR Safe device is

nonmagnetic, contains no metal, does not conduct electricity and poses

no known hazards in all MR environments. An MR Conditional device

may be used safely only within an MR environment that matches its

conditions of safe use. Any device with an unknown MRI safety status

should be assumed to be MR Unsafe.

Thus, the majority of complications include: heating and/or burns

(thermal injuries), injuries from projectile events (objects being drawn toward

the MRI scanner), crushed and pinched fingers from the patient table, patient

falls, and hearing loss or a ringing in the ear (tinnitus). The correct technique

allows avoiding these complications

Interpretation of a pelvic - MRI results

Leiomyoma - a common gynecologic pathology. Leiomyomas tend to

be of low signal intensity regardless of the pulse sequence used. They are

usually surrounded by a smooth capsule of low signal intensity. When

compared with ultrasonography or hysterosalpingography, MRI is more

accurate in detecting the presence, size, number, and location of leiomyomas.

In patients with menorrhagia or infertility secondary to submucosal

leiomyomas, MRI may be useful in optimizing patient management. In

patients undergoing myomectomies to restore fertility, MRI before the

procedure may help in planning the extent of surgery (Fig. 111).

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Fig. 111. A. Leiomyoma. The sagittal (T1) image of a woman with a pelvic

mass. On both clinical examination and US, distinction between an ovarian

and uterine mass could not be made. B. Axial image (T2) shows the

leiomyoma ( m) to have decreased signal intensity when compared with the

uterus ( u ).

Adenomyosis is a relatively common disease, occurring in about 15-25%

of women in the premenopausal period. This leads to progressive severe and

longer menstrual periods and is often associated with severe dysmenorrhea.

The diagnosis is usually done after a hysterectomy of pathological specimens.

MRI is used to evaluate this disease. When visualizing the uterus with

adenomyosis increases and has smooth external configurations. Diffuse

adenomyosis distorts the normal zonal anatomy of the uterus, causing

enlargement of the junctional zone. Old hemorrhagic regions a few

millimeters in diameter are often considered as high-intensity spots both on

T1 and T2-weighted images. Unlike leiomyomas that have well-defined edges,

adenomyosis has irregular and fuzzy edges due to its more invasive nature.

Since adenomyosis is often treated with a hysterectomy, but myomectomy

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may be sufficient for some leiomyomas, such visualization can be a very

useful clinical tool for preoperative evaluation and surgical planning.(Fig. 112,

Fig 113).

Fig.112. Sagittal MRI of the uterus of the patient with focal uterine

adenomyosis showing focal thickening of the junctional zone along the

posterior wall (arrow), heterogeneity of the myometrium and small cervical

cysts.

Fig. 113. A. Adenomyosis. Sagittal T2-weighted image of adenomyosis (a)

seen as an irregular, hypointense, enlarged junctional zone with indistinct

margins infiltrating into the myometrium (arrowheads ). B. Transverse

T2-weighted image of the same patient showing adenomyosis (a).

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Endometrium. MRI is particularly useful for assessing the

endometrium, which can easily be identified and distinguished from the

myometrium. The endometrial tissue is approximately isointense with

myometrium onT1-weighted images but appears higher in signal intensity

relative to myometrium on T2-weighted images. The thickness of the

endometrium in a normal menstruating female varies depending on the phase

of the menstrual cycle, being thinner in the follicular phase and thicker in the

secretory phase. Among patients who use oral contraceptives, the endometrial

width is significantly smaller in both the follicular and secretory phases.

Additionally, the junctional zone is also smaller in both phases of the

menstrual cycle. Myometrial thickness tends to remain the same regardless of

the phase of the menstrual cycle and the use of oral contraceptives. Such

differentiation allows better assessment of the endometrium and may be

particularly useful when Asherman's syndrome is suspected. The normal

endometrial width varies between individuals, ranging from 1 to 8 mm,

whereas the myometrial width varies from 1.5 to 2.5 cm. During the normal

follicular phase, endometrial width can grow from 1 to 3 mm. MRI is able to

define depth of myometrial invasion, tumor site, and cervical involvement in

patients with endometrial cancer. Invasion of the myometrium is

demonstrated by distortion of the junctional zone (Fig. 114). In patients with

deep myometrial invasion, this low-intensity band is absent. MRI allows

preoperative evaluation of the degree of invasion before a postoperative

pathology assessment. Although MRI cannot diagnose endometrial cancer in

situ (confined to endometrium), it is 92% accurate in the overall staging of

endometrial carcinoma.

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Fig.114. A. Endometrial carcinoma. Slightly T2-weighted sagittal image in a

patient with endometrial carcinoma (e). Normal zonal anatomy has been

disrupted. The central region of high signal intensity represents endometrial

carcinoma that has invaded through the junctional zone and extends deeply

into the myometrium. Only a small rim of normal myometrium remains

(arrow). B. A more T2-weighted image than in A, showing similar findings.

Ovary. Several types of ovarian lesions are particularly well evaluated

by MRI; these include hemorrhagic cysts, endometrial cysts, benign

teratomas, and simple follicular cysts. (Fig.114). MRI can readily identify

hemorrhage because of relaxation differences (difference of transferring of

energy) between methemoglobin, fresh hemoglobin, and hemosiderin.

However, depending on the biochemical state and age of the blood, the signal

may be bright or dark on either T1- or T2-weighted images. Endometrial cysts

tend to have more adhesions on the external surface and may lack a distinct

margin from the uterine body.They may also demonstrate multiple

loculations within the cyst. These loculations tend to have high-intensity

signals on T1- and T2-weighted images, in contrast to water, which has high

signal intensity on T2- and low signal intensity on T1-weighted images. In the

fibrous tissue surrounding the cyst, a low-intensity area is occasionally

identified surrounding areas of acute and chronic bleeding and is thought to

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represent the presence of hemosiderin-laden macrophages at the hematoma

margin. One other feature that is characteristic of endometrial cysts is

shading within loculi. It is thought to be due to the presence of

deoxyhemoglobin in unlysed red blood cells or a higher concentration of

paramagnetic (signal-enhancing) methemoglobin within those regions. The

presence of any or all of these features should strongly suggest an endometrial

cyst (Fig. 116). Because of the large fat content within these tumors, ovarian

cystic teratomas produce signal intensities very similar to that of adjacent fat

on both T1- and T2-weighted images (Fig. 117).

F

Fig.115.A. Hemorrhagic cyst. Longitudinal view of the pelvis on US showing a

large fluid-filled mass in the pelvis. B. Sagittal T1-weighted image showing a

mass with high signal intensity superior to the bladder (c). C. T2-weighted

sagittal image showing the cyst to have persistently high signal intensity.

Findings are consistent with a hemorrhagic cyst subsequently confirmed at

surgery.

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Fig. 116. Endometrioma. Transverse T1-weighted image showing a left

adnexal mass with areas of both increased and decreased signal

(arrow). B. T2-weighted image showing change in signal intensities within

the cyst consistent with different stages of blood. Findings are consistent with

the final diagnosis of an endometrioma.

Fig. 117. A. Dermoid. T1-weighted transverse image showing a left adnexal

cyst of high signal intensity (arrow). B. With increased T2 weighting, the cyst

shows persistently high signal intensity. Findings are consistent with the

diagnosis of a dermoid.

Solid ovarian benign and malignant tumors tend to have variable T1 and

T2 values and tend to have lower signal intensities overall. Improving the

image with gadolinium gives higher accuracy. The size of the lesion, the

presence of solid components and septations, the presence of a thickened cyst

wall and extravariant interference are determined.(Fig.118).

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Fig.118. A. Simple ovarian cyst. T1-weighted image showing a right adnexal

soft-tissue density of low signal intensity (arrow). B. With increased T2

weighting, the abnormality shows high signal intensity. The thin wall and the

appearance on both T1- and T2-weighted images are consistent with the final

diagnosis of a simple ovarian cyst.

Fallopian tubes. A fallopian tube MRI scan is done to check for certain

cancers or other illness. Primary fallopian tube carcinoma (PFTC) is an

extremely rare malignancy that arises from the fallopian tube. Typical

symptoms, together with the presence of some of the most characteristic MRI

signs, such as a “sausage-shaped” pelvic mass, hydrosalpinx, and hydrometra,

may signal the presence of primary fallopian cancer, and allow the radiologist

to report it as a differential diagnosis.(Fig.119).

Fig.119. Serous PFTC in a 63-year-old female, presenting with pelvic pain. c -

Coronal MRI, with the “sausage”-shaped mass (asterisk) folded upon itself, as

depicted by the portions of wall visible inside the mass (red arrow), which

approximates the “spoke-wheel” sign, usually better depicted when the mass

is predominantly cystic. Once again, the “synechiae” sign can be observed

(red arrowhead).

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Cervix. A normal cervix has two distinguishable zones on MRI. The

stroma is of low signal intensity on T2-weighted images, whereas the

endocervical canal is represented by high signal intensity. The multiplanar

capabilities of MRI allow excellent visualization of the cervix and the

surrounding tissue, which is sometimes difficult on CT or ultrasonographic

examination. Cervical cancer has an overall poor survival in the presence of

advanced invasive disease. Clinical staging has emphasized differentiation

between Stages IB, IIA, and IIB. The distinction is important, because

carcinomas staged less than or equal to IIA (i.e., disease without parametrial

involvement) are usually treated with surgery, whereas carcinomas of Stage

IIB or greater (i.e., disease with parametrial involvement) are usually treated

with radiotherapy. Clinical staging of cervical cancer is currently performed

by physical examination, chest radiography, cystoscopy, intravenous

pyelography, and sigmoidoscopy. CT, the traditional method of radiologic

staging, is limited by an inability to image in multiple planes and by poor soft-

tissue delineation. MRI can detect cervical cancer, which has increased signal

intensity on T2-weighted images in contrast to surrounding tissues; therefore,

it is an important tool for clinical staging (Fig. 120).

Fig.120. A. Cervical carcinoma. Sagittal T1-weighted image showing

prominence in the region of the cervix. Distinction between the vagina, cervix,

and a soft-tissue mass is difficult ( arrows ). B.Sagittal T2-weighted image in

the same location. The cervical carcinoma can now be seen extending toward

the fundus as well as into the vaginal vault ( arrows ).

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Breast. For a breast MRI, the woman usually lies face down, with her

breasts positioned through openings in the table. In order to check breast

positioning, the technologist watches the MRI through a window while

monitoring for any potential movement.

A breast MRI usually requires the use of contrast that is injected into a vein in

the arm before or during the procedure. For premenopausal women, the best

timing for breast MRI is day 7-15 of the menstrual cycle. There is no

recommended timing for breast MRI for women after menopause. The dye

may help create clearer images that outline abnormalities more easily.

(Fig.121).

Fig.121. Breast MRI

MRI can locate some small breast lesions sometimes missed by

mammography. It can also help detect breast cancer in women with breast

implants and in younger women who tend to have dense breast tissue.

Mammography may not be as effective in these cases. Since MRIs do not use

radiation, they may be used to screen women younger than 40 and to increase

the number of screenings per year for women at high risk for breast cancer.

Some common uses for breast MRI include:

Further evaluation of abnormalities detected by mammography

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Finding early breast cancers not detected by other tests, especially in

women at high risk and women with dense breast tissue

Examination for cancer in women who have implants or scar tissue that

might produce an inaccurate result from a mammogram. This test can

also be helpful for women with lumpectomy scars to check for any

changes.

Detecting small abnormalities not seen with mammography or

ultrasound (for example, MRI has been useful for women who have

breast cancer cells present in an underarm lymph node, but do not have

a lump that can be felt or can be viewed on diagnostic studies)

Assess for leakage from a silicone gel implant

Evaluate the size and precise location of breast cancer lesions, including

the possibility that more than one area of the breast may be involved

(this is helpful for cancers that spread and involve more than one area)

Determining whether lumpectomy or mastectomy would be more

effective

Detecting changes in the other breast that has not been newly diagnosed

with breast cancer (There is an approximately 10 percent chance that

women with breast cancer will develop cancer in the opposite breast. A

recent study indicates that breast MRI can detect cancer in the opposite

breast that may be missed at the time of the first breast cancer

diagnosis.)

Detection of the spread of breast cancer into the chest wall, which may

change treatment options

One should describe morphology of a mass: round, oval lobulated or

irregular shape of a mass in a breast tissue. Margins can be described as

smooth, irregular, or speculated. Spiculated margins are frequently a

feature of malignant breast lesions and radial scars. If a mass has

spiculated margins, it has an 80% chance of being malignant. The pre-

contrast T1 sequence can show the presence of fat in a lesion. Breast

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lesions containing fat are benign unless they are rapidly growing. Rapidly

growing lesions should be biopsied.(Fig.122, Fig.123). Very small and deep

lesions, found on breast MRI, also require an MRI guided biopsy.

Fig.122. Fibroadenoma (left) and a colloid carcinoma (right

Fig. 123. The image on the far left shows an irregularly shaped mass

with irregular margins, this was an invasive ductal carcinoma. The image

on the right shows a similarly irregularly shaped and irregularly

emarginated lesion, this time an adenoid cystic carcinoma.

Mammography

A mammogram is an x-ray picture of the breast. An x-ray (radiograph) is a

noninvasive medical test that helps physicians diagnose and treat medical

conditions. Imaging with x-rays involves exposing a part of the body to a

small dose of ionizing radiation to produce pictures of the inside of the body.

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X-rays are the oldest and most frequently used form of medical imaging.

(Fig.124)

Fig.124. Mammography

Mammography is specialized medical imaging that uses a low-dose x-

ray system to see inside the breasts. A mammography exam, called a

mammogram, aids in the early detection and diagnosis of breast diseases in

women.

There are 3 recent advances in mammography, widely used in current

clinical practice, they are:

digital mammography,

computer-aided detection

breast tomosynthesis.

Digital mammography, also called full-field digital mammography

(FFDM), is a mammography system in which the x-ray film is replaced by

electronics that convert x-rays into mammographic pictures of the breast.

These systems are similar to those found in digital cameras and their

efficiency enables better pictures with a lower radiation dose. These images of

the breast are transferred to a computer for review by the radiologist and for

long term storage. stores the image directly on film. (Fig.125). Digital

mammography is an electronic image stored as a computer file. The digital

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image can be enhanced, magnified and or manipulated for further evaluation

much more easily than the film counterpart.

Computer-aided detection (CAD) systems search digitized

mammographic images for abnormal areas of density, mass,

or calcification that may indicate the presence of cancer. The CAD system

highlights these areas on the images, alerting the radiologist to carefully

assess this area.

Breast tomosynthesis, also called three-dimensional (3-D)

mammography and digital breast tomosynthesis (DBT), is an advanced form

of breast imaging where multiple images of the breast from different angles

are captured and reconstructed ("synthesized") into a three-dimensional

image set. In this way, 3-D breast imaging is similar to computed tomography

(CT) imaging in which a series of thin "slices" are assembled together to

create a 3-D reconstruction of the body. Although the radiation dose for some

breast tomosynthesis systems is slightly higher than the dosage used in

standard mammography, it remains within the safe levels for radiation from

mammograms.

A mammogram allows the doctor to have a closer look for changes in

breast tissue that cannot be felt during a breast exam. Women ages 50 to 74

years should get a mammogram every 2 years. Women younger than age 50

should talk to a doctor about when to start and how often to have a

mammogram.

Different types of mammograms are distinguished:

Screening mammograms are done for women who have no

symptoms of breast cancer. Usually it includes two x-rays of each

breast. Screening mammograms can detect lumps or tumors that are

not felt in palpation. They can also find microcalcification or tiny

calcium deposits in the chest, which sometimes means that breast

cancer is present. Current recommendations in most countries

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recommend screening mammography for women starting at age 40.

Regular mammograms (once a year or once every two years) lead to

early detection of breast cancer, when they are the most curable and

contribute to breast preservation.

Diagnostic mammography is used to evaluate a patient with

abnormal clinical findings—such as a breast lump or nipple discharge—

that have been found by the woman or practitioner. Diagnostic

mammography may also be done after an abnormal screening

mammogram in order to evaluate the area of concern on the screening

exam. This type of mammogram also can be used to find out more

about breast changes found on a screening mammogram, or to view

breast tissue that is hard to see on a screening mammogram. A

diagnostic mammogram takes longer than a screening mammogram

because it involves more x-rays in order to obtain views of the breast

from several angles. The technician can magnify a problem area to make

a more detailed picture, which helps the doctor make a correct

diagnosis. (Fig.126, 127,128. 129)

A. B.

Fig. 125. A – Digital mammogram. B – Conventional mammograpgy (film)

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Fig. 126. Normal mammogram.

Fig.127. Fibroadenoma

Fig.128.Bilateral cysts associated to duct ectasia, no prior history of

breast disorders

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Fig.129. Breast cancer

It is proved that screening with breast mammography results in improved

breast cancer detection rates. Finding breast cancer as early as possible before

it has grown or spread greatly improves a woman’s chance for a successful

treatment.

Invasive methods of examination

Sounding of the uterus

Sounding of the uterus (uterine probing). It is employed to measure the

length and determine the shape of the uterine cavity, relief of the walls and

the length and patency of the cervical canal. A metallic uterine sound is used

for this purpose. (Fig. 130). Uterine sounding is contraindicated in patients

with purulent vaginal discharge (grade III and IV colonization), signs of acute

or subacute uterine and adnexal inflammation, and pregnancy. After exposing

the cervix it is cleaned with an antiseptic. A uterine sound is passed through

the cervix to check the direction and length of the uterus.

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(A) B. C.

Fig. 130. Utyerine probing: A - Uterine probe; B - Uterine probing; C –

Measuring of the uterine depth

Culdocentesis

Culdocentesis is the transvaginal puncture of posterior vaginal fornix and

aspiration of peritoneal fluid from the Douglas pouch (aka as cul-de-suc).

Indications:

suspected interrupted ectopic pregnancy or other causes producing

haemoperitoneum,

suspected pelvic abscess.

Technique. The procedure is done under sedation. The patient is put in

lithotomy position. Vagina is purified by betadine or another drug to comply

with asepsis rules. Using the vaginal speculum, the posterior vaginal fornix is

exposed. A needle (18 gauge), equipped with a syringe, is inserted at a point 1

cm below the cervicovaginal junction in the posterior fornix. After inserting

the needle to a depth of about 2 cm, the content of a Douglas pouch is sucked

(Fig. 131). If unclotted blood is obtained, the diagnosis of intraperitoneal

bleeding is established. If purulent content is obtained, the diagnosis of pelvic

inflammatory diseases is established. In case of rupture of a follicular cyst, the

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follicular fluid would be obtained. The diagnosis is confirmed with the help of

microscopic and biochemical exam of obtained fluid.

Fig. 131. Culdocentesis: check for abnormal fluid in the abdominal cavity

behind the uterus corpus.

Histological investigations

Cervical biopsy

Cervical biopsy: A cervical biopsy is the removal of tissue from the

cervix, the lower third of the uterus to be analyzed for cellular abnormalities,

precancerous conditions, or cervical cancer. In a biopsy, the healthcare

provider removes a small amount of tissue for examination under a

microscope to look for precancerous cells or cancer cells. Most women have

the biopsy outpatient office, and no anesthesia is needed. A cervical biopsy is

performed to evaluate abnormal cervical tissue found during a Pap test or

colposcopy.

Colposcopic biopsy: A biopsy can be done during a colposcopyWhen an

extended colposcopy is performed after applying 3% acetic acid solution or

2% Lugol solution, the health care provider removes a tiny part of the

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acetochite or dark brown tissue from the cervical surface at the border

between the normal and colored (abnormal) part with special tweezers. The

deleted site is then subjected to a histological examination.

Types of cervical biopsy:

Punch biopsy: A surgical procedure to remove a small piece of tissue

from the cervix. One or more punch biopsies may be performed on

different areas of the cervix. This procedure uses a circular blade, like a

paper hole puncher, to remove a tissue sample. One or more punch

biopsies may be done on different areas of the cervix.(Fig. 132).

Cone biopsy or Conization: A surgical procedure that uses a laser or

scalpel to remove a large cone-shaped piece of tissue from the

cervix. This procedure uses a laser or scalpel to remove a large cone-

shaped piece of tissue from the cervix.(Fig. 132). A loop electrosurgical

excision procedure (LEEP) is advanced modification of a knife (cone)

biopsy, it uses an electrical current passed through a thin wire hook.

The hook removes tissue for examination in the laboratory. A LEEP may

also be used to remove a precancer or an early-stage cancer.(Fig. 133)

Endocervical curettage (ECC). This procedure uses a narrow

instrument called a curette to scrape the lining of the endocervical

canal. This is an area that can’t be seen from the outside of the cervix.

During the procedure the mucous membrane of the cervical canal is

scraped using a spoon-shaped instrument (a curette). The procedure

may be done both in out-patient office and in-patient department. May

be done without anesthesia. Can be done without anesthesia. After the

procedure, there may be some cramping and bleeding. A scrap of the

cervical mucosa is subjected to a histological examination to determine

the presence of abnormal cells.

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Fig. 132. Types of cervical biopsies.

Fig. 133. A loop electrosurgical excision procedure (LEEP)

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Endometrial biopsy

The endometrial biopsy is a medical procedure that involves taking a

tissue sample of the lining of the uterus. The tissue subsequently undergoes

histologic evaluation which aids the physician in forming a diagnosis

Indications for endometrial biopsy include:

abnormal uterine bleeding: postmenopausal bleeding,

malignancy/hyperplasia, ovulation/anovulation;

evaluation of patient with one year of presumed menopausal

amenorrhea;.

assessment of enlarged uterus (both US and HCG do not detect

pregnancy);

evaluation of infertility;

abnormal Pap smear with atypical cells;

Follow-up of previously diagnosed endometrial hyperplasia

cancer screening (e.g., hereditary nonpolyposis colorectal cancer)

inappropriately thick endometrial stripe found on US;

detection of precancerous hyperplasia and atypia;

etc…

Contraindications for endometrial biopsy include:

pregnancy;

acute pelvic inflammatory disease;

clotting disorders (coagulopathy);

acute cervical or vaginal infections;

cervical cancer;

conditions possibly prohibiting endometrial biopsy;

morbid obesity;

severe pelvic relaxation with uterine prolapse;

severe cervical stenosis.

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Endometrial biopsy is a blind procedure and should be considered part

of the evaluation that could include imaging studies, such as hysteroscopy or

transvaginal ultrasonography.

Types of endometrial biopsy:

diagnostic dilatation and curettage (D&C) of the cervical and uterine

mucosal membranes,

suction biopsy of endometrium (non-invasive diagnostic procedure)

Diagnostic dilatation and curettage (D&C) of the cervical and uterine

mucosa membranes (separate D&C of the cervical and uterine mucosa). This

is necessary to diagnose ovulation in case of sterility or to determine the type

of endometrium in dysfunctional bleeding.

Technique.

1. The patient is placed in the lithotomy position and bimanual

examination is performed (with nonsterile gloves) to determine the

uterine size and position, and whether marked uterocervical angulation

exists. Then the speculum should be inserted in to the vagina . Once the

cervix is centered in the speculum, the cervix can be anesthetized by

spraying 20 percent benzocaine spray for 5 seconds and then cleansing

it with povidone-iodine solution.

2. The tenaculum is placed on the anterior lip of the cervix, grabbing

enough tissue that the cervix will not lacerate when traction is applied.

The cervix is gently probed with the uterine sound.

3. If the uterine sound will not pass through the internal os, consider

placement of small Pratt uterine dilators. The smallest size is inserted,

followed by insertion of successively larger dilators until the sound

passes easily to the fundus. The distance from the fundus to the external

cervical os can be measured by the gradations on the uterine sound and

generally will be 6 to 8 cm. (Fig. 134)

4. The biopsy curette will be inserted into the uterine fundus and with a

scraping and rotating motion some tissue will be removed. The removed

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tissue will be placed in formalin or equivalent for preservation. The

tissue will be sent to a laboratory, where it will be processed and tested.

It will then be read microscopically by a pathologist who will provide a

histologic diagnosis.

5. The uterine cavity should be treated with an antiseptic solution for the

prevention of inflammation. If necessary, the contractile agent should

be used to minimize bleeding.

Fig. 134. Dilatation and curettage of the cervical and uterus mucosa

membrane

Suction biopsy of endometrium is an office procedure that serves as a

helpful tool in diagnosing various uterine abnormalities. The technique is

fairly easy to learn and may be performed without assistance. The biopsy is

obtained through the use of an endometrial suction catheter that is inserted

through the cervix into the uterine cavity. Twirling the catheter while moving

it in and out of the uterine cavity enhances uptake of uterine tissue, which is

aspirated into the catheter and removed. Postoperative infection is rare but

may be further prevented through the use of prophylactic antibiotic therapy.

Intraoperative and postoperative cramping are frequent side effects.

Endometrial biopsy is a safe and accepted method for the evaluation of

abnormal or postmenopausal bleeding. The procedure is often performed to

exclude the presence of endometrial cancer or its precursors (Tables 1 and 2).

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Office endometrial suction catheters are easy to use, and several have been

reported to have diagnostic accuracy that is equal or superior to the dilatation

and curettage (D&C) procedure. Suction is generated by withdrawing an

internal piston from within the catheter, and the tissue sample is obtained by

twirling the catheter while moving it up and down within the uterine cavity.

Technique.

1. The patient is placed in the lithotomy position and bimanual

examination is performed (with nonsterile gloves) to determine the uterine

size and position, and whether marked uterocervical angulation exists. Then

the speculum should be inserted in to the vagina . Once the cervix is centered

in the speculum, the cervix can be anesthetized by spraying 20 percent

benzocaine spray for 5 seconds and then cleansing it with povidone-iodine

solution.

2. The tenaculum is placed on the anterior lip of the cervix, grabbing

enough tissue that the cervix will not lacerate when traction is applied.The

cervix is gently probed with the uterine sound.

3. The endometrial biopsy catheter tip is inserted into the cervix,

avoiding contamination from the nearby tissues. The catheter tip is then

inserted into the uterine fundus or until resistance is felt. Once the catheter is

in the uterine cavity, the internal piston on the catheter is fully withdrawn,

creating suction at the catheter tip. The catheter tip is moved with an in-and-

out motion, but the tip does not exit the endometrial cavity through the

cervix, which maintains the vacuum effect. Use a 360-degree twisting motion

to move the catheter between the uterine fundus and the internal cervical os

(Fig. 134). Make at least four up and down excursions to ensure that adequate

tissue is in the catheter.

5. Once the catheter fills with tissue, it is withdrawn, and the sample

is placed in the formalin container. To remove the sample from the

endometrial catheter, the piston can be gently reinserted, forcing the tissue

out of the catheter tip. Some physicians prefer to make a second pass into the

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uterus with the catheter to optimize tissue sampling. If a second pass is to be

made, the catheter should not be contaminated when being emptied of the

first specimen.

6. The tenaculum is gently removed. Pressure can be applied with

cotton swabs if the tenaculum sites bleed following removal of the tenaculum.

Excess blood and povidone-iodine solution are wiped from the vagina, and

the vaginal speculum is removed.

Fig.134. Suction biopsy. The catheter tip is inserted into the uterus

fundus or until resistance is felt. (B) Once the catheter is in the uterus cavity,

the internal piston is fully withdrawn. (C) A 360-degree twisting motion is

used as the catheter is moved between the uterus fundus and the internal os.

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Pipelle biopsy. It is an advanced type of aspiration biopsy of

endometrium.

In the course of this procedure, a flexible small tube is introduced, the

diameter of which is about 3 mm. The inner part of the tube is equipped with

a piston as on a syringe. When the tube is inserted into the uterine cavity a

small number of endometrial cells is taken. According to the patients' reviews

such manipulation does not cause painful sensations. Features of the

procedure When a pin is inserted into the uterus, the doctor pulls the piston

in the tubule by half. This creates a negative pressure with simultaneous

absorption of endometrial tissue. The procedure lasts only 30 seconds, which

makes it easier to conduct.(Fig. 135). Also, the patient cannot be afraid of

infections, because the pipe is a one-time tool. If suspicions of carcinoma

occur, the analysis can be carried out at any time. In other cases, precision is

needed for what the pipette of the endometrial biopsy shows:

with bleeding: an analysis on the first day of the onset of bleeding;

with global bleeding: analysis for 5-10 days themselves monthly;

infertility: analysis at the beginning of the menstrual period or the day

before the onset;

no pregnancy in the absence of menstruation: biopsy once a week;

establishing the exact day of the cycle itself: between 18 and 24 in the

afternoon.

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Fig.135. Pipelle biopsy

Other diagnostic procedures.

Hydrotubation.

To assess the patency and functional capacity of the uterine tubes

(oviducts, fallopian tubes) air (perturbation) or fluid (hydrotubation) may be

administered into the tubes.

To perform perturbation or hydrotubation special devices are imployed,

which consists of a tip connected through a system of tubes with an air

balloon (or a device for fluid administration) and a pressure gauge.

Both procedures are performed under aseptic and antiseptic conditions.

Both show permeability of tubes and may be used for diagnosis of

infertility (evaluation of tubal factor).

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Self test

1. Which of the following is not a special gynecological

examination?

A. speculum examination

B. vaginal examination

C. rectal or rectovaginal examination

D. palpation of lower abdomen

2. Which examination is the best to reveal the cause of infection?

A. microscopic examination of vaginal smears

B. bacteriological examination of smears

C. examination of the clinical signs of infection

D. patient complaints

3. Cusco’s specula are

A. bivalved specula

B. spoon-shaped specula

C. tubular specula

D. univalve specula

4. Cytological examination is used for

A. early detection of uterine and oviduct cancer

B. determination of causative agents of inflammation in female

genitalia

C. determination of organic disorders of female genital organs

D. determination of congenital abnormalities of female genitalia

5. Diagnostic dilatation and curettage of the cervical and uterine

mucous membranes should be used to diagnose

A. the histological abnormalities of the mucosa

B. the placement of the uterus in abdominal cavity

C. congenital abnormalities of internal genital organs

D. the pregnancy

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6. The basal body temperature is measured

A. in the morning before getting up

B. in the evening before sleeping

C. in the daytime before eating

D. three times a day before eating

7. The Schiller’s test is negative if

A. the entire cervix and vagina take up the stain

B. the certain areas or islands remain unstained

C. the entire cervix and vagina remain unstained

D. the uterine mucosa remain unstained

8. The positive Schiller’s test means

A. the abnormal areas may be the seat of carcinoma-in-situ or

dysplasia

B. the abnormal areas have the inflammation

C. the abnormal areas have scars

D. the abnormal area is congenitally malformed

9. Histologic examination involve all enumerated below, except of

A. uterine probing

B. diagnostic dilation and curettage of the uterus cavity

C. suction biopsy

D. cone biopsy

10. Type III of vaginal cytology means

A. pronounced estrogen deficiency

B. moderate estrogen deficiency

C. sufficient estrogen saturation

D. absence of estrogenic hormones

D. absence of estrogenic hormones

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Chapter 3. CONGENITAL ANOMALIES AND

DISPLACEMENTS OF THE FEMALE GENITALIA

Congenital anomalies of female genital organs

Congenital anomalies of female genital organs occur in 1,0–2,7 % of

gynecologic patients. They associate with various disturbances of

reproductive system (disturbances of menstrual function, sterility,

spontaneous abortions, premature delivery). More frequently they may be

due to failure of fusion of Mullerian ducts. The Müllerian ducts are the

primordial anlage of the female reproductive tract. They differentiate to form

the fallopian tubes, uterus, the uterine cervix, and the superior aspect of the

vagina. A wide variety of malformations can occur when this system is

disrupted. The most important kinds of such anomalies are: atresia, aplasia

and hypoplasia of organs. Most Müllerian duct anomalies (MDAs) are

associated with functioning ovaries and age-appropriate external genitalia.

These abnormalities are often recognized after the onset of puberty. In the

prepubertal period, normal external genitalia and age-appropriate

developmental milestones often mask abnormalities of the internal

reproductive organs. After the onset of puberty, young women often present

to the gynecologist with menstrual disorders. Late presentations include

infertility and obstetric complications.

Atresia of the Hymen

It is the most common form of genital atresia. Imperforate hymen may

be diagnosed with prenatal ultrasound documentation of bladder outlet

obstruction due to hydrocolpos or mucocolpos. However, in spite of the

recommendations for inspection of the external genitalia during the neonatal

and early childhood period, variations in hymenal anatomy commonly escape

diagnosis until the time of menarche. An imperforated hymen usually escapes

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attention until puberty, when menstruation fails to appear, or is absent, and

the patient has periodic attacks of lower abdominal pain. With recurrent

menstrual cycles the blood collects in the vagina behind the hymenal

membrane and forms a hematocolpos. (Fig. 136) In a few progressive cases,

besides the hematocolpos the uterus (hematometra) or even the tubes

(hematosalpinx) may be involved.

A. B.

Fig. 136. A - imperforated hymen. B – Haematocolpos

Symptoms and diagnosis in infancy and childchood. Bulging, yellow-

gray mass at or beyond the introitus, the presence of an abdominal mass in

association with urinary obstruction may be find in carefull examinationof a

child. Before puberty careful examination with pressure applied to the

fourchette may reveal microperforations, sometimes with an anteriorly

displaced opening just beneath the urethra. Sometimes, a cribriform

(fenestrated), septate, or navicular configuration may take place in patient,

and this can be associated with retention of vaginal secretions (up ti

hematocolpos) and development of a mixed bacterial vulvovaginitis.

Symptoms and diagnosis in adolescence. Usually, shortly after the

breasts and pubic hair begin to grow, the first period occurs (menarche). In

patients with imperforated hymen with the onset of menarche (which may be

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suspected due to breast development and appearance of other signs of

puberty) menstruations are absent. Failure to menstruate beyond 6 months

from the telarche and pubacrhe, is statistically uncommon, and should be

investigated to determine a cause. Imperforate hymen is one uncommon, but

important, anatomic cause of primary amenorrhea. Thus the typical

presenting complaint is primary amenorrhea. If the unperforated hymen has

not been diagnosed before, after a few months of amenorrhea, there are

complaints of frequent urination and painful bloating, first cyclically for a

month, then the symptoms become more pronounced and permanent. The

most common scenario is that in which a young woman presents with

increasingly severe intermittent abdominal and pelvic pain due to a large

hematocolpos and hematometra. Examination shows excessive stretching of

the vagina, protrusion of the lower sections of the anterior abdominal wall,up

to appearance of abdominal mass, the uterus is elevated upwards. (Fig. 137).

When examining the vulva, a bluish, sometimes convex, hymenal membrane

is found. TAUS shows collection of fluid (the menstrual blood) in the uterine

cavity (hematometra), in vagina (hematocolpos).

Treatment. The use of nonsteroidal anti-inflammatory drugs can

provide pain relief; narcotic analgesics may be required. Surgical repair after

the onset of puberty but before menarche is optimal. Hymenotomy - a

surgical technique, used to correct such a defect. In asymptomatic patients,

waiting until puberty is generally recommended before deciding whether such

a technique is necessary. The hymenal changes that result from

estrogenization (increased elasticity and fimbriation) may reveal the hymen

to be open and obviate the need for surgery with the onset of pubertal period.

With estrogen stimulation, the hymen could be described as having the

appearance of an annular "scrunchie" (ie, a fabric-covered elastic hair tie). In

addition, surgical procedures to the vagina and hymen during childhood,

when endogenous estrogen levels are low, may result in scarring and the need

for subsequent surgical revision. Thus, surgery during this time should

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generally be avoided if possible. If the hymen is suspected to be imperforate

during childhood, re-examination should be performed after the onset of

estrogen production, as signaled by breast development. If required, surgery

can be performed at this time when healing is optimal and prior to the

accumulation of a hematocolpos.

Fig. 137. Abdominal mass with imperforated humen

The technique of hymenotomy. The objective of a hymenotomy

procedure is to open the hymenal membrane in such a way as to leave a

normally patent vaginal orifice that does not scar. Infiltration of the

membrane prior to the incision with a long-acting local anesthetic (eg, 0.25%

bupivacaine) provides preemptive analgesia. If a large hematocolpos is

present, it typically is under pressure, and the surgeon should be prepared to

dodge the pressure-driven stream of thickened old blood (typically the

consistency and color of chocolate syrup) and to evacuate the hematocolpos

and hematometra using one or more suction cannulae. The revision of the

initial incision in the hymenal membrane must await the evacuation of the

hematocolpos. The hymenal orifice is enlarged using a circular incision

following the lines of the normal annular hymenal configuration.

Alternatively, a cruciate incision along the diagonal diameters of the hymen,

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rather than anterior to posterior, avoids extension injury to the urethra and

can be enlarged by removal of excess hymenal tissue. In either approach,

hemostasis is required using interrupted stitches with fine absorbable suture

(eg, 4-0 polyglycolic acid suture). The technique of making a small central

incision with the placement of a Foley catheter, which is then left in place for

2 weeks, accompanied by the application of estrogen cream may also be used

as less invasive. This technique may require a repeat surgical procedure in a

small number of cases. The application of 2% lidocaine jelly to the vaginal

introitus is suggested to provide postoperative analgesia.

Atresia of the Vagina

Atresia of the vagina is congenital anomalies of the female genitourinary tract

and may occur as an isolated developmental defect (extremely rare) or as part

of a complex of anomalies (more common). Vagina may be absent, in whole

or in part, (in upper, middle and lower part and have any length) with absent

or rudimentary non-functional uterus and tubes. In these cases the ovaries

are present and function normally. Rarely the uterus and tubes may be

normal and give rise to a hematometra. If vagina is absent in whole it is called

aplsia of vagina.

More frequently, vaginal atresia associated with complex of anomalies, such

as:

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, also referred to

as Mayer-Rokitansky syndrome, or Rokitansky-Küster-Hauser

syndrome, or, simply, Rokitansky syndrome

Bardet-Biedl syndrome

Kaufman-McKusick syndrome

Fraser syndrome

Winters syndromeSym

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Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome consists of

vaginal aplasia with other müllerian (ie, paramesonephric) duct

abnormalities. This condition causes the vagina and uterus to be

underdeveloped or absent, although external genitalia are normal. Affected

women usually do not have menstrual periods due to the absent uterus.

Often, the first noticeable sign of MRKH syndrome is that menstruation does

not begin by age 16 (primary amenorrhea). Women with MRKH syndrome

have a female chromosome pattern (46,XX) and normally functioning

ovaries. They also have normal breast and pubic hair development. Although

women with this condition are usually unable to carry a pregnancy, they may

be able to have children through assisted reproduction.

McKusick-Kaufman syndrome is an autosomal recessive disorder, in

this case vaginal atresia is associated with hydrometrocolpos, postaxial

polydactyly, imperforate anus, and congenital heart defects; the patient has

secondary sexual characteristics

Bardet-Biedl syndrome is a genetically heterogeneous group of autosomal

recessive disorders; vaginal atresia in Bardet-Biedl syndrome is associated

with retinal dystrophy or retinitis pigmentosa (appears at age 10-20 years),

postaxial polydactyly, obesity, nephropathy, and mental disturbances.

Fraser syndrome consists of vaginal atresia associated with eye

anomalies.

Winter's syndrome is an ear anomaly in combination with vaginal

atresia.

Symptoms. Symptoms in adolescents may include abdominal pain,

difficulty voiding, and backache, the most of them are associated with

primary amenorrhea. Adults have complaints of sexual intercourse and

infertility. The diagnosis can also be determined before puberty as an

unexpected result in an ultrasound study that was caused by other complaints

or indications. If any of these symptoms are present, an evaluation for vaginal

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obstruction should be performed, in addition to assessment of the whole

reproductive system and renal system.

Diagnosis. Ultrasound examination, sounding of the vagina, and rectal

examination can help to determine the length of atresia. One can palpate an

elastic formation in front of the rectum during the rectal examination. In

cases with hematometra and hematosalpinx, there are some elastic

formations in small pelvis. In all cases complex anomalies should be

excluded.

Standard evaluation of primary amenorrhea includes an evaluation of

levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH),

prolactin, estradiol, and progesterone. A study of the total testosterone level is

a way to differentiate between Mayer-Rokitansky-Küster-Hauser (MRKH)

syndrome and androgen insensitivity. If the level is in the reference range for

males, high for females, it is consistent with androgen insensitivity.

Karyotyping should also be performed.

Assessment of kidney function is reasonable because of the association

of congenital anomalies of the genitals with anomalies of the urinary system.

Ultrasonography is the cornerstone of imaging in patients with

suspected vaginal atresia. Abdominal, pelvic and transperineal sonograms

represent the ovaries, uterus and proximal vagina. They allow an anatomical

evaluation of the urinary tract to identify abnormalities. MRI, three-

dimensional US may also be used in diagnosis and planning of the further

follow-up of the patient. Laparoscopy may be necessary to evaluate the uterus

and adnexal structures if they are not clearly identified on ultrasonography or

MRI.

Treatment. Treatment options for vaginal agenesis include creation of a

neovagina. If a functioning uterus is diagnosed early, reconstructive vaginal

surgery can give a good effect. In all cases of congenital atresia, surgery for

artificial vagina should be delayed till sexual activity. It is impossible to have

pregnancy if the uterus is poorly developed and vagina is absent.

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Anomalies of the Uterus

Anomalies of the uterus may be due to congenital defects with a failure

of the fusion of Mullerian ducts giving rise to uterus unicornis or absence of

urogenital system on the opposite side. Failure of the fusion in whole gives

rise to uterus didelfus (double uterus): two uteri, two cervices and two

vaginae. Other kinds of malformations: uterus unicornis with normal vagina;

uterus bicornis with two cervices and one normal vagina; uterus unicornis

with hypoplastic (or rudimentary) opposite horn and normal vagina; partition

of the uterus and vagina – uterus septus or uterus subseptus, when the

partition is only partial may rarely be.

In whole, uterine anomalies are categorized as follows (Fig. 138):

I. Hypoplasia/Agenesis

II. Unicornuate uterus – a banana shaped uterus with a single horn and

sometimes a rudimentary second horn. Bicornuate uterus is characterized by

a heart shape.

III. Uterus didelphys – a double uterus that may also be associated with a

double cervix and/or vagina.

IV. Uterus bicornuate - A uterus which has 2 horns

V. Septate uterus – a wall or septum partially or fully divides the uterus into

two cavities.

VI. Arcuate uterus - A uterus that has an arc

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Fig. 138.Uterine anomalies.

Symptoms depend on menstrual drainage, fertility and character of

pregnancy. In most cases of duplication or fusion defect no symptoms are

present and diagnosis may be accidental in the course of a bimanual

examination or during a cesarean section or laparotomy. These women are

fertile and have delivery at term.In many cases uterine anomaly may remain

undetected until menstruation begins or pregnancy is attempted. If a uterine

anomaly such as bicornuate uterus results in a rudimentary uterine horn with

no outlet, menstrual outflow will be obstructed. This can result in pain and/or

a mass similar to endometriosis that gets worse during periods. If untreated,

blood collects in the uterus and may become infected. A uterine anomaly may

also be associated with dyspareunia and reproductive problems. These

include: infertility, ectopic pregnancy, recurrent miscarriage, premature

delivery, intrauterine fetal growth restriction, abnormal fetal presentation –

breech and transverse lies. Some patients, however, complain of

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dismenorrhea, menorrhagia, sterility, etc. Thus, the incidence of reproductive

complications depends on the particular type of anomaly.

Diagnosis: bimanual examination, ultrasound examination,

hysterosalpingography, laparoscopy, hysteroscopy, MRI.

Treatment. Many cases of such anomalies call for surgical corrections.

Metroplasty is most often used to reshape the uterus. However, surgery is not

indicated in every case and it can not be performed on a unicornuate uterus,

as there is no way to surgically enlarge a uterus. Cervical cerclage may be

performed in some cases to prevent the cervix from dilating prematurely and

to increase the fetal survival rate.

Acquired anomalies of female genital organs

Displacement of the Uterus

The normal disposition of the uterus is in the center of the small pelvis,

at the same distance from symphysis, sacrum and lateral walls of the pelvis.

The fundus of the uterus is tilted forward and the cervix is backward, so that

the corpus lies almost horizontally, when a woman stands erect. There is an

obtuse angle between the corpus and the cervix of the uterus, and this angle is

opened forward (disposition anteversion and anteflexion).

Classification of the uterus, displacement:

1. Displacements of the uterus along the vertical plane (upwards and

downwards). They include: elevation of the uterus, descent of the uterus

(womb), prolapse of the uterus (complete and incomplete).

2. Displacement of the uterus along the horizontal plane.

3. Displacement of the uterus around the longitudinal axis (rotation and

torsion of the uterus).

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Displacement of the Uterus along the Vertical Plane.

Elevation of the Uterus.

The uterus is elevated upward, the fundus of the uterus is situated

higher than the plane of the pelvic inlet. The external os of the cervix is

situated higher than the spinal plane. This displacement may occur due to

overfilling of the bladder and rectum and it is a kind of norm. Pathological

elevation of the uterus may occur as a result of hematocolpos due to vaginal

or hymenal atresia, sometimes due to voluminous tumor of the vagina and

rectum, exudate and hemorrhage in Douglas, pouch, adhesion (or union) of

the uterus with abdominal wall, etc.

Descent of the Uterus.

The uterus is situated lower than normally, the external os of the cervix

is lower than the spinal plane, but not protruding even when it is

strengthened. Descent of the uterus can occur only if the cardinal and

uterosacral ligaments are stretched, the perineal body does not support the

uterus. The vagina usually descends first, but in a few cases the uterus

descends first and the vaginal walls follow it. Degrees of descent are: 1)

descent of the cervix to the vaginal orifice; 2) cervix protrusion, 3) uterus is

outside the vulva with complete vaginal inversion.

Prolapse of the Uterus.

It may be complete and incomplete. Incomplete prolapse: cervix is

protruding; the corpus of the uterus is behind the introitus of vagina.

Complete uterine prolapse: uterus is outside the vulva with complete vaginal

inversion. (Fig. 139)

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Fig. 139. Complete prolapse of the uterus.

The prolapsed mass contains bladder, uterus, adnexae, peritoneal

pouches, gut, rectal wall. Anterior vaginal wall together with bladder descent

(cystocele) and posterior vaginal wall together with rectum descent

(rectocele) occur with uterine descent, but can occur alone.

Etiology. Prolapse (and descent) of the uterus is the result of weakening

of the pelvic supports. In 99 % of cases the patients are parous. During

pregnancy the structures are hyperemic and softened, and during labor the

fascia and muscles of perineum may be stretched or torn. If pregnancies are

repeated at short intervals the supports will have little chance to recover.

After the menopause the pelvic structure atrophies, and prolapse frequently

appears. Sometimes prolapse and descent of the uterus (and vagina) may

occur as a result of atrophy due to infantilism, congenital hypoplasia of

perineal muscles, failure of pelvic innervation, general asthenia, etc.

Symptoms. There is a sensation of perineal discomfort. Urinary

symptoms include frequency, incontinence or retention of urine. One of the

frequent complaints is feeling of foreign body in vagina, and between the legs.

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Discharge may occur from the exposed cervix. The prolapsed mass usually

becomes ulcerated, infected. The chronic ulcer is developed around the

cervical os.

Treatment. Operating treatment is recommended whenever possible.

Palliative: pessary treatment may be recommended to patients, who are too

old for operation, or for young women, who hope for further pregnancies, and

in early pregnancy. Pregnancy in patients with descent and incomplete

prolapse is possible, it is often complicated due to failure of blood supply of

the uterus, fetus and in most cases caesarian section is considered.

Displacement of the Uterus along the Horizontal

Plane.

1. Position. It is a displacement of the uterus in whole.

Anteposition is a displacement of the uterus forwards. It may be as a physical

sign when the rectum is overfull. At the same time, it may be a pathological

sign due to tumors in Douglas’ pouch.

Retroposition is a displacement of the uterus backwards. It may be due to

overfilling of the bladder, tumors and cysts.

Lateroposition (dextroposition and sinistroposition) – lateral displacements

of the uterus. It is very often due to inflammatory processes in parametric fat.

2. Pathological version. Corpus of the uterus displaces to one side, but

the cervix – to the other (opposite) side. There are:

Anteversion – corpus of the uterus is displaced forwards, and the cervix –

backwards.

Retroversion – corpus of the uterus is displaced backwards, and the cervix –

forwards.

Dextroversion – corpus is displaced to the right, and the cervix – to the left.

Sinistroversion – corpus of the uterus is displaced to the left, and the cervix –

to the right.

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Pathological versions of the uterus most often may be due to inflammatory

diseases in peritoneum, ligaments and fat.

3. Flexion of the uterus. There is an obtuse angle between the corpus

and cervix of the uterus, and it is a normal sign. This angle is opened

forwards. Pathological changes are:

Hyperanteflexion of the uterus. This is the flexion forwards, and there is an

acute angle between the corpus and cervix of the uterus. Most often it may be

due to congenital anomalies, inflammations. Symptoms: painful menses,

sterility, pain in the sacrum and lower abdomen.

Retroflexion. This is the flexion of the uterus backwards, and the acute angle

between the corpus and cervix of the uterus is opened backwards.

Symptoms. Painful menses, sterility, pains in the sacrum, constipation.

(Fig. 140)

Treatment. Sports, vitamins, symptomatic treatment, gynecological

massage (Fig. 141) There are some operations, which can help to correct

displacements of the uterus, such as ventrofixation, and one can do it if it is

necessary.

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Fig. 140. Displacements of the uterus: A- Anteversion of the uterus; B –

Anteflexion;

C - Retroversion; D- Retroflexion.

Fig. 141. Gynecologic massage: manipulations on retroverted uterus

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Displacement of the uterus along its longitudinal axis

1. Rotation of the whole uterus (the corpus and the cervix). This may be to

any side (right or left);

2. Torsion of the uterus. This is the turning of the corpus to the right or left,

when the cervix is fixed (immobile).

Symptoms: painful menses, sterility, pains in the sacrum, constipation.

Treatment is the same.

Self test

1. The normal disposition of the uterus is

A. in the center of the small pelvis, at the same distance from symphysis,

sacrum and lateral walls of the pelvis

B. near the symphysis pubis

C. near the rectum

D upper then the pelvic inlet

2. Anteposition is a

A. displacement of the uterus forwards

B. displacement of the uterus backwards

C. displacement of the uterus downwards

D. displacement of the uterus upwards

3. Displacement of the uterus may be

A. only congenital

B. due to another reasons

C. without any reason

D. due to mental disorder

4. Anomalies of the uterus may lead to

A. disturbances of menstrual cycle

B. сomplications during pregnancy and labor

C. malignant tumors

D. benign tumors

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5. Pathological version means

A. displacement of the uterus along the horizontal plane

B. displacement of the uterus along the vertical axis

C. uterine eversion

D. uterine inversion

6. Rotation of the uterus means

A. displacement around its longitudinal axis

B. displacement around its horizontal plane

C. twist downwards

D. twist upwards

7. The elevation of the uterus may be only in pathological

condition.

A. yes

B. no

C. absolutely impossible

D only regular position of the uterus is possible

8. The treatment of prolapse of the uterus should be

A. surgical

B. conservative (pessaries)

C. both surgical and conservative

D. not treated at all

9. Retroposition is a

A. displacement of the uterus forwards

B. displacement of the uterus backwards

C. displacement of the uterus downwards

D. displacement of the uterus upwards

10. Which is the most common complaint in case of vaginal

atresia?

A. purulent discharge from vagina

B. periodic pains in the lower abdomen and absence of menstruation

C. absence of any discharge from vagina

D. absence of vagina

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Chapter 4. INFLAMMATORY DISEASES OF THE

FEMALE GENITALIA

Inflammatory diseases of the female genitalia occur in 60-65 per sent of

all gynecologic patients. The most frequent causes of inflammatory diseases of

the female genitalia are infection pathogens, as well as thermal, chemical,

mechanical factors.

Classification

All gynecological disorders, accompanied by inflammatory processes in

the reproductive system, are usually differentiated depending on:

the clinical course of the pathological process,

the pathogen,

the localization of the inflammatory process.

So, depending on the clinical course of the pathological process

following forms of inflammatory disease are distinguished:

acute (disease develops rapidly, duration is 2-3 weeks);

subacute (symptoms for these disorders are observed within 6

weeks);

chronic (signs of the disease may experience more than one and a

half months, disease develops slowly, is continual or recurrent).

latent/silent: the pathogen remains inactive for a long period of

time before beoming active.

Depending on the origin, specific and nonspecific diseases are

distinguished in RF.

Specific inflammatory diseases affecting the female genital organs

usually include chlamydia, TB disease, gonorrhea, trichomoniasis, herpes

infection, and others. The term “sexually transmitted diseases” (STD) is

currently used for most of these diseases.

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Among nonspecific inflammatory diseases affecting the female sexual

organs are most often those caused by effects on the reproductive system of

staphylococci, streptococci, E. coli, Pseudomonas aeruginosa and Proteus.

Depending on the localization of inflammatory lesions, diseases of the

lower reproductive organs (vulvitis, colitis, bartholinitis, endocervicitis) and

upper (endometritis, metendomitis, parametritis, salpingo-oophoritis) are

distinguished. The term: "Diseases, characterized by abnormal

vaginal discharge» is currently used for inflammation of the lower

genitalia. The term: "Pelvic inflammatory disease (PID)” is currently

used for inflammation of the upper genital organs.

Epidemiology. The rate of inflammatory diseases is over 60% of all

gynecologic diseases and about 30% patients of female hospitals have the

inflammatory processes of genital organs. The number of inflammatory

diseases has increased due to increased sexual activity at a young age, liberal

sexual orientation, prostitution. Those who are most at risk are young

unmarried women with several sexual partners. First of all, inflammatory

diseases affect the fertility of a person due to infections of the female upper

reproductive tract and their continuation. Women with a stable viral infection

are particularly at risk for developing cervical dysplasia and fetal death.

Pathogenesis. Inflammatory diseases of female genital tract are

considered as a result of a complex interaction between the infected organism

and the causative microorganism. It is established that the occurrence and

progression of the inflammatory process in the reproductive system of a

woman depends on its systemic resistance, which is determined by such

factors as age, general condition and the presence of other diseases (anemia,

vitamin deficiency, etc.).

Anatomically, the female genital tract consists of cavities (fallopian

tubes, uterine cavity, endocervix, vagina) that communicate with the vulvar

cleft. This structure allows for the exteriorization of the menstrual flow and

the delivery of the fetus during childbirth; on the other hand, it allows sexual

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intercourse, and the penetration of pathogenic microorganisms to the

overlying cavities. The vaginal microflora is one of the most important

mechanisms for protecting the reproductive system of a woman, maintaining

a normal environment in the vagina and preventing the spread of

microorganisms into the vagina.

The female genital tract, especially the vaginal secretions, contain from

108 to 109 bacteria per gram of fluid examined. Bacterial flora of the vagina

makes up the normal part of female physiology from the life of the fetus to

death. Flora changes typically throughout the entire life cycle of a woman. At

birth, the vagina is sterile. A few days later, when estrogen from the mother

leads to an increase in the glycogen content in the epithelial cells of the vagina,

the colonization of lactobacilli from the mother occurs. With estrogen levels

slowly diminishing, glycogen disappears. But due to breast-feeding,

colonization of a new-born organism with appropriate flora happens. Human

milk not only contains bacteria, but is also the predominant source for creating

a "healthy microbiome" in a newborn. Thus, breastfeeding is the reason for the

colonization of a healthy newborn with normal flora (hydrogen peroxide-

producing lactobacilli. At the time of menarche, the rise in estrogen increases

glycogen deposition in the vaginal epithelial cells, which is a prerequisite for

the development of the adult vaginal microflora. In adult women more than 50

different species of bacteria live in a woman’s vagina, with lactobacilli being the

predominant microorganism found in healthy women. Lactobacilli produce

lactic acid from glucose keeping the vagina at an acidic pH (3,8-4,2). Lactic

acid is a major antimicrobial factor produced by lactobacilli. Cells of vaginal

epithelium contain glycogen, which serves as a substrate for Lactobacilli, which

then metabolized to glucose. Lactobacilli from a healthy vaginal ecosystem

produce H2O2. Production of hydrogen peroxide (H2O2) is a mechanism of

inhibiting growth of microorganisms via direct interaction or via human

myeloperoxidase. Hydrogen peroxide-producing lactobacilli have been shown

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to inactivate HIV-1, herpes simplex virus type 2 (HSV-2), Trichomonas

vaginalis, G. vaginalis, P. bivia and E. coli.

In turn, the level of glycogen is dependent on the level of estrogens in

female organism. The hydrogen peroxide-producing flora is predominant until

menopause, when it is replaced with a flora similar to the flora found prior to

the menarche, unless hormonal replacement therapy is started.

But not only Lactobacillus acidophilus provide the self-cleaning of the

vagina. The normal vaginal ecosystem of reproductive age women contains 7

kinds of Lactobacillus: L acidophilus (42,8%), L. Paracasei, L. Fermentum, L.

Plantarum (10-18,6%)), L.cateforme, L.corineformis, L. Brevis (2,5-5,7%), H202

producing Lactobacillus may play an important role in acting as a natural

microbicide within the vaginal ecosystem. Normal vaginal microflora

contains: Lactobacillus (70-90%), Staphylococcus epidermalis (30-60%>),

diphteroids (30-60%>), Hemolytic Streptococci (10-20%), nonhaemolytic

streptococci (5-30%>), Escherichia coli (20-25%), Bacte-roides (5-15%),

Peptococcus (10-60%), Peptostreptococcus (10-40%), Clostridium (5-15%).

Presence of pathogenic flora without inflammation isn't a sign of patho-

logic processes.

Many endogenous and exogenous factors can change the balance of the vaginal

ecosystem. Some vaginal microorganisms can cause inflammation in certain

conditions. Both vaginal and cervical epithelial cells have the ability to convert

glycogen into glucose, which is further metabolized to lactic acid. Vaginal acidity

depends on adequate estrogen levels, as well as on the presence of bacteria

producing lactic acid, such as Lactobacilli. The concentrations of lactobacilli are

likely to be important determinants of vaginal pH. An increased concentration of

bacteria producing lactic acid in the vaginal fluid can lead to a decrease in pH,

which determines a decrease in susceptibility to infection. Estrogens have a

direct effect on the number of organisms and the composition of the bacterial

flora. The surface of the mucous membrane provides protection from penetrating

pathogens. Mucous can act to eliminate a variety of pathogens or antigens.

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Mucous also serves to attach immunoglobulin A, lysozyme, lactoferrin and other

biologically active substances. The mucous membrane of the female genital tract

is under hormonal control. Any abnormality with a low level of estrogen and a

decrease in the level of estrogen with age can damage the protective mechanisms

of the female reproductive tract. Using contraceptives, excessive use of the

shower can affect the vaginal ecosystem by changing the vaginal pH, changing

the vaginal fluid by direct dilution. Imbalances of the vaginal flora caused by a

reduction in the proportion of Lactobacilli can lead to failure of a vaginal

microbiome, to overgrowth pathogens, up to development of inflammatory

process.

DISEASES, CHARACTERIZED BY ABNORMAL

VAGINAL DISCHARGE

Normal physiological discharge changes with the menstrual cycle. It is

thick and sticky for most of the cycle, but becomes clearer, wetter, and

stretchy for a short period around the time of ovulation. These changes do not

occur in women using oral contraceptives. Abnormal vaginal discharge is

characterized by a change of color, consistency, volume, or odor, and may be

associated with symptoms such as itch, soreness, dysuria, pelvic pain, or

intermenstrual or post-coital bleeding.

A number of different infections can cause a change in the amount,

consistency, color, or odor of vaginal discharge. These include:

Bacterial vaginosis

Trichomoniasis (trich)

Gonorrhea

Chlamydia

Yeast infection (candidiasis)

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Trichomoniasis, Gonorrhea, and Chlamydia are examples of sexually-

transmitted diseases (STDs), while bacterial vaginosis and yeast infection are

not considered to be STDs.

On the other hand, inflammatory process may develop due to

overgrowth of any pathogens, especially against the background of decreased

immune protection, trauma, etc.

Bacteriology. Diseases, characterized by abnormal vaginal discharge

include following (according to localization):

bartholinitis

vulvitis

vaginitis

vulvovaginitis

bacterial vaginosis

cervicitis

Etiology. Inflammation of genitals may happen because of lack of

hygiene, unprotected sexual intercourse, use of some drugs (antibiotic

agents), diabetes mellitus, other metabolic disorders, as well as due to

hormonal imbalance, etc.

Genital inflammations are often associated with abortions (criminal,

artificial, spontaneous), labors and diagnostic therapeutic intrauterine

manipulations. Genital infection may occur due to inflammation of other

organs of the abdominal cavity (appendicitis, sigmoiditis, etc.), which is

explained by close anatomical relationships between these organs.

Bartolinitis

Bartolinitis - is an inflammation of Bartholin’s Glands. Bartholin’s

glands are paired glands, which are located in 4 O’ clock and 8 O’ clock

positions in the labia minora, or the two inner folds of the vagina.

Etiology. Pathogens, causing the disease, are:

staphylococci and streptococci;

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E. coli;

fungi.

gonorrhea;

trichomoniasis;

chlamydia.

Pathogenic microbes enter the duct through the urethra or through the

vagina. In some cases, the infection penetrates into the gland with blood flow.

When infection occurs, swelling of the tissue, irritation and retention of

secretion develop, leading to blockage of the excretory ducts of Bartolin's

glands. This leads to the formation of the Bartholin gland cyst. If left

untreated, the Bartolin cyst can turn into an abscess, which, as a rule, does

not break up spontaneously. On the other hand, the spread of infection is

possible. The recurrent course of bartholinitis is rather frequent.

Symptoms: extreme pain in labia when sitting and walking, fever and an

elevated pulse rate. Physical examination reveals edema and hyperemia in the

area of vestibulum of vagina. The onset of an abscess is characterized by the

appearance of an extremely painful tumor in the genital area. It can be

clinically detected as a local redness, which begins to bulge, and then

progresses to a fluctuation (abscess). (Fig. 142). Suppuration, softening and

fluctuation are typical for Bartilin's gland abscess.

Diagnosis is based on clinical findings and the patient’s history.

Treatment: bed rest; local hypothermia (cold applications); administration of

antibiotics and sulfanilamides. Antibiotics should be administered under the

results of bacteriological examination of a secret:

Ceftriaxone (Rocephin)

Ciprofloxacin (Cipro)

Doxycycline (Bio-Tab, Doryx, Vibramycin)

Example: oral cephalexin therapy (500mg) every six hours for 7 days;

doxycycline 100 mg PO q12hr for 7 days.

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Fig. 142. A – Bartolinitis. B – abscess of a Bartolin’s gland

Operative treatment is administered in cases of suppuration and

abscess forming. The excision of an abscess, its drainage should be

performed. After the opening of abscess the instillations of a 5% iodine

solution may be used every two days.(Fig. 143). Antibiotic treatment should

be continued within 7 days after surgical intervention.

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Fig. 143. Surgical treatment of Bartolin’s gland abscess

Vuivitis

Vulvitis is inflammation of the female external genitalia – vulva that

include the labia majora, labia minora, clitoris, and introitus. Vulvites are

usually combined with vaginitis, and are called vulvovaginitis in such a case.

Causes of vulvitis: 1). general diseases (such as diabetes); 2). infection

pathogens; 3). mechanical, chemical and thermal factors, 4). allergy to some

substances. Vulvitis commonly occurs in girls and old women. In postpubertal

women it may be associated with ovarian hypofunction and avitaminoses.

Vulvitis is differentiated into primary (isolated vulval inflammation) and

secondary (attending inflammations of the internal female genitalia).

Symptoms: burning tenderness, extreme and constant itching in the

paravulval area, especially after walking, vaginal discharge, micturition. On

examination: edema, hyperemia and swelling of the external genitalia, ulcers

with a purulent coat.

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Diagnosis is based on: patient’ complaints, clinical findings, CBC,

urinalysis, microscopic and bacteriological examination of discharge.

Treatment. It is depend on underlying disease, if any, and results of

laboratory investigations. In general, treatment of genitalia with 5 % solution

of potassium permanganate, chamomile tea, 3% solution of boric acid several

times a day; “sitting” bath with the described solutions are also effective.

After washing the skin of the vulva may be powdered with talcum and

powder, containing antibiotic agent. Medication is dependent on the origin of

inflammation: allergy, pathogens, etc. Anti-fungal creams and low-dose

hydrocortisone creams help reduce the inflammation. "Bed rest" regimen

may be administered in severe cases simultaneously with medication

Vaginitis and vulvovaginitis

Vaginitis (inflammation of the vagina) is the most common gynecologic

condition encountered in the outpatient office. It is an inflammation of a

vaginal cavity. Vaginitis may be accompanied with vulvitis (vulvovaginitis)

and cervicitis (inflammation of the uterus’ cervix.

Etiology. Approximately 90% of all cases of vaginitis are thought to be

attributable to 3 causes: bacterial vaginosis, vaginal candidiasis (or

vulvovaginal candidiasis [VVC]), and Trichomonas vaginalis infection

(trichomoniasis).

Symptoms. A major symptom common to all these forms is a pathological

vaginal discharge. The character of discharge so typical for the flora that

caused the inflammation that the primary diagnosis is sometimes

formulated based on the type of discharge from vagina. Discharge in

vaginitis may be purulent, mucous, bloody, curd-like; yellow-green,

white; thin, thick, plentiful, malodorous, etc. Discharge due to vaginitis is

accompanied by pruritus, erythema, and sometimes burning, pain, or mild

bleeding. Pruritus may interfere with sleep. Dysuria or dyspareunia may

also occur.

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In atrophic vaginitis, discharge is scant, dyspareunia is common, and

vaginal tissue appears thin and dry. Symptoms vary among particular

types of causative agent.

The diagnosis based on the presence of symptoms of abnormal

discharge, vulvovaginal discomfort, or both; and results of clinical and

laboratory examination:

specula (and bimanual) exam;

serum human chorionic gonadotropin (hCG).

saginal pH,

microscopy of smears,

KOH wet mounts,

Whiff test;

bacteriological investigation of vaginal smears.

Bacterial vaginosis

BV is a polymicrobial clinical syndrome resulting from replacement of

the normal hydrogen peroxide-producing Lactobacillus sp. in the vagina with

high concentrations of anaerobic bacteria (e.g., Prevotella sp.

and Mobiluncus sp.), G. vaginalis, Ureaplasma, Mycoplasma, and numerous

fastidious or uncultivated anaerobes. BV is the most prevalent cause of

vaginal discharge or malodor. It is not a true bacterial infection but rather an

imbalance of the bacteria that are normally present in the vagina. Bacterial

vaginosis, also known as vaginal dysbiosis.

Risk factors that may predispose patients to BV include the following:

Recent antibiotic use

Decreased estrogen production

Wearing an intrauterine device (IUD)

Douching

Sexual activity that could lead to transmission (eg, having a new sexual

partner or a recent increase in the number of sexual partners)

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Symptoms. Typical sign and symptoms of BV include following:

vaginal odor (fishy odor is the most common, and often initial,

symptom of BV); often after sexual intercourse and during

menstruation;

increased vaginal discharge;

itching and irritation

dysuria or dyspareunia (rare).

Physical findings in BV may include the following:

gray, thin, and homogeneous vaginal discharge, which adheres to the

vaginal mucosa;

increased light reflex of the vaginal walls, but typically with little or no

evidence of inflammation;

normal-appearing labia, introitus, cervix, and cervical discharge;

in some case, evidence of cervicitis.

Characteristics of vaginal discharge:

thin,

white or gray

cloudy

malodorous (with a fishy odor, which may become stronger after sexual

intercourse or during menstrual periods)

Diagnosis is made by:

Physical examination

o observation made with the naked eye and nose

o undergoing a pelvic examination

Laboratory tests:

o pH of vaginal secretions

o Whiff test (clue cells)

o KOH slide ((fisher odor)

o Gram staining smears.

o High vaginal swab (vaginal discharge culture and sensitivity)

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A sample of the vaginal discharge is obtained and viewed under the

microscope, either stained or in special lighting, to determine: absence

of Lactobacilli, presence of 'clue cells', presence of Gardnerella bacteria,

Mobiluncus. Demonstration of clue cells on a saline smear is the most specific

criterion for diagnosing BV. Clue cells are vaginal epithelial cells that have

bacteria adherent to their surfaces. The edges of the squamous epithelial cells,

which normally have a sharply defined cell border, become studded with

bacteria. The epithelial cells appear to be peppered with coccobacilli.

BV can be diagnosed by the use of clinical criteria (i.e., Amsel's

Diagnostic Criteria) or Gram stain (considered the gold standard laboratory

method for diagnosing BV). If a Gram stain is not available, clinical criteria

can be used and require three of the following symptoms or signs ( aka

Amsel's Diagnostic Criteria for Bacterial Vaginosis):

Homogeneous, thin, white discharge that smoothly coats the vaginal

walls

Presence of clue cells on microscopic examination

pH of vaginal fluid >4.5

Clue cells

Amine (fishy) odor when potassium hydroxide solution is added to

vaginal secretions (commonly called the "whiff test")

Treatment. Antibiotics are the mainstay of therapy for bacterial

vaginosis (BV), but asymptomatic women with Gardnerella

vaginalis colonization do not need treatment.

Recommended Regimens:

o Metronidazole 400 mg BD (twice a day) orally within 5 - 7 days;

o Metronidazole 0.75% vaginal gel (5g applicator-full at night) or

Clindamycin 2% cream (5g applicator-full at night) – 5-7 nights

After anthibacterial therapy, it is necessary to restore the normal

vaginal microflora. For this purpose, the Lactoginal vaginal capsules are

prescribed: 1 capsule per day (14 days) or 1 capsule twice a day (7 days).

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Trichomonas vaginitis

Trichomonas vaginitis is a sexually transmitted infection (STI), caused

by one-celled parasite called Trichomonas vaginalis.

Risk factors that may predispose patients to Trichomonas vaginitis

include the following:

o multiple sexual partners;

o having unprotected sexual intercourse

o a history of other sexually transmitted infections;

o a previous episode of trichomoniasis;

Symptoms. Many women with trichomoniasis have no symptoms, at

least not at first. Most of the symptoms described below are not specific for

trichomoniasis and can occur in other vaginal or cervical infections. Typical

sign and symptoms of Trichomonas vaginitis include following:

A profuse and often foul-smelling vaginal discharge

Genital redness, burning and itching

Pain with urination or sexual intercourse

Lower-abdominal tenderness

Physical findings in Trichomonas vaginitis may include the following:

o Profuse vaginal discharge, thin and frothy;

o Edema and erythema of vaginal mucosa (colpitis macularis)

o Cervicitis: a diffuse or patchy macular erythematous lesion of the cervix

o (strawberry cervix)

o Offensive vaginal odor

Characteristics of vaginal discharge:

The discharge profuse, classically thin and frothy,

The discharge is often yellow, may be green, gray,

Edema and erythema

Vaginal pH is often elevated (>4.5). which may be white, gray, yellow or

green

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Complications of Trichomonas vaginalis infection (TVI) include:

In women, vaginitis is the most common manifestation of infection.

Other complications include infection of the adnexa, endometrium, and

Bartholin glands. Pelvic inflammatory disease and tubo-ovarian abscess

may also occur.

Research has shown that infection with Trichimonac vaginalis

increases the risk of HIV transmission in both men and women.

TVI also increases the susceptibility to other viruses, including herpes

and human papillomavirus (HPV).

TVI also increases the risk of cervical intraepithelial neoplasia.

In pregnant women, TVI has been associated with an increased risk of

miscarriage, low birth weight, preterm delivery, and intrauterine

infection.

Diagnosis is made by:

Physical examination

o evaluation of previous history

o visual inspection

o undergoing a pelvic examination

Laboratory tests:

o pH of vaginal secretions

o Whiff test

o KOH slide,

o Gram staining smears (shows parasite Trichomonal vaginalis).

o High vaginal swab (vaginal discharge culture and sensitivity)

o Vaginal or endocervical swab for Chlamydia

Criteria for diagnosis of Ttichomonas vaginitis:

o Identification of causative organism by microscopy (occasionally by

culture)

Treatment. Treatment should be instituted immediately and, whenever

possible, in conjunction with all sexual partners. Patients undergoing

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pharmacotherapy should be advised to avoid alcohol consumption during the

course of treatment and for an appropriate amount of time after the

completion of their medication.

Recommended Regimens:

o Metronidazole (Flagyl, Protostat, Metronid, Novonidazolo) orally 500

mg twice daily for 7 days.

o When standard treatment regimens fail, a regimen of 2 g of oral

metronidazole or tinidazole for 5 days may be considered.

o Inpatient intravenous (IV) therapy may be indicated when resistance is

present.

After anthibacterial therapy, it is necessary to restore the normal

vaginal microflora. For this purpose, the Lactoginal vaginal capsules are

prescribed: 1 capsule per day (14 days) or 1 capsule twice a day (7 days).

Vulvovaginal candidiasis (VVC)

Vulvovaginal candidiasis develops due to an overgrowth of yeasts within

the vagina, most often C albicans. About 20% of non-pregnant women aged

15–55 have C albicans in the vagina without any symptoms. The disease

spectrum ranges from “innocent bystander,” where visible symptoms are

absent, to complicated disease where VVC is severe, persistent, or recurrent.

Risk factors. Vulvovaginal candidiasis is most commonly observed in

women the reproductive age group. It is quite uncommon in prepubertal and

post menopausal females. The higher risk to get VVC may be associated with

the following factors:

o Pregnancy

o Higher dose combined oral contraceptive pill

o Oestrogen-based hormone replacement therapy after the

menopause, including vaginal oestrogen cream

o A course of broad spectrum antibiotics such as tetracycline or

amoxicillin

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o Diabetes mellitus

o Obesity

o Iron deficiency anemia

o Immunodeficiency eg, HIV infection

o An underlying skin condition, such as vulval psoriasis, lichen

planus or lichen sclerosus

o Other illness.

Symptoms of VVC include:

o Itching, soreness and/or burning discomfort in the vagina and vulva

o Stinging when passing urine (dysuria)

o Heavy white curd or cottage cheese-like vaginal discharge

o Pain during sexual intercourse

o Flares just before and during menstruation are typical

o Non-offensive odor

Physical findings in VVC may include the following:

o pH of vaginal secretions is < 4.5

o Vulval edema, erythema, fissures and excoriations

o Thrush patches - Usually found loosely adherent to the vulva

o Thick, white, curdlike vaginal discharge

o Bright red rash affecting inner and outer parts of the vulva,

sometimes spreading widely in the groin to include pubic areas,

groin and thighs.

Characteristics of vaginal discharge:

o Сopious

o Thick,

o White,

o Cottage cheese-like discharge adhered to vaginal wall, with fissures,

ulcers under these patches

Complications of VVC include:

o Recurrent VVC (>4 episodes within 1 year)

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o Chronic, persistent VVC

o Atrophic vaginitis

o Lichen simplex (localized area of chronic,

lichenified eczema/dermatitis, neurodermatitis).

o Depression and sexual problems

o Candidemia, invasive candidiasis (the yeast infection affects other

parts of the body including the blood, brain, and heart).

Diagnosis is made by:

Physical examination

o evaluation of anamnestic data and visual inspection

o pelvic examination

Laboratory tests:

o pH of vaginal secretions

o a wet mount with KOH

o Whiff test

o Gram staining smears (budding yeasts, hyphae, or pseudohyphae)

o High vaginal swab (vaginal discharge culture and sensitivity) may not

need unless recurrent

Criteria for diagnosis of VVC:

o Identification of causative organism by microscopy (occasionally by

culture)

Treatment.

Recommended Regimens:

Topical use:

o Clotrimazole 1% cream 5 g intravaginally (one applicator-full)

daily for 7-14 days

o Miconazole 2% cream 5 g (one applicator-full) daily for 7 days

o Butoconazole 2% cream 5 g intravaginally in a single application

Oral agents:

Fluconazole 150 mg orally in a single dose

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Fluconazole 100 mg oral once weekly for 3-6 months (for recurrent

VVC)

Itraconazole 400 mg orally once monthly before menses for 3-6 months

(for recurrent VVC)

After anthibacterial therapy, it is necessary to restore the normal

vaginal microflora. For this purpose, the Lactoginal vaginal capsules are

prescribed: 1 capsule per day (14 days) or 1 capsule twice a day (7

days).Treatment of underlying disease/condition.

PELVIC INFLAMMATORY DISEASE

Pelvic inflammatory disease (PID) comprises a spectrum of infectious

and inflammatory diseases of the upper genital tract of women. PID can

involve infection of the endometrium (endometritis), the oviducts

(salpingitis), the ovaries (oophoritis), the uterine wall (myometritis), or

portions of the parietal peritoneum (peritonitis), including perihepatic

structures (Fitz-Hugh−Curtis syndrome).

Etiology (or bacteriology). PID is usually the result of a sexually transmitted

disease (STD) and less often results from iatrogenic causes after

instrumentation of the female reproductive tract. Chlamydia trachomatis is

the predominant sexually transmitted organism associated with PID. Other

organisms implicated in the pathogenesis of PID include Neisseria

gonorrhoeae, Gardnerella vaginalis, Haemophilus influenzae, and

anaerobes such as Peptococcus and Bacteroides species. Other causative

agents of PID are: staphylococci, streptococci, viruses, Escherichia coli,

peptostreptococci, etc. Currently, the most of PIDs are developed against the

background of microbe associations (combinations of several types of

pathogens).

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Pathogenesis. PID is initiated by infection that ascends from the vagina and

cervix into the upper genital tract. PID should be considered as a result of a

complex interaction between the infected organism and the causative

microorganism. Hence, emergence and progression of the inflammatory

process in the reproductive system of a woman depends on her systemic

resistance which is determined by such things as age, the general state and

the presence of other diseases (anemia, avitaminosis, etc.).

Classification of PID by the clinical course:

• Acute PID

o Acute PID refers to the acute symptoms accompanying ascending

infection from the cervix to the endometrium, tubes, ovaries, and pelvic

peritoneum.

• Chronic PID

o Chronic PID refers to chronic pelvic pain, often periodic in

exacerbation, that can follow an acute episode of PID, a sequela to an

inflammatory response to an acute infection in the pelvis. Chronic

pelvic infection can also be caused by the more rare pelvic infection with

tuberculosis (TB) and actinomycosis.

• Silent PID

• Silent PID refers to asymptomatic or mildly symptomatic pelvic

infection, which is usually diagnosed when the sequela of tubal damage

is found at a later date.

PID can occur at any age in women who are sexually active. It is most

common among young women. Those younger than age 25 years are more

likely to develop PID. Women with the following risk factors also are more

likely to have PID:

Infection with an sexually transmitted infection, most often

gonorrhea or chlamydia

Multiple sex partners (the more partners, the greater the risk)

A sex partner who has sex with others

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Past PID

Other sources if infection in the organism, because it may spread by

blood and lymph vessels.

The inciting event, leading to PID include:

• Menstrual periods.

o Degenerating endometrium is a good culture medium and retrograde

menstruation encourages ascending infection. In addition, cervical

mucus changes during menses allow ascending infection. Two-thirds of

acute PID cases begin just after menses.

• Sexual intercourse.

o Bacteria-laden fluids may be pushed into the uterus, and uterine

contractions may assist their ascent.

• Iatrogenic events

o Elective abortion

o Dilation and curettage or endometrial biopsy

o IUD insertion or use

o Hysterosalpingography

o Chromopertubation at laparoscopy

Characteristic signs of the inflammation are: damage to tissues,

impaired blood circulation, transudation of fluid, migration of leucocytes and

lymphocytes into tissues, and impaired tissue metabolism.

Clinical features, common for PID are: lower abdominal pain, usually

bilateral, combined with either adnexal tenderness or cervical excitation on

vaginal examination. The initial diagnosis of PID is based on the presence of

these features.

Other clinical features can support a diagnosis of PID but are not

essential before starting empirical therapy:

• intermenstrual or post coital bleeding – resulting from endometritis

and cervicitis

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• deep dyspareunia

• abnormal vaginal discharge – indicating lower genital tract infection

• fever – non-specific and usually only present in moderate to severe PID

• nausea/vomiting – may occur in severe PID but is more commonly

associated with appendicitis.

Diagnosis. The diagnosis is based on clinical finding. It is very

important to establish whether the inflammatory process is primary or

secondary. It is necessary to do a microscopic examination to establish

etiology of this process (to differentiate pathogens of this process).

Clinical criteria for diagnosis of PID:

Minimum criteria for diagnosis

o Lower abdominal tenderness

o Uterine or adnexal tenderness

o Cervical motion tenderness: lateral motion of the cervix on

examination causes pain by putting tension on the adnexa.

• Additional criteria. For women with severe signs, these additional

criteria are used to increase the specificity of the diagnosis:

o Body temperature higher than 38.3В°C

o Abnormal cervical or vaginal discharge. Mucopurulent

cervical discharge with white blood cells (WBCs) seen on

wet mount is almost always seen in women with PID. If this

finding is not present, other diagnoses should be seriously

entertained.

o Elevated erythrocyte sedimentation rate (ESR)

o Elevated C-reactive protein

o Positive test for gonorrhea or chlamydia

o Tubo-ovarian abscess seen on ultrasound

o Evidence of endometritis on endometrial biopsy

o Laparoscopic evidence of PID

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Differential diagnosis of PID(Table 5) should include:

• Ectopic pregnancy

• Ruptured ovarian cyst

• Appendicitis

• Endometriosis

• Inflammatory bowel disease

• Degenerating fibroids

• Spontaneous abortion

• Diverticulitis

Table 5.

Differential diagnosis of PID

Differential diagnosis Significant features

Ectopic pregnancy Menstrual history, initially unilateral

pain

Ovarian accident Initially unilateral pain, often mid-

cycle

Appendicitis Gastrointestinal symptoms, right

sided pain

Irritable bowel syndrome Central or left sided pain, no cervical

exitation

Inflammatory bowel disease Colicky central or left sided pain,

bowel symptoms

Urinary tract infection Urinary symptoms, loin pains,

Bowel torsion Central pain

Psychosomatic pain Usually inconsistent symptoms

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Recommended diagnostic techniques are:

• Cervical Gram stain. If Gram-negative intracellular diplococci are

present, gonorrhea is the presumed diagnosis. However, Gram stain

alone misses one-half of the gonorrhea cases. Chlamydia is not

diagnosed on Gram stain.

• Blood studies

o Leukocytosis is not a reliable indicator of acute PID. Less

than 50% of women with acute PID have a WBC count

greater than 10,000 cells/mL. Also, it is nonspecific; other

infectious causes of symptoms are associated with an

elevated WBC count.

o An increased ESR is a nonspecific finding, but the ESR is

elevated in approximately 75% of women with

laparoscopically confirmed PID.

• Serum human chorionic gonadotropin (hCG). A sensitive pregnancy test

is important in the differential diagnosis of pelvic pain to rule out the

possibility of ectopic pregnancy.

• Ultrasound. This technique may help define adnexal masses and

intrauterine or ectopic pregnancies, especially when a patient has a

tender abdomen that does not permit an adequate pelvic examination.

This is important for detecting the presence of tubo-ovarian abscesses

since antibiotic therapy protocols may be different from PID without

tubo-ovarian abscesses. Response to therapy can be measured

objectively as pelvic masses and induration regress. Transvaginal

ultrasound of the pelvis mostly useful.

• Culdocentesis. If purulent fluid is obtained, a culture may assist in

antibiotic selection. However, infections may be secondary to another

primary process. In addition, the pain associated with this test limits its

use.

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• Laparoscopy. If the disease process is unclear, this technique is the

ultimate way to establish the diagnosis.

• Follow-up. After initiation of appropriate treatment, clinical

improvement should be observed in 48 to 72 hours. If no improvement

occurs, alternative diagnoses should be considered.

• Testing for HIV and assurance of current Pap smear screening should

be offered to all women diagnosed with PID. Additionally, testing for

syphilis and hepatitis B should be considered.

PID has three principal complications, as follows:

Chronic pelvic pain

Infertility

Ectopic pregnancy

Management of PID. Common principles of management of patients

with acute PID include:

• Treatment should always include sexual partners.

• The physician must decide between outpatient management of the

woman, with close follow-up in 48 to 72 hours, or hospitalization.

• Hospitalization of PID patients and intravenous antibiotic therapy is

indicated in the following scenarios:

o Until other serious diagnoses are excluded, including appendicitis and

ectopic pregnancy

o If the patient is an adolescent

o If a pelvic abscess is suspected on examination or ultrasound

o Severe systemic/peritoneal symptoms including high fever, or signs of

peritonitis

o Inability to tolerate oral outpatient treatment because of vomiting

o If the patient is pregnant

o If the patient is unable or unlikely to comply with outpatient therapy

and/or 48-to 72-hour follow-up

o If HIV infection is present

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o If the patient has not responded to outpatient management at 48-to 72-

hour follow-up

Recommended regimens for out-patient treatment of patient with PID:

• Regimen A

Ofloxacin (Floxin) 400 mg orally two times a day for 14 days or

Levofloxacin 500 mg orally once daily for 14 days with or without

Metronidazole (Flagyl) 500 mg orally two times a day for 14 days

• Regimen B

Ceftriaxone (Rocephin) 250 mg intramuscularly once or Cefoxitin

(Mefoxin) 2 g intramuscularly plus probenecid 1 g orally in a single dose

concurrently once or

Other parenteral third-generation cephalosporin (e.g., ceftizoxime [Cefizox]

or cefotaxime [Claforan])plus Doxycycline (Vibramycin, Doryx) 100 mg orally

two times a day for 14 days with or without Metronidazole (Flagyl) 500 mg

orally two times a day for 14 days.

• Regimen C

Moxifloxacin 400 mg QD

Recommended regimens for in-patient treatment of patient with PID:

• Regimen A

Cefotetan (Cefotan) 2 g IV every 12 hours hours plus Doxycycline

(Vibramycin) 100 mg orally or intravenously every 12 hours

• Regimen B

Clindamycin (Cleocin) 900 mg intravenously every 8 hours plus

Gentamicin (Garamycin) loading dose intravenously or intramuscularly

(2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg)

every 8 hours.

• Alternative parenteral regimens

Ofloxacin (Floxin) 400 mg intravenously every 12 hoursorLevofloxacin

500 mg intravenously once daily with or without Metronidazole

(Flagyl) 500 mg intravenously every 8 hours or Ampicillin/sulbactam

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(Unasyn) 3 g intravenously every 6 hours plus doxycycline (Vibramycin,

Doryx) 100 mg intravenously or orally every 12 hours.

• Regimen C

• Ofloxacin 400 mg BD IV+ IV Metronidazole 500 mg TID followed by

oral Ofloxacin 400 mg BD =otral metronidazole 400 mg BD

• Regimen D

• IV Ciprofloxacin 400 mg +oral Doxycycline 100 mg BD + IV

Metronidazole 500 mg TID followed by oral Doxycycline 100 mg+

Metronidazole 400 mg BD

These regimens are to be used until at least 24 hours after the patient

demonstrates substantial clinical improvement. They may then be changed to

doxycycline (Vibramycin) 100 mg orally two times a day for a total of 14 days

of treatment. If tubo-ovarian abscess is present, many health care providers

use clindamycin (Cleocin) 900 mg orally three times a day or metronidazole

500 mg twice a day for continued therapy with doxycycline.

Hospitalization of PID patients and intravenous antibiotic therapy is

indicated in the following scenarios:

• Until other serious diagnoses are excluded, including appendicitis and

ectopic pregnancy

• If the patient is an adolescent

• If a pelvic abscess is suspected on examination or ultrasound

• Severe systemic/peritoneal symptoms including high fever, or signs of

peritonitis

• Inability to tolerate oral outpatient treatment because of vomiting

• If the patient is pregnant

• If the patient is unable or unlikely to comply with outpatient therapy

and/or 48-to 72-hour follow-up

• If HIV infection is present

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• If the patient has not responded to outpatient management at 48-to 72-

hour follow-up

Surgery isn't usually done to treat PID unless it is needed to:

• Drain or remove a pocket of pus, such as a tubo-ovarian abscess.

• Cut scar tissue that is causing pain. This hasn't been shown to relieve

pain when the scarring is severe.

• Surgery-usually laparoscopy- is sometimes used when a diagnosis is still

unclear after other tests are done or when antibiotic treatment is not

working.

Endometritis

Endometritis is an inflammation of the mucosa membrane of the

uterine body. Rarely it may be isolated, most often the muscular layer of the

uterus is also involved in the process (metroendometritis).

Clinical picture: The acute stage of endometritis (metroendometritis) is

characterized by pain in the lower abdomen, which irradiates to the loin and

thighs, malaise, fever and profuse purulent discharge. Chronic endometritis

is a rare condition because of the frequency with which the endometrium is

shed. In the chronic stage these symptoms are less pronounced, there are no

specific signs or symptoms. Patient may complain of disturbances of

menstrual cycle, infertility. Acyclic sanguineous discharge may be observed

too. Sometimes patients at gynecological examination are found to have an

enlarged mobile “flabby” uterus, often retroverted and sometimes associated

with general pelvic inflammation or inflammation in anamnesis. Menstrual

irregularities and congestive discomfort or pain are complained of and the

cause is not known.

Diagnosis. It is based on the history (connection of the disease with

parturition, abortion, diagnostic curettage of the uterine cavity,

hydrotubation and other diagnostic manipulations). Objective findings in case

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of acute endometritis include general signs of the inflammatory process

(fever, tachycardia, tenderness upon abdominal palpation, purulent vaginal

discharge, enlargement and tenderness of the uterus). Laboratory studies

help to detect leucocytosis and increased erythrocytes sedimentation rate

(ESR).

Data on the history of acute endometritis help to make the diagnosis in

the chronic stage of endometritis. The diagnosis of chronic endometritis is

histological, but the microscopic appearances are of infiltration mainly by

plasma cells and lymphocytes.

Treatment. Bed rest. Cold applications to the lower abdomen.

Antibiotics (see above), non-steroid anti-inflammatory drugs (NSAIDs),

desensitizing and vitamin drugs.

Salpingitis and Salpingo–Oophoritis (adnexitis)

Salpingitis means inflammation of Fallopian tube. It may be unilateral

and bilateral (Fig. 144). Salpingo-oophoritis means inflammation of uterine

tube and the associated ovary. Non-specific infection (staphylococci,

streptococci, Escherichia coli, associations of microbes), as well as (gonococci,

mycobacteria tuberculosis) can be the causative agents of this inflammation.

Salpingo-oophoritis ascends from the uterus and descends from peritoneum.

It may also have lymphogenous (from the rectum, sigmoid colon) and

haematogenous (from remote foci of infection in the body) routes. Edema and

damage of tissues lead to obstruction of the lumen in the tube with the

accumulation of exudate and formation of sactosalpinx (bag-like tumor in the

tube) and pyosalpinx in the presence of pus. Isolated inflammation of

fallopian tube is a rare finding since it also involves the ovary, which becomes

edematous and hyperemic. Abscess of the ovary (pyo-ovarium) emerges with

the development of marked purulent inflammation in the ovary. Purulent

process in the uterine tube and ovary leads to destruction and the formation

of a tuboovarian abscess.

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Fig, 144. PID – salpingitis: A – drawing , B – photo

Clinical picture. Typical symptoms are pain, whites, menstrual cycle

disorders (bleeding) and infertility. Adnexitis is commonly accompanied by

gnawing pain, which may gradually intensify. In rupture of the pyosalpinx the

pain becomes violent, knife-like. Pain is localized in the iliac area and

irradiates to the sacrum. General clinical symptoms include fever (from

subfebrile to high), chill, indisposition, headache, dry mouth, nausea and

vomiting, tachycardia, dry tongue, abdominal flatulence and its tenderness to

palpation.

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Painful tenesmus, compressed rectum and bladder are common in the

case of imminent rupture of pus into the gut. The chronic stage of the disease

is characterized by constant, dull pain intensifying during menstruation,

physical overstrain, gynecologic examination, sexual intercourse. Another

symptom is leucorrhea; it may be mucous, serous or purulent. When

pyosalpinx drains into the uterus, a large amount of purulent discharge can be

suddenly evacuated from the vagina. Patients complain of itching and

irritation of external genitalia, which occur due to secondary vulvitis.

Menstrual cycle disorders can be manifested both by cyclic and acyclic

bleedings. Menstruations are scant but last longer. Infertility occurs when

inflammation is transformed into a chronic stage and is associated with

occlusion of fallopian tubes due to adhesion of their mucosa or the

peritoneum. Hormonal dysfunction of the ovaries, which may also develop as

a result of inflammation, leads to sterility as well.

Diagnosis is based on history (abortions, diagnostic intrauterine

manipulations, chronic diseases such as tonsillitis, recent appendectomy,

overcooling) and typical development of a disease. Objective findings: fever,

tachycardia, dry coated tongue, abdominal flatulence, abdominal muscles,

which are tender and tense on palpation, and positive (Shchetkin-Blumberg

symptom). Dullness in sloping places, which is related to exudation, can be

elicited by percussion. Large tuboovarian abscess can be diagnosed on

abdomen palpation. Gynecologic examination discloses purulent discharge

from the cervical canal, displacement of the cervix, and tenderness of the

uterus. Thickened, soft and tender adnexa are palpated laterally to the uterus,

while a tuboovarian abscess is palpated as a tumor-like formation.

Flattening or overhanging of the posterior and lateral fornices is observed in

the presence of exudate in the abdominal cavity.

Treatment. Conservative treatment should include antibacterial therapy

(see above), hypothermy (ice bags applied to the lower abdomen and

hypothermy of the vagina), desensitizing agents, desintoxication (infusion)

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therapy, vitamins, resolution therapy (biostimulator, enzymes) and

physiotherapy (diadynamic currents, ultrasound, inductotermy) in subacute

and chronic stages. The indications for surgical treatment of salpingitis,

salpingo-ophoritis may arise in the acute stage of the diseases:

o rupture of abscess, (or pyosalpinx, pyovarium) or suspicion on

rupture

o pelvioperitonitis resisting conservative treatment,

o tuboovarian abscess

o diffuse peritonitis,

o ineffectiveness of laparoscopic drainage during 24-48 hours

o etc

Parametritis

It is isolated inflammation of the parauterine cellular tissue. Anterior,

posterior and lateral parametritis are distinguished.

Etiologically parametritis is caused by pathogenic microorganisms

(streptococci, staphylococci, Escherichia coli, anaerobes).

Clinical picture. Usual symptoms include malaise, shivering, fever, low

abdominal pain. Micturition and defecation are painful and difficult. The

formation of an abscess in the parametrical infiltrate is associated with abrupt

increase of temperature, shivering, intensification of pain and its irradiation

to the sacrum and hip. Rupture of the abscess is evidenced by profuse effusion

of pus from the gut or its passage with the urine (if the abscess is ruptured

into the bladder). Parametritis has a long course. The process may

occasionally subside, just to resume again with a new force later. Parametritis

may cause scarring of the cellular tissue, which may alter the position of the

uterus and adnexa.

Diagnosis. The objective findings include symptoms of intoxication

attending the inflammatory process: high pyrexia, tachicardia, dry coated

tongue, change of blood formula. Abdominal palpation reveals a dense,

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immobile, tender infiltrate communicating with the internal surface of the

iliac bone (most often from the side). Percussion elicits dullness in the

infiltrate area. Vaginal examination demonstrates uterine displacements (to

the healthy side), laterally to the uterus there is an infiltrate, which either

smoothes out or protrudes the lateral fornix of the vagina.

Treatment. In the stage of edema and infiltration the treatment includes

bed regimen, cold applications to the lower abdomen, and vaginal

hypothermia. Antibacterial (see above), NSAIDs, desensitizing,

desintoxication (infusion) and sedative therapy are administered as a rule.

Symptomatic therapy consists of administration of analgesic (suppositories

with belladonna, analgin).

At the stage when an abscess is formed in the area of the parametrical

infiltrate it is recommended to empty it through the posterior fornix (by

puncturing and drawing).

Pelvic Peritonitis

Pelvioperitonitis is an inflammation of the pelvic peritoneum

developing as a complication of inflammatory process in the pelvic organs

(salpingo-ophoritis, pyo-ovarium, torsion of the ovarian cyst pedicle, necrosis

of a myomatous node).

Clinical picture. Acute and chronic pelvioperitonitis are recognized.

Clinical symptoms include sharp abdominal pain, particularly in the lower

abdomen, high pyrexia, tachycardia, nausea, vomiting, abdominal distension,

flatulence and constipation. Abdominal examination reveals that the

abdominal wall does not participate in respiratory movements. Other findings

include tension of the abdominal wall, tenderness, positive Shchetkin-

Blumberg symptom. All these symptoms are more pronounced in the lower

abdomen. Bimanual examination discloses overhanging of the posterior

fornix, its tenderness upon palpation, and tenderness with cervical

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displacement. The uterus and adnexa cannot usually be palpated since

examination is very painful and the anterior abdominal wall is tense.

Diagnosis is based on clinical findings, bimanual disclosing and

laboratory evaluations.

Treatment. The treatment should be combined and include:

1) antibiotic therapy;

2) NSAIDs

3) sedative and soporific drugs;

4) infusion therapy is recommended to control intoxication and impaired

metabolism;

5) If there is a danger that the process may spread to the peritoneum of the

upper abdominal cavity surgical intervention is indicated.

SEXUALLY TRANSMITTED PELVIC INFLAMMATORY

DISEASES

Gonorrhea

Etiology. Gonorrhea refers to the infection caused by Neisseria

gonorrhoeae (gonococcus). It is an intracellular, Gram-negative diplococcus.

Gonococcal PID is seen most often in younger women. The bacterium infects

the mucous membranes of the reproductive tract as well as those of the

mouth, throat, eyes, and anus. When symptoms are present, they may include

burning with urination, and vaginal discharge and pelvic pain in women.

Untreated gonorrhea can lead to pelvic inflammatory disease (PID),

infertility, and, rarely, disseminated gonococcal infection (DGI), a life

threatening infection of the blood. The incubation period of gonorrhea is 2 – 7

days, rarely 10 –15 days. Gonococci usually propagate in place with cylindrical

epithelium: in the cervix, uterine tubes, rectum, and urethra. Yet, the

gonococci may also infect the vaginal wall (in puerperants, girls).

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Traditionally, Classification of gonorrhea is based on the duration of the

process and the clinical course of the disease.

Fresh (with duration of the disease up to two months) and chronic

forms of gonorrhea are distinguished.

Fresh gonorrhea is divided into acute, subacute and torpid. In fresh

torpid gonorrhea (G) the clinical manifestations are either insignificant or

absent. Examination of smears obtained in patients with fresh G usually

reveals gonococci. In fresh subacute gonorrhea the duration of process is

about 2 weeks, and clinical symptoms consist of subfebrile condition and

non-marked (non-pronounced ) signs.

Chronic gonorrhea. When the disease with torpid course has continued

for over two months or when its onset is unknown. Gonorrhea is often

combined with trichomoniasis, and staphylococcal and colibacillary infection.

With regard to the localization of the process gonorrhea of the lower

urogenital tract and gonorrhea of the upper genital tract are recognized. The

first form includes gonorrhea of the urethra, para-urethral ducts, Bartholin’s

glands and cervix. The second form includes gonorrhea of the uterine body,

oviducts, ovaries, peritoneum. The clinical courses of these two forms are

different.

The ICD10 coding system does not distinguish between acute and

chronic gonorrhea (table 6).

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Table 6

ICD 10 codes of gonorrhea in women

Condition ICD-10-CM Codes

Gonorrhea

acute

A 54 (gonococcal infection)

-A 54.0 Gonococcal infection of lower genitourinary

tract without periurethral or accessory gland abscess

-A54.00 (gonococcal infection of lower genitourinary

tract, unspecified)

- A54.01 (gonococcal cystitis and urethritis,

unspecified)

- A54.02 (gonococcal vulvovaginitis, unspecified)

- A54.03 (gonococcal cervicitis, unspecified)

- A54.09 (other gonococcal infection of lower

genitourinary tract)

- A54.1 (gonococcal infection of lower genitourinary

tract with periurethral or accessory gland abscess)

- A54.2 (gonococcal pelviperitonitis and other

gonococcal genitourinary infection)

Gonorrhea of the Lower Urogenital System in Women.

Gonorrheal urethritis

The characteristic symptoms are unremarkable, may be mild pain and

burning during micturition (in patients with fresh acute form). Inspection of

the external orifice of the urethra discloses hyperemia and edema of the

mucous membrane, and the appearance of purulent exudate from the urethra.

Urethral palpation through the anterior vaginal wall is painful. Symptoms of

chronic urethritis are rather insignificant; micturition may be frequent.

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Gonorrheal endocervicitis

Gonorrheal endocervicitis is observed in 82 – 90 % of patients with

fresh gonorrhea. The acute stage is characterized by dull low abdominal pain

and mucous or purulent discharge from the vagina. Examination of the cervix

discloses infiltrates, hyperemia, and exudation of mucous and purulent

discharge from the cervical canal. In the chronic form of gonorrheal

endocervicitis one can see insignificant pyo-mucous discharge from the

vagina and occasionally dull low abdominal pain. Menstrual disorders and

infertility (primary or secondary) are also diagnostically important.

Gonorrheal Bartholinitis, vulvitis and proctitis have similar symptoms.

Gonorrhea of the Upper Genital Tract in Women.

Gonorrheal endometritis

Having found the way into the uterine cavity, gonococci spread in its

mucous membrane, then the epithelial desquamation takes place in

individual sites, and gonococci penetrate into the subepithelial layer, where

leukocyte infiltration occurs. If infection with gonorrhea happens during

menstruation, gonococci get directly into the basal layer of the mucous

membrane.

Clinical picture. Acute gonorrheal endometritis is characterized by

fever, malaise, sharp low abdominal pain, and purulent discharge from the

uterus. The menstrual cycle is disrupted (menstrual delay, acycling bleeding).

General symptoms of intoxication are observed (dry tongue, tachycardia).

Gynecologic examination reveals an enlarged, soft and tender uterus, as well

as pyo-mucous and sanguineous purulent discharge.

Diagnosis is based on clinical findings and confirmed by laboratory

tests.

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Gonorrheal salpingo-oophoritis

Gonorrheal infection first localized in the uterine cavity usually spreads

to the tubal mucosa by the canalicular pathway and then spreads to the ovary

and peritoneum.

Clinical picture. Gonorrheal salpingo-oophoritis has very pronounced

manifestation in the acute stage: acute pain through the abdomen, nausea

and vomiting, abdominal distension, constipation, fever and chill.

Intoxication symptom, namely dry tongue, tachycardia, headache, etc, are

also present. The abdomen is very tender upon palpation and percussion, and

tense in its lower portions; the Shchetkin-Blumberg symptom is very

pronounced. Percussion reveals tympany. Chronic form of gonorrheal

salpingo-oophoritis has the following symptoms: malaise, dull pain in the low

abdomen, periodically menstrual disorders (dysmenorrhoea,

menometrorrhagia), infertility and bladder and intestinal dysfunctions.

Patient’s working capacity is decreased.

Gonorrheal Pelvioperitonitis

The gonococci reach the abdominal cavity through its fimbrial end. As a

result, an exudative-inflammatory process develops in the peritoneum.

Clinical picture. Meteorism, constipation, difficult micturition, high

fever and chill are the main symptoms. Objective findings include

tachycardia, dry tongue, distended abdomen (which is tense and very tender

on palpation and percussion), and a positive Shchetkin-Blumberg symptom.

Gynecological examination may elucidate urethritis and endocervicitis, and

overhanging of the vaginal fornices.

Complication of gonococcal infection

Complication in women include:

PID development (because of the possibility of ascending infection)

Tubal scarring and infertility

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Perihepatitis secondary to gonorrhea

Ectopic pregnancy with increased fetal and maternal mortality rates.

Diagnosis of gonococcal infection

Diagnosis is based on history, clinical findings and confirmed by

laboratory tests.

Laboratory Criteria for Diagnosis

Observation of gram-negative intracellular diplococci in a urethral

smear obtained from a male or an endocervical smear obtained from a

female, or

Isolation of typical gram-negative, oxidase-positive diplococci by

culture (presumptive Neisseria gonorrhoeae) from a clinical specimen, or

Demonstration of N. gonorrhoeae in a clinical specimen by detection of

antigen or nucleic acid NAAT). Culture and NAAT are available for the

detection of genitourinary infection with N. gonorrhoeae ; culture requires

endocervical swab specimens in females. A nucleic acid test (NAT) or

nucleic acid amplification test (NAAT) is a molecular technique used to

detect a particular pathogen (virus or bacterium) in a specimen of blood or

other tissue or body fluid. It does so by detecting and amplifying the RNA

or DNA of the pathogen, that is, making extra copies of its nucleic acids.

The term includes any test that directly detects the genetic material of the

infecting organism or virus, such as polymerase chain reaction, ligase

chain reaction, and others.

The most important methods of the laboratory diagnosis of gonorrhea

are bacterioscopic, cultural and serological. Specific microbiologic diagnosis

of infection with N. gonorrhoeae should be performed in all persons at risk for

or suspected to have gonorrhea. A specific diagnosis can potentially reduce

complications, reinfections, and transmission. Any patients with insignificant,

chronic forms of PID should be suggested with gonorrhea. The examination

and evaluation of the diagnosis of such cases, and chronic and fresh torpid

250

forms, may be performed after provocation, which increases the significance

of specific signs and helps to confirm diagnosisin latent, chronic, and mixed

forms of infection.

Methods of provocation. Provocation of gonorrhea is an artificial

exacerbation of the inflammatory process, which helps to diagnose and treat

the disease successfully.

Physiological provocation means the obtaining of smears for

bacterioscopy during menstruation.

Biological provocation consists in a single intramuscular administration

of gonovaccine (500 million microbic bodies).

Thermal provocation makes use of inductothermy with a vaginal

electrode.

Chemical provocation involves treatment of the urethral and rectal

mucosa with

1% solution of silver nitrate and the cervical canal with 5% solution of

silver nitrate

or Lugol’s solution in glycerol.

Combined provocation. Smears are taken 24, 48 and 72 hours after the

above mentioned procedures.

Treatment of gonorrhea

Gonorrhea therapy should be combined and include both systemic

effect and local influence on inflammation foci. A patient with an acute stage

of fresh gonorrhea, as well as a patient with exacerbation of chronic

gonorrhea, should be hospitalized. General treatment is: bed rest, special diet

(alcoholic beverages and spicy food should be excluded), antibacterial

therapy, methods aimed at increasing of immune resources, symptomatic

treatment.

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Recommended Regimen of antibacterial treatment:

o Ceftriaxone 250 mg IM in a single dose

PLUS

o Azithromycin 1g orally in a single dose

Alternative Regimens, if ceftriaxone is not available:

o Cefixime 400 mg orally in a single dose

PLUS

o Azithromycin 1 g orally in a single dose

Gonovaccine is used after ineffective treatment with antibiotics and

relapses in the latent fresh torpid and chronic form of the disease (200-300

million from microbial bodies, 2-3 days later intramuscularly). During

pregnancy, immunotherapy and antibiotics with a negative effect on the fetus

are not applied.

For topical treatment of external genitalia, 0.002% solution of

Chlorhexidine, Rekutan, Baliz-2 is prescribed. Local treatment for chronic

gonorrhea is performed after the disappearance of signs of acute

inflammation. In the chronic and subacute stages of the inflammatory

process, physiotherapeutic methods of treatment are used: laser radiation,

paraffin therapy, mud therapy, diathermy, inductothermy.

Syphilis

Syphilis is a chronic systemic disease caused by Treponema pallidum

that has a multitude of clinical manifestations. The disease is contagious

during the primary and secondary stages and through the first year of the

latent stage. The organism can penetrate skin or mucous membranes, and the

incubation period is 10–90 days.

Primary syphilis. Signs and symptoms include a hard, painless chancre

that is usually solitary and that may appear on the vulva, vagina, or cervix.

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Commonly, lesions occur on the cervix or in the vagina and go unrecognized.

Extragenital lesions may occur. Nontender inguinal lymphadenopathy

frequently is present. Even without treatment, the primary chancre resolves

within 2–6 weeks.

Secondary syphilis is a systemic disease that occurs 6 weeks to 6 months

after the primary infection through hematogenous spread of the organism.

Patients in this stage present with skin and mucous membrane lesions. Signs

and symptoms are generalized maculopapular rash involving the palms and

soles, mucous patches, condyloma latum (large, raised gray-white lesions),

and generalized lymphadenopathy. These symptoms spontaneously clear in

2–6 weeks.

Latent-stage syphilis follows untreated secondary stage disease and can

last 2–20 years. Signs and symptoms of the early latent phase (less than 1

year) include exacerbations of secondary syphilis in which the mucocutaneous

lesions are infectious. The late latent phase (longer than 1 year) is not

infectious by sexual transmission, but the spirochete may infect the fetus

transplacentally.

Tertiary syphilis develops in up to one-third of untreated or inadequately

treated patients. Signs and symptoms include involvement of the

cardiovascular system (e. g., endarteritis, aortic aneurysms, and aortic

insufficiency) and involvement of the CNS and musculoskeletal system, which

results in varied disorders. Gummata of skin and bones occur in late tertiary

syphilis. The CNS manifestations may include generalized paresis, tabes

dorsalis, changes in mental status, optic atrophy, and Argyll Robertson pupil,

which is pathognomonic of tertiary syphilis. Neurosyphilis must be ruled out

in those with more than 1 year's duration of disease. Cerebrospinal fluid

should be tested for fluorescent treponemal antibody absorption reactivity.

Diagnosis is made definitively by Wassermann test, dark-field

examinations and direct fluorescent antibody tests of lesion exudate or tissue.

After screening with nonspecific serologic tests and rapid plasma reagin

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(RPR) tests, clinicians can then use specific tests to confirm the diagnosis.

The specific serologic tests are FTA-ABS and microhemagglutination assay for

antibody to T. pallidum. False-positive results may be seen in 1% of the

nonspecific serologic tests. Biologic false-positive results, usually of low titers,

may be caused by pregnancy, autoimmune disorders, chronic active hepatitis,

intravenous drug use, febrile illness, and immunization. Serologic tests

become positive 4–6 weeks after exposure, usually 1–2 weeks after

appearance of the primary chancres.

Treatment. T. pallidum is sensitive to many antibiotics, but reactions

are common and care is required in treatment. Most patients receiving

effective treatment for early syphilis with any antibiotics will display some

degree of reactions – rigors, sweating, headache, for about 24 hours. It can be

modified by giving prednisolon 5mg 6-hourly. Erythromycin 2,0 g per day in

the course of 15 days. Doxycycline, azithromycin may be used too.

Molluscum Contagiosum

Molluscum contagiosum is a benign infection of the skin by poxvirus and is

spread by sexual or nonsexual contact and autoinoculation. The incubation

period ranges from several weeks to months.

Clinical picture. Signs and symptoms include the appearance of dome-

shaped papules with central umbilication ranging from 1 to 5 mm in diameter.

Multiple lesions may arise but generally fewer than 20. The lesions are

usually asymptomatic but occasionally are pruritic. They are usually self-

limited and may last for 6–9 months.

Diagnosis is made by gross inspection or microscopic examination of

white, waxy material expressed from a nodule.

Treatment consists of evacuation of the white material, excision of the

nodule with a dermal curette, and treatment of the base with ferric subsulfate

(Monsel's solution) or 85% trichloroacetic acid. Cryotherapy with liquid

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nitrogen can also be used. Sexual partners should be examined and treated as

well.

Genital Herpes

Genital herpes is a recurrent, sexually transmitted infection by the

herpes simplex virus (HSV) (80% of cases are due to type II) that results in

genital ulcers. Infection with genital herpes has reached epidemic

proportions, with an incidence in the United States of 500,000 to 2 million

cases per year. The prevalence is 10 million to 30 million cases per year. The

incubation period is 3–7 days.

Clinical picture. Primary infection may result in systemic as well as local

manifestations. The patient may experience a virus-like syndrome with

malaise and fever, then paresthesias of the vulva that are followed by vesicle

formation. These are often multiple, resulting in shallow, painful ulcers that

may coalesce. Multiple crops of vesicles and ulcers can occur in a 2–6 week

period. The symptoms last for approximately 14 days, peaking at

approximately day 7. The outbreak is self-limited, and lesions heal without

scar formation. Viral shedding can continue for 2–3 weeks after the

appearance of lesions. Cervical lesions are common in true primary

infections.

Recurrent herpetic outbreaks are usually shorter in duration (averaging

7 days), with less severe symptoms. They are often preceded by a prodrome of

itching or burning in the affected area. Systemic symptoms are usually absent.

Fifty percent of infected women experience their first recurrence within 6

months and have an average of 4 recurrences in the first year. Thereafter, the

rate of recurrence is quite variable. Latent herpes virus resides in the dorsal

root ganglia of S2, S3, and S4. Its reactivation can be triggered by an

immunocompromised state such as pregnancy.

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Complications include herpes encephalitis (rare) and infection of the urinary

tract, which results in retention or severe pain or both.

Diagnosis is usually by inspection alone; however, if a definitive

diagnosis is needed, a viral culture can be obtained. The vesicle should be

opened, then vigorously swabbed. Sensitivity of a viral culture is

approximately 90%. Immunologic or cytologic tests are not as sensitive.

Polymerase chain reaction (PCR) has potential use as a rapid and sensitive

diagnostic technique but needs further testing.

Treatment. Aciklovir 200 mg orally 4-5 times a day 1 -10 weeks course

is administered. Viferon 150,000 – 500,000 units of interferon in vaginal

suppositories may be used 2 times a day during 5-7 days.

Goals of treatment are to shorten the clinical course, decrease transmission,

and prevent complications and recurrence. The virus cannot be completely

eradicated. An effective HSV vaccine is not yet available.

Counseling. Patients should be advised to remain abstinent from the

onset of prodromal symptoms until complete reepithelialization of lesions.

HSV infection may facilitate human immunodeficiency virus (HIV) infection.

There is no probable association with the development of squamous

intraepithelial lesions.

Chlamydia infection in women

Chlamydial Infection of the genitourinary tract is the most common

sexually transmitted disease (STD) in females. It is caused by chlamydial

strains D-K (which means chlamydial strain D, chlamydial strain E, etc., until

chlamydial strain K. The causative agent of chlamydial infection is a gram

negative bacteria Chlamydia trachomatis. Chlamydia - very interesting from a

scientific point of view, microorganisms. Despite the fact that they belong to

the kingdom of bacteria, nevertheless, chlamydia has certain traits that bring

them closer to viruses. This applies, above all, to their ability to infect cells of

the body and multiply directly in them. Bacteria are not able to produce some

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enzymes necessary for their life, and therefore can live only in foreign cells.

Thus, chlamydia are intracellular parasites. Chlamydial transmission usually

is caused by sexual contact through oral, anal, or vaginal intercourse.

Neonatal infection (eg, conjunctivitis or pneumonia) may occur secondary to

passage through the birth canal of an infected mother.

Risk factors that may predispose patients to Chlamydial infection (ChI)

include the following:

Multiple sexual partners or a new sexual partner

Age 15-24 years (especially < 19 years)

Poor socioeconomic conditions (eg, homelessness)

Commercial sex workers

Non-use of barrier contraceptives

History of previous sexually transmitted disease: Chlamydial Infection

is often accompanied by other STDs

This infection is easily spread because it often causes no symptoms and

may be unknowingly passed to sexual partners. In fact, about 75% of infections

in women are without symptoms. Chlamydia infects columnar epithelial cells,

which places the adolescent female at particular risk because of the presence

of the squamocolumnar junction on the ectocervix until early

adulthood. Infection with chlamydial organisms invokes a humoral cell

response, resulting in secretory immunoglobulin A (IgA) and circulatory

immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies and a

cellular immune response.

Symptoms. Early-stage Chlamydia trachomatis infections often cause

few or no signs and symptoms. When signs or symptoms occur, they usually

start one to two weeks after exposure to chlamydia. Even when signs and

symptoms occur, they're often mild and passing, making them easy to

overlook. Chlamydia trachomatis can also infect the rectum. While these

infections often cause no signs or symptoms, patient may experience rectal

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pain, discharge or bleeding. It's also possible to acquire chlamydial eye

infections (conjunctivitis) through contact with infected secretions.

Signs and symptoms of chlamydia trachomatis infection may include:

Painful urination (dysuria)

Lower abdominal pain

Mucopurulent cervical or vaginal discharge

Urethral discharge( thin and mucoid)

Mucopurulent rectal discharge

Painful sexual intercourse in women

Intermenstrual bleeding and bleeding after intercourse

In gynecological examination one can find cervical friability ( easy

bleeding on manilulation), cervical motion tenderness, adnexal fullness or

tenderness, associated with progression to pelvic inflammatory disease,

lower abdominal tender to palpation,upper right quadrant abdominal

tenderness (Fitz-Hugh-Curtis syndrome).

Complications. The complications associated with Chlamydial Infection

in Females could include:

Pelvic inflammatory disease, which is an infection of the uterus, ovaries,

and fallopian tubes

Sepsis: A severe infection that spreads via the blood stream

Fitz-Hugh Curtis disease: Perihepatitis, inflammation of membrane

around the liver

Tubo-Ovarian abscess: Abscess formation in the ovaries and fallopian

tubes

Infected pregnant women can transmit the infection to the child during

delivery, causing chlamydial pneumonia and chlamydial conjunctivitis

in the newborn

Ectopic pregnancies due to scarring of fallopian tubes

Infertility (either relative or absolute).

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Reactive arthritis. People who have chlamydia trachomatis are at higher

risk of developing reactive arthritis, also known as Reiter's syndrome.

Diagnosis. Nucleic acid amplification tests (NAATs) are the most

sensitive tests for detecting chlamydia and gonococcal infections. NAATs can

be performed on endocervical, urethral, vaginal, pharyngeal, rectal, or urine

samples (first-void is preferred).The accuracy of NAATs on urine samples has

been found to be nearly identical to that of samples obtained directly from the

cervix or urethra. On wet mount, a finding of leukorrhea (more than 10 white

blood cells per high-power field on microscopic examination of vaginal fluid)

has been associated with chlamydial and gonococcal infections of the cervix.

Oropharyngeal and rectal swabs may also be used.

Treatment of Chlamydia infection. Antibacterial treatment is effective

in 95% of patient with uncomplicated Chlamydial infection. Uncomplicated

genitourinary chlamydia infection should be treated with azithromycin

(Zithromax; 1 g, single dose) or doxycycline (100 mg twice daily for 7days).

Alternatives regimens are:

Erythromycin, 500 mg four times daily for 7 days

or

Erythromycin ethylsuccinate, 800 mg four times daily for 7 days

or

Levofloxacin (Levaquin), 500 mg once daily for 7 days

or

Ofloxacin (Floxin), 300 mg twice daily (or 600 mg once daily) for 7

days

Partners should be notified of infection and treated appropriately.

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Self test

1. Which of the following is not a characteristic of acute

endometritis ?

A. increasing of temperature

D. enlargement of the uterus

C. softening of the uterus

D. induration of the uterus

2. Acute bartolinitis:temperature is 38. 2, infected area is

hyperemic,painful, and fluctuated. What is the likely

treatment?

A. antibiotics

B. antibiotics+ sulfanilamides

C. surgical incision, dreinage, antibiotics

D bed-rest, cold application, and waiting for spontaneous resorption

3. Which of the following is more frequent causative agent of acute

endometritis?

A. trichomonas

B. streptococcus

C. staphylococcus

D. mixed infection

4. Which of the following is not a characteristic of acute

endometritis?

A. pain in lower abdomen

B. high temperature

C. enlargement of the uterus

D. normal general condition

5. Which of the following is not an indication for the surgical

treatment?

A. diffuse peritonitis

B. peritubal abscess

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C. gonorrheal pelvioperitonitis

D. acute bartolinitis

6. In fresh subacute gonorrhea the duration of process is

A. about 2 weeks

B. about 2 months

C. about 2 days

D. about 2 hours

7. The treatment of gonorrheal pelvioperitonitis should be

A. surgical

B. conservative

C. short-distance radiation therapy

D. treatment is not necessary at all

8. Diagnosis of vulvovaginal candidiasis is made by

A. specula examination, microscopic examination of smears

B. questioning of the patient

C. surgical intervention

D. questioning of patient’s family

9. What drugs should be used for treatment of candida infection?

A. antibiotic drugs

B. hormonal drugs

C. antifungal drugs

D. antipruritic drugs

10. What should be used for treatment of trichomonas vaginitis?

A penicillin

B. fluconazole

C. metronidazole

D. aciklovir

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Chapter 5. NEYROHUMORAL CONTROL OF THE

MENSTRUAL CYCLE

Each menstrual cycle is a complex interaction between the

hypothalamus, pituitary, ovaries and endometrium, which are integrated into

an functional system called the hypothalamus-pituitary-ovarian axis. The

menstrual cycle is controlled by this axis, which acts as a system with negative

feedback in addition to its burst gonadotropin mean cycle, resulting peptide

gonadotropins stimulate the production of steroid hormone in the ovaries,

which in turn inhibits the secretion of gonadotropin, thus allowing carry out

cycles.

The biological clock, which is responsible for the rhythmicity of the

cycles, consists in the pulsatile release of an hypothalamic decapeptides: the

Gonadotropin Releasing Hormones (GnRH). The hypothalamus secretes

follicle-stimulating hormone releasing hormone (FSH-RH) and luteinizing

hormone releasing hormone (LH-RH). These decapeptides act on the

pituitary gland in a pulsatile manner, which leads to the secretion of the

gonadotropins: follicle-stimulating hormone (FSH) and luteinizing hormone

(LH). It is the frequency and amplitude of these pulses, which determine the

quantity of each hormone ultimately secreted. The pulsatile secretion of

GnRH depends on external events (psychological factors, the nyctohemeral

rhythm) which reach the hypothalamus from the cortex through the limbic

system, but depends also on the feed-back effect that the ovarian steroids

exert on the hypothalamus and the pituitary.

FSH allows recruitment and growth of the ovarian follicles as well as the

selection of the dominant follicle whereas LH induces follicular rupture and

sustains the corpus luteum.

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Ovaries during the menstrual cycle

Ovarian follicles are composed of an outer layer of thecal cells and an

inner layer of granulosa cells, which engulf the oocyte and host an antrum

(fig.145)

At the start of the menstrual cycle, the ovary contains several antral

follicles. These follicles consist of an oocyte, which is separated from a fluid-

filled sac called the antrum, both of which are surrounded by a layer of

granulosa cells (cumulus cells and mural cells respectively). These cells are

surrounded by a basal membrane, around which lies another layer of theca

cells. The thecal cells have LH receptors, and produce androgens

(testosterone and androstenedione) in response to LH. The androgens cross

the basement membrane to reach the granulosa cells where aromatase

transforms them into estrogens (estradiol and estrone respectively).

Conversely, granulosa cells have FSH receptors; androgens are absorbed by

these cells and metabolized to estradiol (E2). Granulosa cells also produce the

peptide hormone inhibin, which includes two isoforms, A and B. Aromatase is

an FSH dependent enzyme and the FSH receptors are located on the

granulosa cells. FSH stimulates maturation of primary oocyte in an immature

follicle.

During the first week after menses (in a 28 days cycle), FSH continues

to increase, the follicles grow intensely and FSH increases the expression of

its own receptor and of the LH receptor on the granulosa cells. During this

period, the follicles produce relatively small amounts of estradiol and the

circulating concentration of this steroid is relatively constant (fig.146).

During the second week, the follicles continue to grow and since they

have increased their FSH receptors on the granulosa cells their aromatase

actively transforms the thecal androgens into estrogens and the circulating

estradiol levels increase. This increase induces a negative feed-back on FSH

which decreases slightly in the blood. 10-15 primordial follicles start

maturing, but only one matures to fully dominant (Graffian) follicle. The

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follicle, which has the highest number of FSH receptors, the maximal

aromatase activity and thus produces the highest concentration of estradiol is

named the dominant follicle (Graffian) and will be selected for ovulation, the

others gradually degenerate during a process called atresia (degeneration).

Fig. 145. The ovarian follicle: structure and hormones (Geneva Foundation for

Medical Education and Research, Training Courses, Edited by Aldo

Campana, September 27, 2017)

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With its development, the dominant follicle secretes increasing levels of

estradiol (E2); this acts on the endometrium to stimulate proliferation. At the

pituitary gland, rising levels of E2 and inhibin B act to reduce FSH secretion

through a negative feedback mechanism. This phase of the cycle (from day 1

to 13) is called follicular phase. The follicular phase of the ovarian cycle

corresponds to uterine phase, which is called proliferative phase

(proliferation of the functional layer of the endometrium cycle is taking place

here). Under the influence of E2 marked cellular proliferation of the epithelial

lining, the endometrial glands and the connective tissue of the stroma of

endometrium.

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Fig. 146. FSH and LH changes in menstrual cycle (Geneva

Foundation for Medical Education and Research, Training Courses, Edited by

Aldo Campana, September 27, 2017)

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During the early and mid-follicular phases, E2 exerts negative feedback

on LH secretion, which ensures basal levels during this period. When ovum

has nearly matured, estrogen levels reaches a threshold above which they

stimulate production of LH, LH Surge (Positive feedback). In the late

follicular phase (i.e about 36 hours prior to ovulation), E2 reaches levels in

the circulation which switch this negative feedback effect to a positive

feedback effect. This leads to a surge in LH (which is accompanied by a

smaller surge in FSH) over a 24-hour period in the 24 hours prior to

ovulation. This LH surge leads to rupture of the dominant follicular wall and

release of the oocyte. Follicular rupture is called ovulation, which occurs

about 36h after the LH peak. It is because granulosa cells have acquired LH

receptors (effect of FSH) and are now responsive to LH. This peptide induces

the secretion of enzymes, which digest the follicular wall. The initial rise of

LH (at the beginning of the peak) is sufficient to allow the granulosa cells to

secrete small amounts of progesterone, which participate in the mechanism of

induction of the LH peak.

The released egg cell is swept into the fallopian tube by the cilia of the

fimbriae. Fimbriae are finger like projections located at the end of the

fallopian tube close to the ovaries and cilia are slender hair like projections on

each fimbria. Ovulation takes place at midpoint of menstrual cycle, thus at

28-days cycle ovulation happens at day 14th.

Once the oocyte has been expelled from the ruptured follicle, LH

induces the secretion of progesterone from the remaining granulosa cells that

organize themselves in a new gland called the corpus luteum (a process

known as luteinisation).

On the 15th day of menstrual cycle, the luteal phase begins. It lasts

until day 28 of the cycle. The following events occur during this phase:

the egg cell released during the ovulation phase stays in the fallopian

tube for 24 hours;

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if a sperm cell does not impregnate the egg cell within that time, the egg

cell disintegrates.

Luteal phase corresponds to secretory phase of endometrial cycle.

Luteal phase is characterized with fixed duration – 14 days.

Following ovulation, there is an abrupt fall in E2 production from the

ruptured follicle. The follicle undergoes a series of changes, which convert it

into an endocrine structure called the corpus luteum (“yellow body” or

“corpus luteum”). This produces E2 and progesterone, which act on the

endometrium to promote implantation. Progesterone hormone (17α-

hydroxyprogesterone):

• it is a steroidal hormone, produced by the mature ovarian follicle;

• it is the predominant hormone is the secretory phase.

17α-hydroxyprogesterone:

stimulates the glandular cells to secrete glycogen, mucus and

other substances (thus the naming is secretory phase, or secretory

change of endometrium);

the glands become torturous and the lumens are dilated and filled

with these substances;

the stroma becomes edematous;

the spiral arteries extend into the superficial layer of the

endometrium and become convoluted.

Progesterone and estradiol increase and reach a plateau around day 22.

This induces a negative feed-back on LH and FSH which decrease in the

circulation. If implantation does not occur, Human Chorionic Gonadotropin

(hCG) is not present, the corpus luteum is not sustained any longer and

estradiol and progesterone decline. The normal life span of the corpus luteum

is 10 days then it regresses and is replaced by an avascular scar called corpus

albicans. If pregnancy doesn’t occur by day 23, the corpus luteum regresses,

secretion of progesterone and estradiol declies, and the endometrium

undergoes involution. This decline induces an increase in FSH, which will

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recruit the follicles for the next cycle. If pregnancy does happen, the embryo

(the fertilized egg) releases human chorionic gonadotropin (HCG). HCG

maintains the corpus luteum instead of it degenerating. The corpus luteum

goes on secreting estrogen and progesterone. The lining of the uterus is thus

maintained and the period does not occur. The lining of the uterus provides

the right environment for the embryo to implant and develop into a baby.

The endometrium during the menstrual cycle

The endometrium is composed of the basal (stratum basalis) and

functional (stratum functionalis) layers. The basal layer is deep and

adjacent to the myometrium, while the functional layer comprises the

superficial two-thirds of the endometrium. The functional layer is divided

into stratum compactum and stratum spongiosum. The stratum compactum

is a superficial thin layer with gland necks and dense stroma, while the

stratum spongiosum is the deeper part of functional composed of glands

and loosely arranged stroma. Only the functional layer of endometrium

is shed with each cycle. The basal layer contains the progenitor cells that

regenerate the functional layer in each cycle. Endometrial tissue responds to

sex steroid hormones produced in the follicular and luteal phases of the

ovarian cycle.

Endometrial Vascular Supply

Arcuate arteries arise from the uterine arteries in the myometrium. The

arcuate arteries divide just inside the border of the endometrium and give rise

to numerous straight arterioles that supply the lower third of the

endometrium. These vessels continue as the spiral arteriole and supply the

functional two-thirds of the endometrium. Endometrial blood vessels have

abundant smooth muscle cells and just beneath the surface of the

endometrium, the capillaries are fenestrated. The venules from the area

drain into the uterine vein. A sketch of the endometrial vascular system can

be seen in Fig. 147.

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Fig.147. Schematic presentation of the endometrial vascular system. The

endometrium is comprised of the stratum basalis (s. basilis) and stratum

functionalis (s. functionalis). Uterine arteries branch within the

myometrium to yield the arcuate and radial arteries. The radial artery

branches within the s. basilis to yield numerous straight and spiral arterioles

in the lower third of the endometrium. Spiral arterioles provide the vascular

blood supply to the s. functionalis through a vast network of fenestrated

capillaries.

In relation to the endometrial change, the menstrual cycle is divided

into proliferative and secretory phases, and cytoarchitectural and molecular

differences between the phases reflect endometrial responses to cyclic

changes in ovarian hormone.

Menstrual phase (from day 1 to 5 of 28th days cycle)

The functional layer (upper 2/3) of the endometrium is shed during

each menstrual cycle. Shedding of the endometrium presents menstrual

bleeding (syn.: menstruation, period). Endometrial bleeding occurs because

the progesterone levels have fallen below those required to maintain a

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secretory endometrium. Because of the minimally lower level of

progesterone, the arteries supplying blood to the functional layer, constrict, so

that cells in that layer become ischaemic and die. A woman’s menstruation

consists of dark-colored blood from the endometrial lining of the uterus

mixed with the mucous secretion of the cervical canal and the secretion of the

vagina. Menstrual blood does not normally clot, as it is low in fibrinogen, does

not contain prothrombin, and is rich in calcium. The mean amount of total

blood loss during menstruation is 30 – 70 ml. Simultaneously with shedding

of the functional layer of endometrium, the process of regeneration starts

because of the influence of FSH and E2.

Proliferative Phase (from day 1 to 13, corresponds to follicular phase in

ovaries)

By the end of menstruation, the endometrial lining is about 2 mm thick

and is composed of epithelial cells that arise from the glands in the basal layer

and migrate to the denuded surface of the endometrium. Of note, the thin

epithelialized basal layer seen in early menstrual cycle is similar to the

endometrial cytoarchitecture observed in postmenopausal women and in

women with hypothalamic amenorrhea. Estradiol, produced by the ovaries on

approximately day 4 or 5 of the 28th day cycle, induces growth and

proliferation of the endometrium. The epithelial and stromal cells undergo

mitoses and multiply, thus causing the glands to increase in length, while the

stromal cells grow and expand the extracellular matrix. There is rapid

growth of the endometrium from cycle D4 or 5. Endometrial thickness

begins from a nadir of approximately 4.5 mm on cycle D4 and increases

linearly to a plateau of approximately 10 mm on cycle D9 or 10. The cessation

of endometrial growth occurs before estradiol levels reach their peak and

prior to the onset of secretory phase progesterone production.

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Secretory Phase (from day 15 to 28, corresponds to ovarian luteal phase)

Secretion of progesterone after ovulation causes complete cessation of

endometrial epithelial proliferation. Progesterone exposure induces sub-

nuclear glycogen-rich vacuoles to appear on approximately day 16 (D16) of

the cycle and inhibits epithelial cell mitosis by D17. The vacuoles become

supranuclear on D18 and secretions are found in the gland lumen by D19–20.

Peak secretory activity is seen by D20–21. These changes are essential for

conception and the generation of an endometrial surface receptive to

blastocyst attachment (implantation). Progesterone provokes profound

stromal fibroblast changes characterized by cellular enlargement, as well as

laminin and type 4 collagen accumulations. In the luteal phase, type 4

collagen and laminin are present in the extracellular space of the

endometrial stroma and the basement membrane of glands and blood vessel

walls. The endometrium also makes large quantities of prolactin and the

insulin-like growth factor (IGF) binding proteins (IGFBP-1). The IGFBP-1

have several functions, including transporting the IGFs in the circulation,

mediating IGF transport out of the vascular compartment, localizing the IGFs

to specific cell types, and modulating both IGF binding to receptors and

growth-promoting actions. These changes in response to progesterone result

in dramatic alterations in both the extracellular matrix and secretory products

of the endometrium. Stromal edema is apparent by D20–23 and in the

few days immediately preceding menstruation, the stroma becomes

infiltrated by natural killer cells, macrophages, and T cells.

Summary:

The early follicular phase starts on the first day of the cycle and ends

when estradiol begins to increase (D1–D5). It is characterised by

increasing LH and FSH and constant low levels of estradiol. Shed of the

functional layer of endometrium takes place in the uterus, presenting

menstrual bleeding (menstrual phase and regeneration in uterus).

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The late follicular phase starts with the increase in estradiol and ends at

its preovulatory peak. It is characterised by increasing estradiol and

decreasing FSH and LH levels (D6-D13).

Ovulation phase – rupture of follicular membrane and release of a

matured ovum from the ovary (D-14).

The early luteal phase starts on the day of ovulation (the day after the

LH peak) and ends when progesterone has reached its plateau. It is

characterized by increasing progesterone and decreasing LH and FSH

levels.

The mid luteal phase corresponds to plateauing progesterone levels. It is

characterized by constant elevated progesterone and constant low levels

of LH and FSH.

The late luteal phase starts when progesterone decreases and ends on

the day preceding the next menses. It is characterized by decreasing

progesterone and increasing LH and FSH levels. The luteal phase of

menstrual cycle corresponds to endometrial secretary phase).

THE NORMAL VALUES OF HORMONES DURING THE

MENSTRUAL CYCLE

Concentrations of pituitary gonadotropins and ovarian steroids stratified by

functional phases are presented in tables I to VI. The functional periods of the

cycle as defined above are compared to the days of the cycle either calculated

from the day of the LH peak or estimated for a 28 and a 35 days cycle. The

distribution of the observed values is given by the concentration of each

hormone at the 2.5th, 50th (median) and 97.5th percentile. By definition,

95% of the normal population is between the 2.5th and the 97.5th percentiles

of the distridution.

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Table 7

FSH values in IU/l during the functional periods of the cycle

Period Days

28 days Cycle

Days

35 days

Cycle

Mean

Early Follicular 1-9 1-15 5.59

Late Follicular 10-14 16-20 4.09

Ealy Luteal 15-17 21-23 5.20

Mid Luteal 18-23 24-29 2.71

Late Luteal 24-29 30-35 2.48

Table 8.

LH values in IU/l during the functional periods of the cycle

Period Days

28 days Cycle

Days

35 days

Cycle

Mean

Early Follicular 1-9 1-15 3.40

Late Follicular 10-14 16-20 5.65

Ealy Luteal 15-17 21-23 7.00

Mid Luteal 18-23 24-29 3.64

Late Luteal 24-29 30-35 2.77

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Table 9.

Estradiol values in pg/ml during the functional periods of the

cycle

Period Days

28 days

Cycle

Days

35 days Cycle

Mean

Early Follicular 1-9 1-15 57.6

Late Follicular 10-14 16-20 196.3

Ealy Luteal 15-17 21-23 129.0

Mid Luteal 18-23 24-29 203.5

Late Luteal 24-29 30-35 132.8

Table 10.

Estradiol values in pmol/l during the functional periods of the

cycle

Period Days

28 days

Cycle

Days

35 days Cycle

Mean

Early Follicular 1-9 1-15 211.4

Late Follicular 10-14 16-20 720.4

Ealy Luteal 15-17 21-23 473.4

Mid Luteal 18-23 24-29 746.9

Late Luteal 24-29 30-35 487.4

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Table 11.

Progesterone values in ng/ml during the functional periods of the

cycle

Period Days

28 days Cycle

Days

35 days Cycle

Mean

Early Follicular 1-9 1-15 0.58

Late Follicular 10-14 16-20 0.50

Ealy Luteal 15-17 21-23 4.49

Mid Luteal 18-23 24-29 11.09

Late Luteal 24-29 30-35 5.38

Table 12.

Progesterone values in nmol/l during the functional periods of

the cycle

Period Days

28 days Cycle

Days

35 days Cycle

Mean

Early Follicular 1-9 1-15 1.84

Late Follicular 10-14 16-20 1.59

Ealy Luteal 15-17 21-23 14.28

Mid Luteal 18-23 24-29 35.27

Late Luteal 24-29 30-35 17.11

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Self test

1. Follicle-stimulating hormone (FSH) stimulates

A. growth and maturation of follicle in the ovaries

B. beginning of menstrual bleeding

C. formation of corpus luteum

D. secretory changes of endometrium

2. The number of primordial follicles is about

A. 35,000-40,000

B. 400,000-500,000

C. 350-450

D. 35 -45

3. The estrogens

A. increase the muscular tone of the uterus

B. decrease the muscular tone of the uterus

C. have no influence on the muscular tone of the uterus

D. increase the depth of muscular layer of the uterus

4. The duration of secretory phase of menstrual cycle is

A. 14-15 days

B. 10-11 days

C. 24-25 days

D. 3-5 days

5. The duration of the desquamation phase is

A. 3-5 days

B. 14-15 days

C. 10-12 days

D. 24-25 days

6. All of the following are stages of the uterine cycle, except of

A. desquamation

B. regeneration

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C. proliferation

D. ovulation

7. Rhythmic changes in the ovaries are divided into

A. three phases

B. two phases

C. four phases

D. five phases

8. What is the ovulation?

A. follicle ripening

B. rupture of the mature follicle

C. formation of the corpus luteum

D. rupture of the yellow body

9. The menstrual bleeding is caused by desquamation

A. of the functional layer of endometrium

B. of the basal layer of endometrium

C. of the intermediate layer of endometrium

D. of the endometrium in whole

10. The corpus luteum is formed during

A. each menstrual cycle

B. menarche

C. every other menstrual cycle

D. the issue of fertilization

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Chapter 6. MENSTRUAL DISORDERS

Definitions and classifications

Menstrual disorder is a physical or emotional problem that interferes with a

normal menstrual cycle, causing various cycle disorders.

Violations of menstrual bleeding are manifested in a wide range. The

key characteristics of the menstrual cycle are the regularity, frequency,

intensity (severity) of bleeding, and the duration of menstrual bleeding.

Violations of the menstrual cycle are expressed in changes in each of these

indicators.

Postulation norms for menstrual bleeding are:

Frequency of menses within a 24 to 38 day window

Regularity (cycle-to-cycle variation) within ± 2 to 20 days

Duration of flow from 4 to 8 days

Volume of blood loss from 5 to 80 ml

Symptoms outside this normal range, or different from normal for the

individual, can become problematic and deserve a trial.

In general, three main groups of menstrual disorders are distinquished:

Classification of menstrual disorders:

Painful cramps (dysmenorrhea) during menstruation.

Heavy menstrual bleeding includes prolonged menstrual periods or

excessive bleeding.

Absence of menstruation (amenorrhea).

Light or infrequent menstruation refers to menstrual flow that occurs

one or two episodes in a 90-day period (menstruation that occur more

than 35 days apart).

In October 2009 the FIGO (International Federation of Gynecology and

Obstetrics) World Congress of Gynecology and Obstetrics in Cape Town

reviewed a series of recommendations, which are used today. According to

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recommendations of FIGO world congress of gynecology and obstetrics

(October 2009) number of previously used terminology should be discarded:

because of their controversial, confusing, and poorly defined usage (Table 13).

Table 13

Discarded gynecological terminology

Menstrual terminologies that should be discarded

Menorrhagia (all usages, including ‘‘essential menorrhagia,’’ ‘‘idiopathic

menorrhagia,’’ ‘‘primary menorrhagia,’’ ‘‘functional menorrhagia,’’

‘‘ovulatory or anovulatory menorrhagia’’)

Metrorrhagia

Hypermenorrhea

Hypomenorrhea

Menometrorrhagia

Polymenorrhea

Polymenorrhagia

Epimenorrhea

Epimenorrhagia

Metropathica hemorrhagica

Uterine hemorrhage

Dysfunctional uterine bleeding

Functional uterine bleeding

The new terminology according abnormal uterine (menstrual) bleeding

and new classification (The PALM-COEIN Classification System) were

accepted.

Disturbances of regularity

o Irregular menstrual bleeding (IrregMB): bleeding of >20 days in

individual cycle lengths over a period of one year.

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o Absent menstrual bleeding (amenorrhea): no bleeding in a 90-day

period.

Disturbances in frequency

o Infrequent menstrual bleeding: one or two episodes in a 90-day period.

o Frequent menstrual bleeding: more than four episodes in a 90-day

period.

Disturbances of heaviness of flow

o Heavy menstrual bleeding (HMB): excessive menstrual blood loss that

interferes with the woman’s physical, emotional, social, and material

quality of life and can occur alone or in combination with other

symptoms.

o Heavy and prolonged menstrual bleeding (HPMB): Less common than

HMB. It is important to make a distinction from HMB given they may

have different etiologies and respond to different therapies.

o Light menstrual bleeding: based on patient complaint, rarely related to

pathology.

Disturbance of the duration of flow

o Prolonged menstrual bleeding: menstrual periods exceeding 8 days in

duration on a regular basis.

o Shortened menstrual bleeding: uncommon, defined as bleeding of no

longer than 2 days.

*Irregular nonmenstrual bleeding

o Irregular episodes of bleeding, often light and short, occurring between

normal menstrual periods. Mostly associated with benign or malignant

structural lesions. May occur during or following sexual intercourse.

**Bleeding outside reproductive age

o Postmenopausal bleeding (PMB): Bleeding occurring >1 year after the

acknowledged menopause.

o Precocious menstruation: usually associated with other signs of

precocious puberty, occurring before 9 years of age.

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* Irregular nonmenstrual bleeding and ** Bleeding outside reproductive age

are not violations of the actual menstrual cycle, refer to abnormal uterine

bleeding in general.

Additionally, following terms are used today

Acute AUB

An episode of bleeding in a woman of reproductive age, who is not

pregnant, of sufficient quantity to require immediate intervention to prevent

further blood loss

Chronic AUB

Bleeding from the uterine corpus that is abnormal in duration, volume,

and/or frequency and has been present for the majority of the last 6 months.

Patterns of Bleeding

The “shape” of the volume of the bleeding pattern over the days of one

menstrual period. It is usually recognized that about 90% of the total

menstrual flow is lost within the first 3 days of the cycle, with day 1 or 2 the

heaviest. In women with AUB this pattern is variable.

The following definitions are proposed for use in practice

Bleeding:

o Any bloody vaginal discharge that requires the use of protection such as

pads or tampons

Spotting:

o Any bloody vaginal discharge that is not large enough to require

sanitary protection

Bleeding/spotting episode:

o One or more consecutive days on which bleeding or spotting has been

entered on the diary card

Bleeding/spotting-free interval:

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o One or more consecutive days on which no bleeding or spotting has

been entered on the diary card

Bleeding/spotting segment:

o One bleeding/spotting episode and the immediately following

bleeding/spotting-free interval

Reference period:

o The number of consecutive days on which the analysis is based (usually

taken as 90 days for women using long-acting hormonal systems and 28

or 30 days for women using once-a-month systems, including combined

oral contraception)

Different types of analysis that can be undertaken on bleeding patterns

within a reference period:

o Number of bleeding/spotting (B/S) days

o Number of bleeding/spotting episodes

o Mean, range of lengths of bleeding/spotting episodes (or medians and

centiles for box-whisker plot analysis)

o Mean, range (medians and centiles) of lengths of bleeding/spotting-free

intervals Number of spotting days and spotting-only episodes

No bleeding:

o no days of bleeding/spotting entered throughout the reference period

Prolonged bleeding:

o 10 days in one episode

Frequent bleeding:

o >4 episodes in one 90-day reference period

Infrequent bleeding:

o 17 days within one 90-day reference period

o

The etiology of menstrual disorders includes nervous and mental

diseases, malnutrition, some occupational hazards, systemic and gynecologic

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inflammatory diseases, illness of the hemopoiesis, cardiovascular and other

systems, gynecologic operations, puberty disorders, and age-specific

reconstruction of the functional state in hypothalamic - pituitary - ovarian

axis in the menopause.

Causes of irregular periods (generally light) include:

Perimenopause (generally in the late 40s and early 50s)

Primary ovarian insufficiency (POI)

Eating disorders (anorexia nervosa or bulimia)

Excessive exercise

Thyroid dysfunction (too much or too little thyroid hormone)

Elevated levels of the hormone prolactin, which is made by the pituitary

gland to help the body produce milk

Uncontrolled diabetes

Cushing's syndrome (elevated levels of the hormone cortisol, used in the

body's response to stress)

Late-onset congenital adrenal hyperplasia (problem with the adrenal

gland)

Hormonal birth control (birth control pills, injections, or implants)

Hormone-containing intrauterine devices (IUDs)

Scarring within the uterine cavity (Asherman's syndrome)

Medications, such as those to treat epilepsy or mental health problems

Common causes of heavy or prolonged menstrual bleeding include:2,7

Adolescence (during which cycles may not be associated with ovulation)

Polycystic ovary syndrome (PCOS) (bleeding irregular but heavy)

Uterine fibroids (benign growths of uterine muscle)

Endometrial polyps (benign overgrowth of the lining of the uterus)

Adenomyosis (the presence of uterine lining in the wall of the uterus)

Nonhormonal IUDs

Bleeding disorders, such as leukemia, platelet disorders, clotting factor

deficiencies, or (less common) von Willebrand disease

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Pregnancy complications (miscarriage)

Common causes of dysmenorrhea (menstrual pain) include:

Endometriosis (uterine lining grows outside the uterus)

Uterine abnormalities (fibroids or adenomyosis)

IUDs

Pelvic scarring due to sexually transmitted infections, such as chlamydia

or gonorrhea

Heavy menstrual flow

Dysmenorrhea

Dysmenorrhea is the occurrance of painful cramps during menstruation

(painful abdominal cramps). More than half of all girls and women suffer

from dysmenorrhea (cramps), a dull or throbbing pain that usually centers in

the lower mid-abdomen, radiating toward the lower back or thighs.

Menstruating women of any age can experience cramps.

While the pain may be only mild for some women, others experience

severe discomfort that can significantly interfere with everyday activities for

several days each month.

Pain can develop before the onset of menstruation and continue

throughout the period of menstrual flow. Sometimes, pain is severe and

attended by nausea, vomiting and other disturbances, which reduce the

patient’s working capacity. In many cases dysmenorrhea is just a

manifestation of systemic diseases. It may be attributed to retroflexion or

anteflexion of the uterus, cicatricial changes and narrowing of the cervical

canal, infantilism, and disturbances of central nervous system, nervous

stresses.

Primary and secondary forms of dysmenorrhea are distinguished. The

1st form does not appear to be linked to any organic disease and is congenital.

It develops in women with previously normal menstruations. Primary

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dysmenorrhea is caused by menstruation itself. It is considered when a girl

does not begin to menstruate by the age of 16.

Secondary dysmenorrhea is triggered by another condition, such as

endometriosis or uterine fibroids. It occurs when periods that were previously

regular stop for at least 3 months.

Etiological factors of primary dysmenorrhea include:

o Elevated prostaglandin levels in the endometrial fluid

o The posterior pituitary hormone vasopressin may be involved in

myometrium hypersensitivity, reduced uterine blood flow, and pain in

primary dysmenorrhea

o Primary dysmenorrhea has also been attributed to behavioral and

psychological factors

Clinical features of primary dysmenorrhea:

o Onset shortly after menarche

o Usual duration of 48-72 hours (often starting several hours before

or just after the menstrual flow)

o Cramping or labor-like pain

o Often unremarkable pelvic examination findings (VE or rectal

exam)

Diagnosis of primary dysmenorrhea:

o Primary dysmenorrhea usually appears within a year after menarche

o The pain begins with the onset of menstruation (or just shortly before)

and persists throughout the first 1-2 days.

o The pain is described as spasmodic and superimposed over a

background of constant lower abdominal pain, which radiates to the

back or anterior and/or medial thigh

o Associated general symptoms, such as malaise, fatigue, nausea and

vomiting, diarrhea, lower backache, and headache may be present with

primary dysmenorrhea

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o Dizziness, nervousness, and even collapse are also associated with

dysmenorrhea

Treatment of primary dysmenorrhea is directed at providing relief

from the cramping pelvic pain and associated symptoms that typically

accompany the onset of menstrual flow. To date, pharmacotherapy has been

the most reliable and effective treatment for relieving dysmenorrhea.

Nonsteroidal anti-inflammatory drugs (NSAIDs), which prevent the

formation and release of prostaglandins, and combination oral contraceptives

(OCs) are the most commonly used therapeutic modalities for the

management of primary dysmenorrhea.

The NSAIDs for treatment of primary dysmenorrhea include:

o Ibuprofen - 400 mg PO q4-6h; not to exceed 3.2 g/d

o Naproxen - 500 mg PO followed by 250 mg PO q6-8h or 500 mg q12h;

not to exceed 1.25 g/d

o Ketoprofen - 25-50 mg PO q6-8hr as necessary; not exceed 250

mg/day;

If an NSAID is not available, opioid analgesics, such as

acetaminophen (Tylenol,Vicodin) may help ease severe pain.

Other option is hormonal treatment: combined oral contraceptive pills

(COCPs), the levonorgestrel intrauterine device, and depot

medroxyprogesterone acetate provide effective pain relief and are associated

with a reduced menstrual flow. COCPs suppress the hypothalamic-pituitary-

ovarian axis and thereby inhibit ovulation and prevent prostaglandin

production in the late luteal phase. This generally significantly reduces the

amount of menstrual flow and effectively alleviates primary dysmenorrhea in

most patients. Ethinyl estradiol and norgestimate (Ortho Tri-Cyclen,

MonoNessa, Previfem, TriNessa): 1 tab/d PO for 21 d followed by 7 d off

medication (or taking inactive tab); begin new course on day 8 after taking

last active tablet. (Fig. 149).

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Fig. 149. Ortho-Cyclen (norgestimate and ethinyl estradiol) 28 tablets

0.25 mg / 0.035 mg

Medroxyprogesterone acetate (DepoProvera) - inhibits secretion of

gonadotropins, thereby inhibiting ovulation and decreasing the thickness of

the endometrium. Usually administered as: 150 mcg IM once every 3 months.

Levonorgestrel-releasing intrauterine device (Mirena) - inhibits

secretion of gonadotropins, thereby inhibiting ovulation and decreasing the

thickness of the endometrium. Should be removed after 5 years.

Heat applied to the painful area may bring relief, and a warm bath twice

a day also may help. Simply changing the position of the body can help ease

cramps. The simplest technique is assuming the fetal position, with knees

pulled up to the chest while hugging a heating pad or pillow to the

abdomen. Dietary recommendations to ease cramps include increasing fiber,

calcium, and complex carbohydrates, cutting fat, red meat, dairy products,

caffeine, salt, and sugar. Smoking also has been found to worsen cramps.

Some research suggests that vitamin B supplements, primarily vitamin B6 in

a complex, magnesium, and fish oil supplements (omega-3 fatty acids) also

may help relieve cramps.

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Secondary dysmenorrhea may be related to inflammatory processes,

endometriosis, and genital tumors.

Treatment. The aim of the secondary dysmenorrhea treatment is

elimination of the underlying cause (antiinflammatory, surgical, and

hormonal). When dysmenorrhea is coupled with infantilism, the treatment

should include invigorating, thermal and hormone therapy.

Symptomatic therapy should be directed at elimination of pain (analgin,

baralgin, papaverine, sedative means and microenemas with a warm

chamomile decoction).

Heavy menstrual bleeding

Heavy menstrual bleeding, heavy and prolonged menstrual periods are

menstrual bleeding due to ovulatory dysfunction (AUB-O) (PALM-COEIN

classification). Abnormal uterine bleeding (formerly, dysfunctional uterine

bleeding [DUB]) is irregular uterine bleeding that occurs in the absence of

recognizable pelvic pathology, general medical disease, or pregnancy. It

reflects a disruption in the normal cyclic pattern of ovulatory hormonal

stimulation to the endometrial lining.

ANOVULATORY MENSTRUAL BLEEDING

Anovulatory uterine bleeding is associated with anovulation caused by

impaired or unestablished functional relationships in the hypothalamic –

pituitary – ovarian axis.

There are various causes for the development of anovulatory uterine

bleedings: impaired secretion of hormones as a result of diseases and psychic

traumas, hypovitaminoses, intoxications, impaired function of the thyroid,

adrenals, and other endocrine glands.

The disease can develop in juvenile and reproductive age and in the

premenopausal period. When occurring in puberty (before 17-18 years of age),

anovulatory bleedings are referred to as juvenile. Occurring in reproductive

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age (18-40 years of age), they are referred to as reproductive age bleedings,

and in menopausal period (after 40-45 years) - as menopausal bleedings. In

reproductive age this condition is commonly consequent upon the genital

inflammation.

In the pubertal period anovulatory uterine bleedings usually occur due

to unestablished interrelations in the hypothalamus – pituitary – ovaries -

uterus system.

In the premenopausal women the age-related changes take place in the

hypothalamic centers, which regulate the secretion of gonadotropic hormones

by the pituitary gland; there are alterations in the cyclic character of secretion

of these hormones and the corresponding ovarian hormones. Primary

changes in the ovaries and uterus can also provoke the disturbances of the

neurohormonal interrelationships.

Anovulatory bleedings are induced by the absence of ovulation and

luteal phase of the cycle. Anovulatory cycles are normal during puberty,

lactation and menopause. According to the age of patient anovulatory

menstrual bleedings are classified as juvenile (at pubertal, at adolescent

patients), bleeding of reproductive age patient, and premenopausal bleeding

(in premenopausal patients).

Anovulatory uterine bleeding develops in patients with persistence of

ovarian follicle or atresia of a few follicles. Persistent follicle prolongs to grow

within several weeks without ovulation, and releases a large number of

estrogens. When ovulation does not occur, no progesterone is produced to

stabilize the endometrium; thus, proliferative endometrium

persists, endometrium become thick. As a result, these patients have

constant, noncycling estrogen levels that stimulate endometrial growth.

Proliferation without periodic shedding causes the endometrium to outgrow

its blood supply. The tissue breaks down and sloughs from the uterus.

Subsequent healing of the endometrium is irregular and dyssynchronous.

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Atresia of some small (unripe) follicles is associated with a low level of

FSH and with hypoestrogenism and the absence of ovulation. Low levels of

estrogen (hypoestrogenism) in such patients continue for a very long time -

more than 3 months. Because of this, the result in patients with follicular

atresia is almost the same: marked proliferation of the endometrium without

periodic shedding causes the endometrium to outgrow its blood supply. The

tissue breaks down and sloughs from the uterus. Subsequent healing of the

endometrium is irregular and dyssynchronous.

Both persistence and atresia are characterized by continuous,

monotonous secretion of estrogens. The persistence of a follicle is

characterized by continuous, monotonous high secretion of estrogens,

whereas atresia is characterized by continuous, monotonous low secretion of

estrogens. Ovulation does not occur and the corpus luteum fails to form, there

is no secretion of progesterone. Excessive proliferation of the endometrium

occurs as a result of prolonged exposure to estrogens in both processes.

Circulation in the endometrium is impaired, the capillary permeability is

decreased, and the sites of dystrophy and necrosis are manifested. In the end

persistent and atretic follicles undergo involution. The necrotic mucosa is

rejected slowly, which causes prolonged bleeding. Anovulatory uterine

bleedings are not attended with pain.

Clinical picture. Anovulatory bleedings normally occur at different

periods of amenorrhea: in 4-8 weeks in case of persistent follicle and 3-4

months in atretic one. Bleedings are more abundant in persistent follicles,

being occasionally profuse. It may lead to anemia and decrease the patient’s

working capacity. Patients complain of general fatigue, headache, poor

appetite and sleep, and so on. There may be pale skin, tachycardia, and

reduced blood pressure.

Secondary blood coagulation disorders, which can develop in the process of

bleeding, disappear when the menstrual cycle is normalized.

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Diagnosis is based on general and gynecologic examination. At general

examination one should pay attention to the typical signs: bleedings that

follow the supression of menses, monophase basal body temperature, high or

low karyopycnotic index. These symptoms are less manifested in the presence

of atretic follicles.

Histological study of the endometrial scrape (preferably on the first

days of bleedings) reveals different types of hyperplasia, which may be

coupled with endometritis.

Anovulatory uterine bleedings should be differentiated from many

disease forms that are attended with bleedings (spontaneous abortions,

interrupted fallopian pregnancy, tumors of the uterus, hormone- producing

tumors of the ovaries, etc.).

Management. The major principles of treatment are: the arresting of

bleeding, prevention of its recurrence and regulation of ovarian function.

Stages of treatment depend on the patient’s age and her general condition.

Sometimes uterine bleedings can be so abundant that emergency care is

required, and the physician should take energetic steps to arrest the bleeding.

The doctor’s tactics largely depends on the patient’s age:

o at juvenile age (puberty) medical treatment is appropriative, while

surgical (D&C) used as a last resort, or in severe case (Hb< 90g/L;

o at reproductive and premenopausal agers D&C with histology –

mandatory ( to exlude malignancy).

Juvenile bleedings are usually treated by conservative methods. In all

patients with heavy menstrual bleeding (HMB), iron deficiency should be

assessed and treated. The target dose is in the range of 150 mg/day to 200

mg/day of elemental iron in 1 to 3 divided doses/day. To aid in absorption,

iron supplements should be taken on an empty stomach with a glass of orange

juice. The duration of replacement should extend at least 3 months beyond

normalization of hemoglobin to allow for replenishment of iron stores.

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Because the underlying problem is bleeding from a hyperproliferative

endometrium that has outgrown its estrogen supply, the primary therapeutic

goal is reestablishment of estrogen supply in the form of high-dose oral or

parenteral estrogen. Estrogen provides hemostasis and progesterone

stabilizes the endometrium. The easiest way to administer these hormones is

by use of combined oral contraceptive pills (COCPs). Monophasic pills

containing at least 30—35 µg of ethinyl estradiol should be used initially and

can be given once daily in the adolescent who is not actively bleeding. Those

who bleed quickly (changing pads or swabs every few hours) may require 4

times a day until the bleeding stops (usually within 2-3 days). Then one tablet

three times a day for 3 days, then one tablet twice a day for 2 days, then one

tablet once a day for 21 days, then 7 days without taking the tablets. with

these 7 days a new menstruation will begin, and from the 1st day of the new

flow a new set of the same COCP tablets should begin with the usual scheme:

1 tablet once a day on the mouth during sleep for 21 days. Consumption of

COCP should be administered within 3-6 months.

In cases of ineffective conservative treatment, when there is a threat to

the life of the patient, the surgical curettage should be used for arresting of

bleeding.

Treatment of bleedings in the child-bearing age and, particularly, the

premenopausal bleedings should be started with curettage of the uterine

mucosa for arresting of bleeding and histological examination of the

endometrial scrape, which is followed by the arrest of bleeding. The day,

when D&C was done would register as the 1st day of the cycle and COCP

should be administered by scheme 1 tablet per mouth once a day at bed time

within 21 days, etc. The COCP should be administered for 6 months. The

histological study of the obtained sample helps to confirm the diagnosis.

As to conservative treatment, hormonal drugs are prescribed to arrest

bleeding (hormonal haemostasis) and for the regulation of the menstrual

cycle. The estrogen hemostasis consists in administration of estrogens, which

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cause regeneration of the endometrium. With this aim, COCP 3 tbl /daily

until arrest of bleeding followed with 1 tbl/day within 21 days. Then – by

schedule 21 days, 3-6 months.

In case of acute, profuse bleeding, 3 steps of treatment are offered.

1. To stop bleeding: Premarin IV 25 mg every 4 hours until bleeding stops.

2. Exogenous progesterone to create secretory changes in the

endometrium and prepare for shading off: Medroxyprogesterone

acetate 10 mg of orally once a day for 10 days, followed by withdrawal

bleeding 3-5 days after completion of the drug.

3. COCP on schedule, 3-6 months.

The progesterone haemostasis is based on the ability of gestagens to

induce secretory changes in endometrium and desquamation of the

endometrium due to sudden stopping of treatment with progesterone

(“medicamentous curettage“). Progesterone is injected intramuscularly, 10-15

mg for 5-6 days. At the onset of treatment with progesterone, the bleeding

normally intensifies after which it gradually lessens and stops. When bleeding

has been arrested, cyclic hormone therapy is administered for 2 or 3 cycles.

Coagulants, hemostatic agents, stimulants of uterine- contractility

(Ergot-dugs) should be used as additional drugs. In all patients with heavy

menstrual bleeding iron deficiency should be assessed and treated. The target

dose is in the range of 150 mg/day to 200 mg/day of elemental iron in 1 to 3

divided doses/day.

In premenopausal and menopausal women the treatment begins with

diagnostic curettage obligatorily. If bleeding is combined with a subacute or

acute inflammatory process, the diagnoctic curettage is carried out only after

anti-inflammatory therapy. Hormone therapy is initiated after the histological

analysis of the endometrial sample. The therapy is directed at regulating the

menstrual function (in women under 48-50 years) or its suppression (in

women over 48-50 years). The drugs used are progesterones, synthetic

progestins,and androgens. Symptomatic treatment with contractile,

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hemostatic, hemostimulating and sedative agents and vitamin therapy are

conducted simultaneously.

In ovulatory dysfunctional uterine bleeding, bleeding occurs cyclically,

and menorrhagia is thought to originate from defects in the control

mechanisms of menstruation. It is thought that, in women with ovulatory

dysfunctional uterine bleeding, there is an increased rate of blood loss

resulting from vasodilatation of the vessels supplying the endometrium due to

decreased vascular tone, and prostaglandins have been strongly implicated.

Therefore, these women lose blood at rates about 3 times faster than women

with normal menses.

OVULATORY MENSTRUAL BLEEDING

In ovulatory uterine bleeding is a bleeding, which occurs cyclically, and

it is thought to originate from defects in the control mechanisms of

menstruation. They are bleedings at three-phase menstrual cycle, (follicular

phase, ovulation and luteal phase), thus named ovulatory bleedings. 3 types of

ovulatory bleedings are distinguished:

shortened follicular phase, resulting in frequent

menstruations (proiomenorrhea);

shortened lutein phase (hypoluteinism);

prolonged lutein phase (hyperluteinism).

Uterine bleedings depending on shortened follicular phase of menstrual

cycle are often in puberty, in patients with inflammations of the uterus and

adnexas.

Clinical picture: the duration of follicular phase is 7-8 days, thus the

duration of menstrual cycle becomes shortened by 14-20 days, while the

duration and volume of menstrual blood loss sometimes increases

(hyperpolymenorrhea); the basal temperature is increased earlier than the10-

th day of cycle and the endometrial secretory phase is present.

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Treatment: uterotonics, cyclic hormonal treatment, or assigning of

small doses of estrogens for 2-4-6 days of cycle.

Uterine bleedings depend on shortening of luteal phase of menstrual

cycle. They occur due to anticipatory involution of a corpus luteum, the

secretory transformation of the endometrium is incomplete. The detaching of

a functional layer of endometrium forming the uterine wall is not

synchronous, so the duration and volume of the flow may be increased

(polymenorrhea, hypermenorrhea).

Treatment: progesterone 1 ml of 1% solution (10 mg) intramuscularly

should be given during 8 days before menstrual flow. Or

Medroxyprogesterone acetate 10 mg should be given orally once daily for 10

days, it would lead to withdrawal bleeding 3-5 days after completion of the

course. Cyclic hormonal treatment may be used too. Vitamin E (50-60

mg/daily) and vitamin C (500 mg/daily) should be given.

Uterine bleedings depend on prolonged luteal phase of menstrual cycle.

They happen due to persistence of yellow body (corpus luteum) because of

prolonged secretion of LH and LTH.

Clinical picture: prolonged luteal phase of menstrual cycle (for 20-25

days), high level of progesteron, prolonged secretory phase of endometrium,

delayed menstrual flow, the duration of menstrual bleeding is about 1-1,5

months (polymenorrhea).

Treatment should be started with curettage of the uterine mucosa for

arresting of bleeding and histological examination of the endometrial scrape.

The n COCP should be administered: 1 tablet once a day within 21 days, from

the 22 day –arrest of intake of tablets, followed by withdrawal bleeding. The

new set of tablets should be started with the 1st day of a next flow.

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Amenorrhea

Amenorrhea is an absent of menstrual bleeding in a 90-day period.

Amenorrhea may be physiological and pathological.

Amenorrhea is physiological before puberty, during pregnancy and

lactation, and after the menopause.

Pathological amenorrhea is termed primary when the patient has never

menstruated, or secondary when the periods are absent for more than 90

days.

Pathological amenorrhoea may be false (cryptomenorrhoea), when the

flow does not escape because of some obstruction, while the cyclic changes in

hypothalamus, pituitary gland, ovaries and uterus are normal; or true, when

the cyclic changes in female organism are absent. Pathological amenorrhea

may also be primary or secondary. Secondary amenorrhea is more common

than primary amenorrhea. The most common etiology is dysfunction of the

hypothalamic-pituitary-ovarian (HPO) axis.

Etiology of pathological amenorrhea includes:

nervous and mental diseases,

malnutrition,

some occupational hazards,

systemic and gynecologic inflammatory diseases,

illness of the haemopoiesis,

cardiovascular and other systems,

gynecologic operations,

puberty disorders, and age-specific reconstruction of the functional

state in hypothalamic - pituitary - ovarian axis in the menopause.

Classification of pathological amenorrhea

Pathological amenorrhea classified depending on the localization of

failure.

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Central, or hypothalamic amenorrhea, sometimes named

stress amenorrhea

Anorexia nervosa

This is a condition, which may be considered as psychological. It occurs

in women in whom the desire to slim becomes obsessional. Fasting affects

hypothalamic function in some way not understood and amenorrhea results.

It is sometimes seen in ballet dancers, models, etc.

Weight loss (acute), malnutrition (chronic). Some acute infectious

diseases (sepsis, typhus), diabetes mellitus, pulmonary tuberculosis, other

severe diseases, chronic poisoning (mercuric, plumbic, phosphoric),

narcomania, alcocholism etc. usually result in amenorrhea due to depression

of hypothalamus and hypophysis.

Psychogenic amenorrhea

It’s occurring in patients with severe stress, for example, during war.

The nervous impulses in a hypothalamus are transformed in humoral

resulting in increased secretion of adrenocorticotropic hormone (ACTH),

depression of LH, FSH, and LTH secretion, low level of estrogen in ovaries

and absence of menses. Adipogenital dystrophy is characterized by dwarfing,

adiposity and genital infantilism, and is usually caused by a

craniopharyngioma that involves the pituitary gland and hypothalamus. The

treatment is surgical.

Pseudopregnancy

This is a curious isterical condition in which the patient either yearns

for or fears a pregnancy. Besides missing periods, she develops symptoms

such as nausea and vomiting, breast discomfort and tightness of her clothes

due to abdominal swelling.

“Amenorrhea and galactorrhea”

“Amenorrhea and galactorrhea” also known as Chiari-Frommel

syndrome. It is characterised with amenorrhea, prolonged galactorrhea, and

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moderate adiposity, significant uterine and ovarian atrophy. It may be

functional due to excessive sedative therapy, it may occur in patients with

pseudopregnancy, in postpartum period. Small pituitary adenoma may

secrete prolactin and cause amenorrhea with galactorrhea. It also may be due

to primary hypothyroidism.

Pituitary amenorrhea due to pituitary disorders

There is a failure of production of gonadotropic hormones. Amenorrhea

is one of the aspects of general disorders and the gynecologist is seldom

responsible for treatment.

Pituitary infantilism (Levi-Loraine syndrome)

The adult resembles a child. No effective treatment is known. It happens

due to insufficiency of gonadotropic and somatotropic hormones, and may be

congenital and acquired, because of severe diseases, tumors of pituitary gland

etc.

Pituitary cachexia (Simmond’s disease)

This is usually due to ischemic necrosis of the pituitary glands

(hypophysis) due to thrombosis of pituitary vessels after postpartumsepsis,

tumors of pituitary gland, tuberculosis, syphilis. The main symptoms are:

weakness, anorexia, significant atrophy of muscles. Treatment with cortisone,

thyroxin and anabolic steroids may cause some improvement.

Amenorrhea and pituitary tumors

It happens due to poor secretion of gonadotropic hormons. In

acromegaly the eosinophillic adenoma of the pituitary gland may destroy the

gonadotropic cells, and the same may happen with other pituitary tumors. In

patients with basophillic adenoma Cushing syndrome develops. This is an

excess production of ACTH and depression of gonadotropic function. Clinical

signs are amenorrhea, obesity, hirsutism, hypertension, and hyperglycemia.

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Postpartum unsufficiency of a hypothalamus and pituitary gland

(Sheehan's syndrome)

It is characterized with amenorrhea, hypotrophy of genital organs, and

loss of pubic hair, hypothyrosis, and depression of the adrenal cortex. The

principal causes are: excessive bleeding after delivery of the fetus, postpartum

sepsis, shock resulting in prolonged and significant failure of blood perfusion

in the area of hypothalamus and hypophysis.

Ovarian disorders

Failure of ovarian development occurs in cases of gonadal dysgenesis.

Stein–Leventhal syndrome is a disorder of unknown cause. After

some years of normal menstruation amenorrhoea occurs with hirsuties,

infertility. Both ovaries are enlarged due to cortical hyperplasia, which is a

characteristic of the disease, and they contain multiple small follicular cysts.

There are now corpora lutea. There is a block in the normal conversion of

progesterone to estrogen so that an intermediate androgen substance

androstenedione appears in excess. The urinary excretion of estrogens is

normal or low, while that of pregnanetriol (a metabolic product of certain

androgens) is raised.

Arrhenoblastoma is a very rare cause of amenorrhea.

Ovarian infections or new growths are processes destroying all ovarian

tissue.

Uterine disorders

Uterus may be congenitally defective.

Endometrium atrophies after irradiation with X-ray or radium, and

hysterectomy.

Other endocrine disorders

Amenorrhea occurs:

o in severe cases of hyperthyreoidism, myxoedema and cretinism;

o in some cases of diabetes;

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o in Addison’s disease;

o with adrenocortical tumors or hyperplasia.

Oral contraception

A delayed first period is common after stopping oral contraception. More

prolonged amenorrhea sometimes occurs.

Diagnosis is based on general and special gynecologic examination,

ultrasonic, X-ray and hormonal tests.

Delayed menses should be evaluated if a girl has no signs of puberty by

age of 13, if menarche has not occurred by age of 16, or if 5 and more than 5

years have passed without menarche since the onset of puberty. Women of

reproductive age who have had menses should be evaluated if they are

amenorrheic for 3 and more than 3 months. First of all pregnancy should first

be ruled out.

History and physical examination can often determine the cause of

amenorrhea. Patients should be asked about abnormal growth and

development, family history of genetic anomalies, dietary and exercise habits,

lifestyle and environmental stresses. Noting hormonal alterations of the

pubertal process and of secondary sexual characteristics is central to the

diagnosis. Signs of virilization (masculinization) due to increased androgen

secretion (hyperandrogenism), especially hirsutism (an increase in hair

stimulated by andrigens), may occur. Other signs of hyperandrogenism

include temporal balding, voice deepening, increased muscle mass,

clitoromegaly, increased libido, and a decrease in feminine secondary sexual

characteristics (defeminisation), such as decreased breast size, and vaginal

atrophy. Galactorrhea may occur. The breast should be inspected accurately

for development and other signs (nonpuerperal secretion of milk, tumor etc).

Internal abnormalities may obstruct menstrual blood flow, causing

hematocolpos, hematometra. Visual inspection of vaginal and cervical mucus

is important because they are sensitive to estrogen. Special tests of functional

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diagnosis (basal, or rectal, temperature, karyopyknotic index, “pupil” test, the

test of extensibility of the cervical mucus) are more appropriate. Usually they

help to determine the phase of menstrual cycle, and approximate level of

estrogen in the organism

Tests of hormonal diagnosis are more appropriate.

A progesterone test can help to differentiate ovarian and uterine forms of

amenorrhea. Medroxyprogesterone acetate 5 to10mg/day orally for 5 days or

progesterone 1 ml of 1% solution (10 mg) intramuscularly is given. Bleeding

confirms the presence of normal endometrium and of sufficient estrogen to

stimulate growth, and it helps to establish the diagnosis of anovulation or

incompetence of the corpus luteum. Absence of bleeding confirms anatomic

abnormality of endometrium (uterine emenorrhea), or absence of estrogen

priming of the endometrium. Thus estrogen – progesterine test should be

performed. Giving orally active estrogen (microfollin 0. 1 mg/day orally for 21

days, plus medroxyprogesterone acetate 5 to 10mg/day orally for the last 5 of

those days produces bleeding if there is no uterine amenorrhea.

Tests with hypothalamic releasing factors, with synthetic progestines,

chorionic gonadotropin, ACTH, and others are useful too. Basal serum level of

FSH, prolactin, thyroid stimulating hormone (TSH) should be measured in all

women with amenorrhea to confirm the clinical impression. X-ray of sella

turcica is indicated for women with hyperprolactinemia and for women with

low gonadotropin levels. It usually helps to ascertain the size of the area,

which is necessary in cases with tumor etc. Hystological examination of

endometrial specimen, obtained with curettage of the uterine cavity, is useful

too. Ultrasonography and computed tomography can usually localize an

androgen-producting neoplasm, and any other types of neoplasm.

By steps, testing of secondary (pathological amenorrhea) includes:

o A pregnancy test (measurement of serum or urinary human chorionic

gonadotropin) is recommended as a first step in evaluation of a

secondary amenorrhea.

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o A CBC, urinalysis, and serum chemistries should be evaluated to help

rule out systemic disease.

o Serum prolactin, FSH, estradiol, and thyrotropin levels should also be

measured routinely in the initial evaluation of amenorrhea once

pregnancy has been excluded.

o Pelvic US may identify congenital abnormalities of the uterus, cervix,

and vagina, or absence of these organs.

o Magnetic resonance imaging can detect hypothalamic/pituitary lesions.

o Hysterosalpingography and hysteroscopy are indicated in cases of

possible Asherman syndrome.

The scheme of investigating to evaluate origin of secondary amenorrhea

presented in Fig.148.

Management. The need for treatment depends on:

o Underlying causes

o Need for regular periods

o Trying to conceive

Treatment depends on the level of damage ( Table 14).

If amenorrhea is of a hypothalamic nature the recommended treatment

includes sedative therapy, physiotherapy (endonasal electrophoresis with 2

per cent solution of vitamin B1, 0. 25 per cent solution of dyphenhydramine

hydrochloride).

In hyperprolactinemic amenorrhea drugs suppressing prolactin

secretion (bromocriptine 2. 5 mg thrice a day) are employed.

The treatment of ovarian amenorrhea (gonadal dysgenesis) is conducted

to facilitate the development of secondary characters and to normalize

processes in the hypothalamic – pituitary – ovarian – uterine axis

(substituting hormonal therapy).

Administration includes adequate nutrition, vitamin therapy, exercise

therapy, and a special diet intended to decrease the body weight in cases with

obesity. The peritoneal – sacral diathermia improving the blood inflow to the

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genital organs is also used. Hormonal therapy of the cyclic hormones

(estrogens followed by progesterone) is administered.

Fig. 148. Investigating secondary amenorrhea

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Table 14

Treatment of amenorrhea

Underlying causes Management

Pituitary tumor Promocryptine/ Surgery

Androgen producing ovarian tumor Surgery

Testicular feminization Gonad removal+ Hormone replacing

therapy

Turner’s syndrome Hormone replacing therapy

Atresia of a hymen Surgical incision

Thyroid disease Appropriate medical treatment

PCOS Appropriate medical treatment

Asherman syndrome Surgical incision of adhesions + IUD

insertion

Self test

1. Amenorrhea and galactorrhea is

A. Sheehan’s syndrome

B. Chiari-Frommel syndrome

C. meno-metrorrhagia

D. uteropathy

2. Heavy menstrual bleeding is

A. a long menstruation

B. a rare menstruation

C. a frequent menstruation

D. a short menstruation

3. Juvenile bleedings should be arrested

A. by conservative methods

B. by curettage of the uterine cavity

C. by physiotherapeutic methods

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D. by manual technique

4. In premenopausal and menopausal women the treatment begins with

A. curettage of the uterine cavity and cytological examination of uterine mucosa

B. hormonal hemostasis

C. contractile agents

D. sedative drugs, cold application, bed rest, contractile agents

5. Cyclic uterine bleeding means

A. anovulatory bleeding

B. ovulatory bleeding

C. menopausal bleedings

D. bleeding due to genital inflammation

6. The principal causes of Sheehan's syndrome are all of the following, except of

A. excessive bleeding after delivery of the fetus

B. postpartum sepsis

C. significant failure of blood perfusion in area of hypotalamus and hypophysis

D. tumor of pituitary gland

7. Which of the following drugs can help to differentiate ovarian and uterine

forms of amenorrhea?

A. progesterone

B. estrogen

C. epinephrine

D. testosterone

8. The cause of uterine bleeding depending on prolonged luteal phase of

menstrual cycle is

A. the persistence of yellow body

B. the shortening of luteal phase

C. inflammations of the uterus and adnexa

D. infantilism

9. The treatment of juvenile bleeding should be started with

A. curettage of the uterine cavity

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B. hormonal hemostasis

C. blood transfusion

D. sedative drugs, cold application, bed rest, anti-inflammatory treatment

10. In premenopausal women the treatment begins with

A. curettage of the uterine cavity

B. hormonal hemostasis

C. blood transfusion

D. sedative drugs, cold application, bed rest

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Chapter 7. NEUROENDOCRINAL SYNDROMES IN

GYNAECOLOGY

Premenstrual syndrome

Premenstrual syndrome (PMS) is defined as the cyclic psychological and

somatic changes that occur for 10 to 14 days during the luteal phase of the

ovulatory cycle. All the changes disappear dramatically within 2 days

following the onset of menstrual flow or the onset of the following cycle in the

case of hysterectomy, and the patients are free of symptoms for at least 2

weeks afterward. Pathological changes include irritability, tension, anxiety,

mood swings, emotional lability, restlessness, decreased concentration,

depression, aggression, and lethargy, poor coordination, craving for sweet or

salty food, crying easily, and increased or decreased sexual desire. Somatic

changes include generalized swelling; breast tenderness; abdominal bloating;

face swelling, hands, and feet; weight gain; change in bowel habits; headache;

dizziness; hot flushes; and acne.

For many years, both physicians and patients were ignorant of this

syndrome; however, recent reports have drawn great interest from patients,

media persons, and health care professionals. The social and economic

concerns are further enhanced by the high prevalence of premenstrual

symptom and the increased number and role of women in the work force.

There is now a definite demand for professional attention to the condition.

ETIOLOGY

Numerous hypotheses regarding etiology have been proposed in the

past 50 years. Although many investigators believe that PMS, like all physical

diseases, arises from disordered physiology, others attempt to explain

premenstrual symptoms on a psychogenic basis, and the pathophysiology

remains elusive. Central nervous system (CNS), hormone dysregulation has

been linked to PMS by the similarity of symptoms or by association with other

emotional syndromes. These hormones include small peptides with opiate

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receptor activity (endogenous opioid peptides) such as serotonin,

norepinephrine, dopamine, α-melanocyte-stimulating hormone, melatonin,

and acetylcholine. Other theories include hypothalamic-pituitary-adrenal

dysregulation, progesterone deficiency or withdrawal, fluid retention,

hyperprolactinemia, abnormal prostaglandin metabolism, hypoglycemia, and

thyroid dysfunction. However, no definite etiology has been identified, and

PMS is still considered as a multifactorial psychosocial-neuroendocrinologic

disorder.

DIAGNOSIS

The most important factor at the first visit is to devote considerable

time listening to the patient relating her history. One should assess the

patient's psychiatric history and explore her relationship with her family

members and co-workers, if any. External stress associated with these

relationships can make the premenstrual symptoms worse. Premenstrual

changes may be confused with other gynecologic or psychiatric problems. The

evaluation should include not only a detailed history, but the formulation of a

differential diagnosis of each complaint and a thorough physical and

psychological examination, with laboratory and radiological tests, if indicated,

and referral to other specialists when appropriate. It has been shown that

PMS is associated with the number of deliveries, postpartum depression, past

birth control pill use, alcohol and drug use, and history of PMS in first-degree

relatives. It is also important to differentiate PMS from psychiatric disorders

with premenstrual aggravation.

It is critical, in establishing the diagnosis of PMS, that symptoms occur

specifically during the luteal phase of the cycle and that there is a symptom-

free period of at least 1 week following the cessation of menstruation.

Symptoms continuing after the fifth day of the menstrual cycle are not

generally considered as PMS. There are still no uniformly accepted objective

criteria for the diagnosis of PMS, and we have to depend on the patient's

subjective report. Prospective recording of symptoms for at least 1 to 2

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months using a daily diary, specific mood assessment charts, or specific visual

linear analogue scales is much more predictive of premenstrual changes than

are retrospective reports, which tend to misdiagnose PMS. Keeping careful

records is also helpful in increasing the patient's awareness of the problems.

Laboratory Evaluation

Thyroid dysfunction, hyperandrogenism, diabetes mellitus,

hypoglycemia, and hyperprolactinemia can cause somatic and affective

symptoms that are occasionally mistaken for PMS. Therefore, thyroid work-

up and measurement of serum afternoon cortisol, testosterone, glucose, and

prolactin levels may be performed to rule out the underlying medical

problems. However, the routine use of peripheral hormonal tests for patients

with premenstrual complaints is not only costly but also not indicated at this

time. This conclusion is based on the findings that no differences in hormone

concentrations were observed in the serum levels or patterns of secretion of

progesterone, estradiol, follicle-stimulating hormone, luteinizing hormone,

sex hormone-binding globulin, dehydroepiandrosterone sulfate,

dihydrotestosterone, prolactin, cortisol, growth hormone, or aldosterone

during the follicular and luteal phases between patients with PMS and healthy

women.

MANAGEMENT

Treatment of PMS requires a multidisciplinary team that integrates the

efforts of a gynecologist, an endocrinologist, a psychiatrist or psychologist, a

social worker, and a nutritionist.

Patient Education

The patient should be reassured that this is a problem common to many

women and that "she is not going crazy. " The physician must attempt to

familiarize the patient with the nature of the syndrome. With this knowledge

and awareness, the patient may recognize the changes in herself and find a

way to cope. The articulate patient can be encouraged to write a diary of her

moods, feelings, activities, and functions during this premenstrual period.

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The diary can serve as another mode of ventilation and describe the pattern of

the patient's premenstrual tension as well. She can then become more

conscious of the changes that seem to occur in that week. Particularly

important is the physician's sensitivity in helping the patient repair her

emotional environment. The patient should be encouraged to join a local PMS

support group, if one is available.

Diet and Exercise

The PMS Prevention Diet emphasizes whole fresh foods. Eating regular

frequent small meals; decreasing the intake of salts, fats, sugar, and caffeine;

and increasing exercise are helpful. Foods that are high in refined sugars and

fats and that are highly processed are to be avoided. Intake of foods made

from whole grains, legumes, seeds, nuts, vegetables, fruits, and vegetable oils

should be encouraged.

Previous studies revealed that women who participated in sports

experienced less premenstrual anxiety than nonathletic women. How exercise

helps PMS is not clear, but exercise was noted to increase beta-endorphin

levels, which may explain the sense of well-being reported by some patients.

If beta-endorphin withdrawal contributes to PMS, it might be corrected, at

least partially, by exercise.

Pharmacologic Therapy

If no improvement is reported within 1 to 2 months using the approach of

education, diet, and exercise, pharmacologic therapy is added.

Treatment of Specific Symptoms

250 mg of prostaglandin synthetase inhibitor mefenamic acid (Ponstel),

administered daily during the luteal phase, significantly improved many

symptoms, particularly fatigue, headache, general aches and pains, and mood

swings. Nonsteroidal anti-inflammatory agents such as acetylsalicylic acid

(aspirin) or acetaminophen (Tylenol) with or without codeine are also used to

relieve headaches, muscle, and joint pain.

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Sumatriptan (Imitrex), a 5-hydroxytryptamine receptor agonist, has

been shown to be effective and well tolerated by patients for menstruation-

associated migraine as it is for nonmenstrual migraine. Women were treated

for a menstruation-associated migraine (1 day before and 4 days after the

onset of menstrual flow) with 6 mg of sumatriptan in a 0. 5-mL subcutaneous

injection. A second injection was available to those who did not have

significant improvement of headache 1 hour after the first injection. At 1 hour,

80% of the sumatriptan-treated patients had significant headache relief,

compared with 19% of the placebo group.

Anxiolitic alprozalam by 0.25–0.5 mg/day during 2-3 months is usually

administered too.

Other associated symptoms, such as nausea and photophobia were also

improved. The most common adverse side effects were injection-site

reactions, dizziness, tingling, nausea and vomiting, warm sensation, and chest

tightness. Most adverse side effects lasted less than 1 hour. Clinical trials

using other forms of the medication, such as rectal suppositories and oral

pills, are currently under way.

Studies have shown significant improvement in reduction in weight and

psychological symptoms using spironolactone (Aldactone, Veroshpiron), a

potassium-sparing diuretic. If the patient gains weight, experiences bloat-

edness and edema premenstrually, and weight loss occurs dramatically after

the onset of menstruation, spironolactone, 25 mg four times a day, or 100 mg

once daily during the luteal phase, is recommended.

The dopaminergic agonist bromocriptine (Parlodel, Bromocriptin), 2. 5

- 5 mg at night daily from days 10 to 26 of the cycle, was noted to produce a

significant reduction in breast tenderness and swelling but was ineffective in

controlling other symptoms of PMS. The dose should be administered

individually: from 1. 25 to 5 mg/day depending on the level of prolactin in

blood.

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Danazol (Danocrine), 200 mg once or twice daily, could effectively suppress

breast and other generalized symptoms.

Treatment of Generalized Symptoms

Naltrexone (Trexan). The beta-endorphin withdrawal and deficiency of

hypothesis suggests treatment of PMS with exogenous beta-endorphin, but it

is not practical because of addiction and the route of administration

(intramuscular or intravenous). An opiate antagonist, given before the

periovulatory beta-endorphin peak and withdrawal, might offer a rational

treatment for PMS by keeping a rather constant level of beta-endorphin.

Naltrexone is an oral pure narcotic antagonist that has been used in the

treatment of withdrawal symptoms for patients with heroin addiction. Unlike

drugs that have mixed agonist and antagonist effects, it does not cause

addiction or withdrawal.

Progesterone by vaginal suppository, or by injection (5 to 10 mg

intramuscularly) for 10 to 12 days premenstrually may be effective in some

cases. Progesterone has been noted to increase beta-endorphin levels in

blood. It is possible that the beneficial effect of progesterone is mediated by

beta-endorphin; however, such data on human subjects are still lacking.

Gonadotropin-releasing hormone agonists with low-dose estrogen-

progestin therapy to eliminate cyclic changes may also be used.

Recent studies suggest that naltrexone alleviates PMS symptoms and may be

an effective treatment for this syndrome. The acceptability of this medication

in the study was good, with only low incidence of nausea, decreased appetite,

dizziness, and fainting, which may be minimized by further dividing or

decreasing of the dosage. Previously, we demonstrated a decrease of plasma

beta-endorphin at periovular period and near menses in PMS patients, and

proposed that the premenstrual decrease of beta-endorphin may be

responsible for the PMS symptoms. It is possible that naltrexone inhibited

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beta-endorphin withdrawal prevented the decrease of beta-endorphin levels,

and thus, reduced the severity of symptoms significantly.

Vitamins and Minerals

It has been suggested that deficiencies of vitamins and minerals are

related to PMS. However, recent studies did not demonstrate serum vitamin

A, B6, or E or magnesium deficiency in PMS patients compared with the

controls in peripheral blood obtained at 2- or 3-day intervals throughout

three menstrual cycles. However, serum zinc deficiency and copper excess

were found during the luteal phase in PMS patients. Because copper competes

with zinc for intestinal absorption and I serum protein binding sites, the

elevated copper in premenstrual patients reduced the availability of zinc

further. PMS patients were also found to have lower serum calcium levels in

the peripheral blood than controls. Whether these peripheral concentrations

reflect central changes requires further studies.

Although deficiencies of vitamins and minerals in patients with PMS could

not be demonstrated, a number of these supplements have appeared widely

on the market over the past few years. It was reported that a tablet of vitamin

B6 and other essential micronutrients reduced the severity of many PMS

symptoms at daily doses of 2 to 12 tablets that contained 100 to 600 mg of

vitamin Be. In contrast, another study showed that 150 mg of vitamin B6

could improve only those premenstrual symptoms related to automatic

reactions and behavioral changes but not physical or affective symptoms. The

efficacy of vitamin E in the treatment of PMS was studied in a double-blind,

placebo-controlled trial. A significant improvement in certain affective and

physical symptoms was noted in subjects treated with daily 400 IU of vitamin

E.

The effects of vitamins and minerals in these studies could be due to a

pharmacological response rather than correction of a deficiency state. The

roles of these supplements in beta-endorphin and other central

neurohormone activities need to be clarified. Until these issues are addressed,

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the supplementation of vitamins and minerals can be considered only as

empirical therapy for PMS.

Serotonin Uptake Inhibitor. Enhancement of serotonin synthesis and

neurotransmission by administration of tryptophan or serotonin-specific

drugs has been used to treat some types of depressive illness. Administration

of large doses of pyridoxine (vitamin B6), a cofactor in serotonin synthesis,

has been observed to alleviate depression, anxiety, irritability, and a number

of other PMS symptoms.

Psychotropic Agents. Several psychotropic agents (tranquilizers) have

been used in the treatment of PMS, such as diazepam (Valium), buspirone

hydrocholoride (BuSpar). Trioxazine

0. 3 g per day may be used for irritability. Because of the required long-term

therapy for PMS patients, these agents may produce undesirable side effects

over time. It is recommended that these agents be given only to patients with

severe symptoms as a short-term adjuvant to other therapies.

Antidepressants: tianeptin 12. 5 mg/day 1-2 times a day for 2-3 months or

sertralin 50-100 mg/day.

Medical oophorectomy

In a cross-over study, it was demonstrated that elimination of ovarian

cyclicity through down-regulation of pituitary gonadotropin secretion with a

daily subcutaneous injection of gonadotropin-releasing hormone agonist

resulted in marked attenuation of premenstrual symptoms. The therapy was

rapidly reversible with no influence on subsequent cycles. Medical

oophorectomy is supposed to prevent the fluctuation and deficiency of beta-

endorphin levels by causing temporary cessation of cyclic ovarian activity.

Studies using monthly leuprolide acetate (Lupron Depot), daily nafarelin

acetate (Synarel), and other gonadotropin-releasing hormone agonists

showed similar results. Danazol (Dan-ocrine), at a dosage of 600 to 800 mg

daily, can also achieve reversible medical oophorectomy. One study showed

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PMS symptoms were improved with danazol, 200 mg daily for 90 days,

during the anovulatory cycles but not during the ovulatory cycles.

The safety and side effects of long-term medical oophorectomy remain to be

determined. Studies using "add-back" synthetic sex steroid therapy to prevent

bone loss in patients given gonadotropin-releasing hormone agonists are

currently under investigation. The use of gonadotropin-releasing hormone

antagonists, which can achieve medical oophorectomy in a much more rapid

fashion with rapid reversal, is anticipated in the near future, assuming its side

effects, such as effects caused by histamine release, and can be minimized.

Climacteric syndrome (syn.: menopausal syndrome)

The mean age of menopause is about 51 years, with a normal

distribution curve and 95% confidence limits between ages 45 and 55. The

average life expectancy for a woman in the Ukraine is about 75 years, and

about one-third of a woman's life will be spent after menopause. This time of

life should be considered an estrogen-deficiency state, and improvement in

both the quality and the quantity of life can be obtained with the use of

estrogen replacement during the postmenopausal years.

Clinical picture

The climacteric syndrome is a complex of abnormal symptoms, which

occur in menopausal period. The clinical picture is characterized by

vegetovascular, endocrine and neuropsychic disorders. The main causes of

menopausal syndrome are the age-related changes in the hypothalamic

centers: decreased level of FSH, LH, reduced level of circulating estrogens

and progesterone. The androgen androstenedione is reduced by half, but

testosterone decreased only slightly.

Genitourinary effects

Atrophy of the genitourinary tract can produce symptoms of atrophic

vaginitis, with itching, burning, dyspareunia (painful coitus), and possible

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vaginal bleeding. Local estrogen therapy rapidly relieves these symptoms, but

because vaginal administration of estrogen results in irregular systemic

absorption, estrogen is best administered systemically for long-term

prevention of vaginal atrophy as well as osteoporosis. Estrogen deficiency

may also cause uterine prolapse because the supporting ligaments lose their

tonicity. In addition, cystocele and rectocele may develop as a result of

estrogen deficiency. These changes can be prevented or alleviated by

administering estrogen. The trigone of the bladder and the urethra are

embryologically derived from estrogen-dependent tissue, and

postmenopausal estrogen deficiency causes atrophy of these structures,

producing symptoms of urinary urgency, incontinence, dysuria, and urinary

frequency. Because of atrophy of collagen in the periurethral fascia, urinary

stress incontinence can also occur. If these symptoms develop after

menopause, estrogen replacement alleviates the problem in a high percentage

of women.

Central nervous system changes

The pathognomonic symptom of the menopause is the hot flush or

flash, which is caused by a decrease in circulating estrogen levels. The best

treatment for the hot flush is estrogen, which has been shown to alleviate

symptoms better than placebo. It is best to administer estrogen at bedtime to

prevent the hot flushes that can interfere with sleep. The usual initial dosage

is 0. 625 mg of conjugated estrogen (Premarin), or 1 mg of estradiol, although

higher doses may be necessary, especially when the ovaries are removed in a

premenopausal individual. For women with contraindications to estrogen

therapy (for example, cancer of the breast or endometrium), other

medications that are effective in treating hot flushes include oral

medroxyprogesterone acetate (Provera) in a dosage of 10 mg per day. Hot

flushes can also be relieved by a single injection of Depo-Provera, 150 mg

given once every 3 months. In addition, clonidine (Catapres) in a dosage of

150 µg per day can also reduce the incidence of hot flushes.

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Symptoms such as anxiety, depression, irritability, and fatigue increase

after the menopause, and it has been shown that estrogen replacement

significantly relieves these symptoms even in women who do not have hot

flushes that interfere with sleep. In addition to decreasing the incidence of

depression, recent studies show that estrogen users are less likely to develop

Alzheimer's disease. Because urinary incontinence and dementia are the two

major reasons why women are admitted to chronic care facilities, estrogen

replacement can enable them to stay in a self-care environment.

Studies have shown that postmenopausal estrogen users have a

significantly thicker skin and a greater amount of collagen in the dermis than

do postmenopausal women who do not use estrogen. Thus, systemic estrogen

use can retard the wrinkling and thinning of the skin that occurs

postmenopausally.

Osteoporosis

Postmenopausal osteoporosis affects about 25% of women but is

uncommon in black persons and in obese women. In thin white and Asian

women, about 1% to 1. 5% of bone mass is lost each year after the menopause.

Bone loss is more rapid in trabecular bone, which is found mainly in the

thoracic spine, than in cortical bone, which is present in the axial skeleton.

Beginning about age 60, fractures occur in the vertebral spine as well as the

distal portion of the radius, which is also composed of trabecular bone. The

incidence of fractures of the neck of the femur, which is made up mainly of

cortical bone, usually start to increase at about age 70 and increase at a

logarithmic rate thereafter. Estrogen therapy reduces the bone loss associated

with postmenopausal osteoporosis and thus reduces the fracture rate in

women, prolonging their productive life span as well as providing great

savings in health care costs. Supplemental calcium therapy and weight-

bearing exercise are ancillary measures that, by themselves will retard but not

prevent postmenopausal bone loss. The following factors are known to

increase the risk of osteoporosis: (1) reduced weight for height; (2) early

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spontaneous menopause or early surgical menopause; (3) family history of

osteoporosis, (4) a diet low in calcium intake, high in caffeine intake, or high

in alcohol intake; (5) cigarette smoking; and (6) sedentary lifestyle. Routine

screening by densitometry or computed tomography scanning is not cost

effective and is not recommended to determine whether osteoporosis is

developing postmenopausally.

Osteoporosis is associated with an increased rate of bone resorption,

and the administration of estrogen will return the resorption rate to normal.

Numerous prospective and retrospective epidemiologic studies have shown

that estrogen therapy reduces the amount of postmenopausal bone loss:

When estrogen is discontinued, the rate of bone loss rapidly increases to the

same rate as that occurring immediately postmenopausally. Therefore,

estrogen replacement therapy should be maintained as long as a woman is

ambulatory. The minimum dosage of estrogen needed to prevent osteoporosis

is 0. 625 mg of conjugated equine estrogen (Premarin), 0. 625 mg of

piperazine estrone sulfate (Ogen), or 0. 5 mg of micronized estradiol

(Estrace). It is recommended that in addition to estrogen, about 700 mg of

calcium should be ingested daily, and weight-bearing exercise such as walking

should be encouraged. Supplemental use of vitamin D is of no benefit. There

is no need for additional calcium supplementation beyond the 700 mg of daily

dietary calcium in women receiving adequate estrogen replacement.

Cardiovascular effects

Because estrogen replacement regimens have a minimal effect on liver

globulins, postmenopausal estrogen users do not have an increase in mean

blood pressure compared with women not ingesting estrogen. It is safe to

provide estrogen replacement for postmenopausal women with or without

pre-existing hypertension. Because natural estrogens do not produce a

hypercoagulable state, available data indicate that postmenopausal women

with or without a past history of thrombophlebitis do not have an increased

incidence of thrombophlebitis with estrogen replacement therapy. Use of

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estrogen replacement has been shown in numerous retrospective as well as

prospective epidemiologic studies to reduce the risk of myocardial infarction

by about 50%. Estrogen replacement also reduces the risk of stroke by about

50%. Oral estrogen increases levels of the cardioproductive high-density

lipoprotein cholesterol as well as directly increasing coronary artery blood

flow. The substantial reduction of rate of myocardial infarction, which is the

major cause of mortality in women, is a major beneficial effect of estrogen.

Age-adjusted data from several studies indicate that the mortality rate from

all causes is significantly lower in estrogen users than in nonusers.

Neoplastic effects

Six meta-analyses, each combining the data of several epidemiologic

studies, have shown there is no significantly increased risk of breast cancer in

women using estrogen replacement therapy compared with nonusers. Only a

few of any epidemiologic studies investigating the relation of estrogen use and

breast cancer have shown an increased risk of breast cancer in some subsets

of postmenopausal estrogen users, specifically long-term users of high doses

of estradiol but not conjugated equine estrogen. Several studies show no

effect of conjugated equine estrogen on this cancer. Because estrogen can

stimulate the growth of a nonpalpable breast cancer, it is advisable that all

women have mammograms performed before the initiation of estrogen

therapy. If no tumor is found, patients can be told that oral estrogen use will

not increase the risk of developing breast cancer. There is a significantly

increased risk of developing endometrial cancer in postmenopausal women

who are ingesting estrogen without progestins. This risk increases with

increased duration of estrogen use as well as with increased dosage. The

endometrial cancer that develops in estrogen users is usually well

differentiated and is usually cured by performing a simple hysterectomy. The

increased risk of developing this endometrial carcinoma in women receiving

estrogen replacement can be eliminated by also administering progestins. The

duration of progestin therapy is more important than the dosage, and it is

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now recommended that the progestin be administered for at least 12 days per

month. The addition of progestin to the estrogen therapy acts synergistically

to cause a slight increase in bone density. However, progestins reverse some

of the beneficial effects of estrogen on serum lipids and, thus, should not be

given to women who do not have uterus. Several epidemiologic studies

investigating the use of progestins with estrogen and the risk of breast cancer

have yielded conflicting results. Therefore, a beneficial effect of progestin on

breast cancer risk has not been substantiated.

Treatment regimens

The treatment consists of replacing hormonal therapy. The treatment

regimen is mostly the sequential regimen of 0. 625 mg of conjugated

estrogen or 1 mg of estradiol orally for the first 25 days each month.

Beginning on day 12 to 15 of estrogen treatment, 5 to 10 mg of

medroxyprogesterone acetate is added daily for 10 to 13 days. With this

regimen, more than half of the women have regular withdrawal bleeding, an

annoying problem that decreases patient compliance to continued use. It is

not necessary to have withdrawal bleeding to slough the endometrium, to

reduce the risk of endometrial cancer. A continuous regimen in which the

estrogen is given daily together with a small dose of oral progestin, such as 2.

5 or 5 mg of medroxyprogesterone acetate, reduces the chance of developing

uterine bleeding as well as avoiding a week off treatment, in which symptoms

may appear.

Climonorm (two types of tablets: estradiol and estradiol + levonorgectrel),

climen (estradiol and estradiol + ciproteron), climodien (estradiol and

dienogest), climara (plaster), divigel (gel) as combined replacing hormonal

therapy may be administered.

Most women do not bleed on this regimen, and the endometrium usually

remains atrophic.

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Post-castration Syndrome

This is a combination of neuropsychic, vegetovascular, and endocrine

disorders. It develops after surgical operations in which the ovaries are

removed. The clinical signs are similar to those at menopausal syndrome:

irritability, fatigability, afflux of fever, tachycardia, violation (disturbance) of

dream, memory etc.

Treatment

It should be combined and include therapeutic gymnastics,

balneotherapy, sedative therapy, physiotherapy, and replacement hormonal

therapy (or additional hormonal therapy). Oral contraceptives are useful as

replacement combined hormonal therapy.

Mono-phase: marvelon, janin, logest, miniziston, microginon -1 tablet once a

day during 21 day is starting from the 1 day of menstrual cycle, then 7 days-

interval (without tablets).

Two-phase: anteovin, and three-phase: trimercy, triregol, tricvilar – 1 tablet a

day from the 1 day of menstrual cycle, then 7 days-interval.

The Stein-Levental Syndrome also known as polycystic ovarian disease is an

important cause of secondary amenorrhea in young women. Main complaints

are amenorrhea with hirsutism and infertility.

These patients are infantile, often obese, hirsute and frequently have

hyperplasia of the breast. On vaginal examination, either ovaries are enlarged

to two or three times their normal size and, laparotomy shows a firm, rubbery

consistence. Estrogen and 17-ketosteroid excretion levels are normal and the

latter point differentiates the Stein-Levental from the adreno-genital

syndrome. Luteinising hormone (LH) level is raised. LH/FSH ratio is raised.

At operation, multiple cysts are found on the surface of the ovaries and, on

histological examination, a thick layer of theca cells surrounds the cysts. No

corpus luteum is present. The endometrium is estrogenic and there is no

secretors change. It is suggested that the hyperthecosis is androgen-

producing and is responsible for hirsutism. Ultrasound reveals multiple small

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cysts on the surface of the both ovaries, and laparoscopy is not always needed

to confirm the diagnosis.

Treatment

Bilateral wedge resection of the ovaries, at one time very popular, is now

not recommended because of postoperative ovarian adhesion formation.

Laparoscopic multiple punctures of the ovaries with monopolar cautery or

laser is recommended in women who do not respond favorably to medical

treatment.

Clomiphene is the drug of choice in infertile patients suffering from

polycystic ovaries. It is of utmost importance, however, that patients should

be properly and adequately investigated before commencing treatment with

clomiphene, the dosage of which is 50-100 mg daily for five days each month,

for six months. Those not responding to drug therapy should have

cauterization or laser ablation of the cysts laparoscopically, preferably under

videopelviscopy. Menses are restored and 60% conceive.

Adreno-genital syndrome (adrenal virilism, AGS)

This is due to hyperplasia of the adrenal cortex and there are two types:

congenital and post-natal.

CONGENITAL OR INTRAUTERINE ADRENO-GENITAL

SYNDROME

It is a syndrome in which the primary defect is a block in the conversion

of 17-hydroxy progesterone into hydrocortisone due to enzyme failure. The

normal adrenal cortex produces three C21 compounds: hydrocortisone,

corticosterone and aldosterone, and in addition, certain androgens - C19

compounds. The production of 17-hydroxy-progesterone, which is mildly

androgenic in action, is controlled by ACTH, and this in turn is controlled by

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the reciprocal action of hydrocortisone. If therefore the hydrocortisone -

ACTH interaction is upset by a deficiency of hydrocortisone, the pituitary

produces an excess of ACTH, which in turn leads to adrenal cortical

hyperplasia and excess output of androgens, notably 17-hydroxy-

progesterone. The main androgenic activity of 17-hydroxyprogesterone is due

to its conversion into Д4 androstenedione and hence to other orthodox

androges. These androgens are responsible for phallus of the female

pseudohermaphrodite showing hypertrophy, the masculine appearance of the

glans, and the persistence of fusion of the labia majora to resemble a scrotum.

The miniature vagina opens into the urogenital sinus and the external

appearance is that of a male with hypospadias.

The diagnostic feature is the very high value of 17-ketosteroids excreted.

As expected the chromosomal pattern in these girls is invariably XX.

Clinical features. The chromosomal and gonadal sex is female and the

accessory sex organs of Mullerian origin are also feminine. The external

genitalia, however, resemble the male. The body conformity is largely male

with good muscular development and broad shoulders. The voice is deep and

the thyroid cartilage is prominent. Hirsutism is present to a remarkable

degree, with a male distribution of hair. The psycological sex is often, but not

invariably, male.

The external genitalia show hypertrophy of the clitoris and fusion of the

labia majora due to failure of the cloacal membrane to divide. The vagina is

often absent if the cause is congenital. The breasts are under-developed.

Treatment of this condition consists in the administration of cortisone or

hydrocortisone or the newer synthetic corticosteroids such as prednisone or

prednisolone (2. 5 mg twice daily is an adequate maintainance dose in the

adult and will restore the output of 17-ketosteroids to normal). The continued

use of these drugs carries certain dangers of adrenal deficiency due to

suppression of ACTH and this especially operates at times of stress such as

when a patient needs an anaesthetic, at which time cortisone coverage should

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be given during the period of stress (i. e. one day before, on the day of

operation and for three days afterwards).

The vulval abnormality is simply corrected by a small plastic operation and as

a rule it is wise to amputate the hypertrophied clitoris between 5 and 10 years

of age.

Certain cases of virilization of the fetus in-utero have been reported following

the use of progesterone in the pregnant mother. The synthetic progestogens

ethisterone and nor-ethisterone are comparatively more androgenic. In fact

all progestogens if given in sufficient dosage are suspect with the exception of

17-hydroxyprogesterone caproate, so that if progestogen is to be used at all on

the pregnant woman, this is the drug of choice.

The effect on the fetus depends largely on the duration of the pregnancy at the

time of administration and the dosage employed. If progestogens are given

before the 12th - 14th weeks of gestation, the neonatal picture may be similar

to that of the intrauterine adreno-genital syndrome, i. e. enlarged phallus and

imperforate perineal membrane.

POST-NATAL ADRENO-GENITAL SYNDROME

This can be due to excessive output of ACTH from a basophil adenoma

of the anterior pituitary (Cushing's syndrome) which gives rise to adrenal

cortical hyperplasia. An adrenal tumour, which can be benign or malignant,

has the same effect. An adrenal tumour is not dependent on pituitary

influence.

Certain virilising tumours and conditions of the ovary such as

arrhenoblastoma, hilus cell tumour, Stein-Leventhal syndrome and hyper-

thecosis. These ovarian causes of virilism produce a clinical picture,

somewhat similar to the postnatal adreno-genital syndrome, and, are due to

excess of testosterone secreted by the ovary. In the postnatal variety of

virilism, the genital tract is normal but the clitoris enlarges, the uterus

atrophies with resulting amenorrhoea, the voice deepens, hirsutism is marked

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and the breasts atrophy. 17 -ketosteroids excretion is raised only if the adrenal

gland is hyperplastic or neoplastic, whereas with a virilising ovarian tumour it

is unaltered. (Fig. 150)

Treatment. If the fault is an enzyme block at the level of 17-

hydroxyprogesterone, the administration of cortisone or synthetic

corticosteroids will effectively control the excess production of ACTH. The

external genitalia can be restored to a feminine pattern by plastic surgery, e.

g. the formation of an artificial vagina if the patient is engaged or married.

Cortisone therapy, if successful, may restore menstruation in a patient with

amenorrhea. It is important in such patients to correct any anatomical defects

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of the lower genital tract in order to obviate the complication of retained

menstrual products such as haematocolpos or haematometra.

If the virilism is due to adrenal hyperplasia or tumor, surgical removal is

the method of choice. This also applies to ovarian androgenic tumors.

A regular maintenance dose of estrogen is usually effective in restoring

some of the secondary sex characteristics, e. g. breast development.

Additional intermittent progesterone therapy prevents breast and uterine

malignancy.

The most effective treatment of facial hirsutism is shaving and

cosmetics.

Icenko-Cushing Disease is due to a basophile adenoma of anterior

pituitary gland, which leads to hyperfunction of the suprarenal cortex. The

main symptoms and signs are those due to a disorder of the suprarenal gland.

(Fig. 151)

Sheehan’s Syndrome. It is the condition, which develops owing to

excessive post-partum hemorrhage, and results with vascular thrombosis

leading to extensive pituitary necrosis. In the fully developed case, all

pituitary functions are suppressed so that the syndrome consists of frigidity,

amenorrhea and loss of thyrotropic hormone. The patient is lethargic and

poikilothermic. The blood sugar is lowered. In some cases there is no loss of

weight and no wasting, though this feature is often included in the syndrome.

Auxiliary and pubic hair is lost and the uterus on bimanual examinarion is

hypoplastic. Skin pigmentation is also deficient, but the patient will often

show areas of the erythema where in attempt to keep warm she has burned

her legs in front of the fire. (Fig. 152)

Chiari-Frommel Syndrome. It is an interesting example of pituitary

dysfunction. Amenorrhea, persistent galactorhea, obesity and headache occur

after delivery. Follicle stimulating hormone (FSH) excretion is diminished

while luteinizing hormone (LH) is increased and lactogenic stimulation

causes increased prolactin secretion. The occasional finding of expansion of

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the pituitary fossa on X-ray suggests an acidophil adenoma as possible cause

and this may later lead to narrowing of the visual field.

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Self test

1. Premenstrual changes usually occur during

A. the luteal phase of the ovulatory cycle

B. the follicular phase

C. the ovulation

D. desquamation phase

2. Which of the following drugs may be used to relieve headaches, muscle, and

joint pain in patients with PMS?

A. tylenol

B. cortizol

C. analgin

D. promedol

3. Parlodel is usually used for treatment of

A. patients with PMS

B. patients with climacteric syndrome

C. patients with post-castration syndrome

D. Icenko – Cushing disease

4. The following factors are known to increase the risk of osteoporosis, except of

A. reduced weight for height

B. early spontaneous menopause or early surgical menopause

C. a diet low in calcium intake, high in caffeine intake

D. increased body weight

5. What drugs cannot be used for replacing of hormonal therapy in patients with

climacteric syndrome?

A. climen

B. climodien

C. climara

D. progestogel

6. The main cause of adreno-genital syndrome is

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A. the hyperplasia of the adrenal cortex

B. the hypoplasia of the adrenal cortex

C. congenital underdevelopment of the adrenal cortex

D. congenital underdevelopment of adnexa

7. Main complaints of the Stein-Levental syndrome are

A. amenorrhea with hirsuties and infertility

B. amenorrhea with galactorrhoea

C. uterine bleeding and infertility

D. persistent obesity and headache

8. Icenko – Cushing disease is due to a basophil adenoma of

A. anterior pituitary gland

B. adrenal gland

C. hypothalamus

D. ovary

9. All of the following are symptoms of Chiari-Frommel disease, except of

A. amenorrhea

B. persistent galactorhea

C. obesity and headache

D. anovulatory cycles

10. Congenital adreno-genital syndrome usually happens due to

A. abnormal conversion of progesterone

B. abnormal conversion of cortisol

C. abnormal conversion of epinephrine

D. abnormal conversion of estriol

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Chapter 8. THE INFERTILE COUPLE

The couple is considered infertile if it has failed to conceive within two

years of unprotected sex life.

If a couple has never achieved pregnancy at any time the infertility is

described as primary; if infertility follows a pregnancy, whatever the outcome,

it is called secondary. Infertility is not an independent disease but a symptom

of various illnesses. Sterility may be classified as male and female infertility.

Male infertility

Male infertility occurs in about 15 per cent of sterile marriages. The

most common cause of male infertility is impaired spermatogenesis due to

inflammatory processes, injuries, damaging chemical and thermal factors,

alcoholism, and neuroendocrine disturbances. Male infertility may also link

cicatricial changes in the deferent duct and urethra. Spermatogenesis may be

depressed by many factors including excessive smoking or alcohol

consumption and overwork. Infertility may be due to azoospermia (absence of

spermatozoa), neсrospermia (dead or motionless spermatozoa), aspermia

(failure of formation or emission of sperm), oligospermia(deficiency of

spermatozoa). Qualitative changes of sperm may lead to infertility and

depend on the biochemical composition of the seminal fluid.

Diagnosis. In some cases the cause of male infertility may be

established already after the patients questioning and inspection. But the

examination of sperm is a more important method of diagnosis. Fresh sperm

is obtained by masturbation and kept in a sterile glass vessel at less than body

temperature during transit to the laboratory, which should be reached within

one or two hours.

Normally, the volume is 2. 5-5 ml, with an alkaline pH about60-80% of

sperms are motile within two hours; about 50% are motile within 4 hours. As

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to sperm count, the normal range is 60-150 million/ml and 20 million/ml is

considered the minimum requirement for fertility. A normal specimen

contains abnormal forms, but less than 25%.

Seminal fluid contains both sperms and plasma. Biochemical investigation of

the plasma gives an index of the function of the male accessory glands.

Fructose, from the seminal vesicle, provides the spermatozoa with the energy

requirements. Phosphate, from the prostate, and glyceryl phosphoryl choline,

from the epididymis, can also be measured. If all these are normal the

deferent duct must be patent and accessory gland function is normal.

In addition a post-coital examination of the cervical mucus for the presence of

sperms may be made.

Female infertility

The causes of infertility in the female can be divided into 5 groups,

which indicate the main areas requiring investigation. The incidence of these

cases is as follows:

Hormonal factors controlling the process of ovulation – 41%.

Abnormalities involving the fallopian tube – 32%.

Uterine factors – 16%.

Cervical factors – 4-5%.

General factors – 4-5%

In some patients no abnormality can be found. The incidence of these

cases is around 5%.

Hormonal Factors

In normal circumstances the control of these factors is initiated at

hypothalamic level.

Primary hypothalamic failure is rare and only occurs as a congenital

autosomal condition. Secondary hypothalamic failure is comparatively

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frequent. In the majority of cases it is a functional condition, the result of a

psychological upset at anorexia nervosa.

Pituitary factors are not so common and are usually limited to two

situations: 1) Hyperprolactinemia, which may be caused by an adenoma of the

pituitary gland, pregnancy or drugs which are antagonistic to dopamine. The

patient frequently complains of amenorrhea, loss of libido and occasionally

may show signs of acromegaly. 2) Pituitary damage by injury or ischemia.

Gonadotropin secretion becomes deficient but more commonly secretion of

all pituitary hormones ceases. The best known clinical example of this is

Sheehan’s syndrome caused by shock due to gross hemorrhage in pregnancy.

Ovarian factors. This group of patients often presents the greatest

difficulty in determining where the fault lies. In some the cases of anovulation

are obvious. Examples are ovarian damage by radiotherapy or chemotherapy,

congenital or genetic disorders, some ovulatory cyclic ones (incompetence of

the luteal phase). Premature menopause is another such condition.

Anovulation is responsible for around 25% of cases of infertility. The

most important ovarian abnormality is the polycystic syndrome. In

approximately 80% of cases menstruation is irregular or absent. It is difficult

to determine whether the initiation of this syndrome is due to a defect in

pituitary or ovarian function. There appears to be an excess of LH production

plus a diminished FSH secretion. The result is a lack of estrogen and an

excess of androgenic substances.

Two other conditions have been suggested as ovarian causes of

infertility. The first is the Luteinized unruptured follicle syndrome (LUF).

In this condition the cyclical changes in endocrine values are apparently

normal, the granulosa layer undergoes luteinization but the follicle fails to

rupture. Diagnosis is very difficult because of normal tests of functional

diagnosis, and normal hormonal level in blood and urine. A luteinized

unrupted follicle can be found in an ovary containing a fresh corpus luteum.

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Another cause of infertility is luteal phase deficiency, either deficient

in length or deficient in progesterone production. It results in incomplete

secretory change of endometrium and violation of an implantation of

fertilized ovum.

Abnormalities of Fallopian Tubes

There are two prominent etiological factors producing changes in the

fallopian tubes leading to infertility. The main factor is infection. This may be

sexually transmitted. Two of the commonest organisms are chlamydia and

gonococci. In many cases, however, the infection arises as a result of

termination of pregnancy, abortion, wearing an intrauterine contraceptive

device and inflammatory condition in other abdominal organs. The damage of

the tubes may be mild, consisting of destruction of the epithelial cilia, but

more commonly the changes are gross and lead to obstruction of the tube, to

pelvic adhesions, etc.

The second factor is endometriosis. Not only endometriosis per se is

important, it is the adhesions formed during the healing of hemorrhages,

especially if these affect the ovary. One more cause is careless surgery.

Uterine Factors

The uterus performs many significant roles in reproduction.

There are several uterine lesions, which can lead to infertility.

Sometimes fibriods can cause gross destruction of the cervical canal, the

uterine cavity or tubal ostia and careful removal will relieve the infertility.

Endometriosis is another condition which certainly results in infertility and

leads to internal adhesions. Chronic endometritis is also one of the reasons of

infertility. It may be nonspecific and specific inflammation (for example,

tuberculosis, which leads to intra- uterine adhesions, or synechiae). Other

factors are congenital abnormalities of the uterus and vagina (uterus

didelphys, bicornus, septus, atresia or aplasia of vagina etc.).

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Cervical Factors

The main problem is damage to the cervix due to childbirth or

spontaneous abortion in late terms of pregnancy, or surgery (careless

dilatation of the cervical canal during artificial abortion, diagnostic curettage

etc.). Thick mucus has been blamed for obstructing the passage of sperm.

Some women have antibodies to their husband’s sperm and positive test

can be demostrated in both plasma and cervical mucus. These cases are rare.

Genital Infantilism and hypoplasia also account for a considerable

number of infertility cases. In this event infertility is due to both anatomical

and functional peculiarities of the genital system linked to its

underdevelopment (long narrow cervical canal, decreased hormonal function,

impaired function of the oviduct etc).

General Factors

Poor general health due to social behaviour may be important. Drugs,

alcohol, smoking, caffeine and obesity will all defect fertility. Similarly,

exposure to toxic chemicals and pesticides at work will influence fertility

although this is more likely in the case of men.

Investigation and Treatment of the infertile couple

Confirmation of ovulation.

Seminal fluid analysis and postcoital test.

Tests for tubal patency.

Endometrial sampling by biopsy.

Endometrial culture to determine the infection.

Hysterography, hysteroscopy.

Laparoscopy.

Postcoital test.

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Postcoital test.

Mucus is examined between 2 and 3. 5 hours after coitus at midcycle for

total number of sperm seen per high-powered field and percentage and

quality of motility. A satisfactory test is one in which more than 10 motile

spermatozoa are seen per high-powered field. An unsatisfactory test (no or

few spermatozoa seen; nonmotile spermatozoa or those with a “shaking”

movement) may be the result of:

azospermia (no spermatozoa in ejaculate),

poor inherent spermatozoa motility,

hostile cervical mucus (infection, antidodies, or not enough estrogen),

poor coital technique.

Treatment of infertility

The aim of the treatment is elimination of the underlying cause

(antiinflammatory, surgical, hormonal).

Treatment of hypothalamic is dependent on underlying condition

(stress, failure of blood supply, tumors etc0.

Treatment of ovarian factors

Ovulation induction. The ovulation induction agents used include

clomiphene citrate (CC), Human menopausal gonadotropin (hMG), Human

Chorionic gonadotropin (hCG), recombinant FSH, and recombinant LH.

Recommended Regimen of Clomiphene citrate (CC) (basic):

The standard dose of CC is 50 mg PO qd for 5 days, starting on the 5th

day of menstrual cycle or after progestin-induced bleeding.

The CC response is monitored using pelvic US starting on the 12th

menstrual cycle day. The follicle should develop to a diameter of 23-24

mm

If a dominant follicle develops, but there is no spontaneous LH surge,

hCG (10,000 units given intramuscularly) can be used for final follicular

maturation/ovulation, followed by timed intercourse or IUI.

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Luteal phase defects treatment. Intramuscular or intravaginal

progesterone until the luteoplacental shift occurs at 8–10 weeks gestational

age.

Treatment of hyperprolactinemia. The aim is blocking of the release of

prolactin from pituitary gland.

Recommended Regimen:

Bromocriptine: 2.5mg on first day, increasing after 2 to 3 days to 2.5mg

twice daily for 14 days.

Treatment of tubal factors

For treatment of inflammations of Fallopian tubes special

investigations, antibacterial, anti-inflammatory treatment are indicated. If

ineffective- assisted reproductive techniques up to gestational carrier may be

used.

Tubal obstructions, adhesions, hydrosalpinx need in surgical correction:

tubal cannulation, microsurgical tubo-cornual reanastomosis. If necessary –

in vitro fertilization may be used.

Treatment of uterine factors

The treatment of uterine factors depend on underlying disease.

The treatment of uterine malformations depends on the severity of the

problem. Unicornuate uterus: patient can have norml pregnancy

Bicornuate uterus: can be associated with a history of recurrent miscarriages,

and its repair is indicated only if other etiologies for the miscarriage have

been excluded.

Arcuate uterus: In general, an arcuate uterus does not cause infertility.

Whether it should be corrected in cases of primary infertility is controversial.

Septate uterus: The hypothesis that a uterine septum can cause infertility is

controversial. Advising surgery in cases of primary infertility is difficult. The

avascular nature of the septum is theorized to interfere with implantation and

maintenance of the embryo.

Uterine malformations: not require treatment /or plastic surgery/ART

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Uterine synechiae: are corrected using operative hysteroscopy.

Leyomyoma, adenomiosis – medication/surgery.

Treatment of cervical factors

Chronic cervicitis should be treated with anti-inflammatory and antibacterial

drugs, physiotherapy.

Treatment of cervical incompetence is surgical:

application of special sutures during pregnancy, known as cervical

cerclage

plastic surgery of the cervix before pregnancy

Assisted Reproductive Techniques

In vitro fertilization is used increasingly, e. g., for patients with tubal

disease, endometriosis, oligospermia, sperm antibodies, and unexplained

infertility. The procedure involves ovarian hyperstimulation, oocyte retrieval,

fertilization, embryo culture, and embryo transfer. Ovarian hyper-stimulation

with clomiphene citrate and HMG, HMG alone, or a GnRH agonist plus HMG

causes 1 to 20 oocytes to mature, depending on the patient's age and ovarian

reserve. After follicular growth is sufficient, hCG is given to induce final

follicular maturation. About 34 h after hCG administration, the oocytes are

retrieved by direct needle puncture of the follicle, usually transvaginally with

ultrasound guidance or less commonly with laparoscopy. The oocytes are

inseminated in vitro with washed sperm, and the embryos are cultured for

about 40h, after which three to four embryos are transferred to the uterine

cavity. Additional embryos can be frozen in liquid nitrogen for transfer in a

subsequent natural cycle. Despite the transfer of multiple embryos, the

average term-pregnancy rate is about 20 to 25% per attempt.

Gamete intrafallopian tube transfer (GIFT) may be used for women

who have normal tubal function and unexplained infertility or endometriosis.

Multiple oocytes and sperm are obtained as for in vitro fertilization but are

transferred—laparoscopically or transvaginally with ultrasound guidance—to

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the distal fallopian tubes, where fertilization occurs. Success rates are about

25 to 35% at most infertility centers.

Other procedures include a combination of in vitro fertilization and

GIFT, zygote intrafallopian tube transfer, use of donor oocytes, and transfer

of frozen embryos to a surrogate mother. Some of these techniques raise

moral and ethical issues—eg, disposition of stored embryos (especially in

cases of death or divorce), legal parentage in surrogate motherhood, and

selective reduction of the number of implanted embryos in multiple

pregnancies.

Intracytoplasmic sperm injection is the primary method of achieving

pregnancy when other techniques have not resulted in fertilization or when

the semen analysis detects marked abnormalities. Sperm is injected into the

oocyte, bypassing sperm abnormalities that affect attachment to or

penetration of the oocyte.

Self test

1. The most serious causative factor of infertility that can be reflected in the

postcoital test is

A. azoospermia

B. congenital abnormalities of the uterus

C. tubal dysfunction

D. luteal dysfunction

2. Which of the following procedures is not appropriate for the evaluation of the

endometrial cavity?

A. laparoscopy

B. endometrial biopsy

C. hysteroscopy

D. endometrial culture

3. Which of the following does not indicate ovulation?

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A. rise of basal temperature

B. secretory endometrium

C. occurence of menses

D. estrogen level dropping

4. Which of the following is not reflected in postcoital test?

A. blocked fallopian tubes

B. low sperm count

C. poor sperm motility

D. high sperm count

5. Which of the following does not contribute to abnormalities in the cervical

mucus?

A. colonization of the cervix with cytotoxic organisms

B. uterine retroversion

C. antisperm antibodies

D. uterine anteflexion

6. What is the indication for in vitro fertilization?

A. oviduct diseases

B. hormonal disturbances

C. vaginal atresia

D. intrauterine synechia

7. What is the indication for gamete intrafallopian tube transfer?

A. normal tubal function and unexplained infertility

B. oviduct diseases

C. hormonal disturbances

D. chronic inflammatory processes of genital organs

8. The incidence of hormonal infertility is

A. 41%

B. 32%

C. 16%

E. 4-5%

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Chapter 9. CONTRACEPTION

Advice on family planning is an important part of gynecological

practice. Such advice is not only for benefit of the individual woman, but also

is of world-wide importance.

Methods will be described in rough order of effectiveness.

Methods can be divided into:

Sterilization

Hormonal contraception

Intrauterine devices

Mechanical methods

Chemical methods

Contraception based on time of ovulation

Coitus interruptus.

Sterilization

Sterilization, named surgical contraception. This method of

contraception is permanent and is therefore only used for those with

completed families or with medical contraindications to pregnancy. Before

sterilization of either partner it is important to obtain detailed information

about the family unit, with social and medical histories and the reasons for

preferring sterilization to contraception. It is wise to obtain the written

consent of both partners.

Female sterilization is performed:

By excision of parts of both tubes and ligature of the cut

ends, through a small abdominal incision. (Fig.153)

By diathermy coagulation of a section of each tube with the

aid of a laparoscope. Another type of sterilization is

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occlusion of the tube by the application of clips or rings

under laparoscopic vision (Fig. 154)

Occasional failures occur with either method, usually because of

recanalization of the uterine end of the tube.

Male sterilization. Vasectomy is usually performed under local

anesthesia. Through a small scrotal incision the deferent duct is identified,

and after excising a small section both ends are doubly ligatured. (Fig. 155).

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Hormonal contraception

Two main types of hormonal contraception are now commonly used:

oral and injections. More common type is oral contraception. Besides,

transdermal administration is useful nowadays. Though, intravaginal

administration of hormonal contraceptives is used too.

Oral contraceptives

Oral contraceptives are subdivided into combined and those containing

only progestogen (acontinuous method).

Combined oral contraceptives

Combined oral contraceptives (COCP) - is the usual method with a very

low failure rate. A pill containing synthetic estrogen plus progestogen is taken

each night for 21 days starting on the 5th day of menstrual cycle. There are

then 7 days without tablets and during this week a withdrawal bleeding

occurs. If the patient forgets to take the pill on one evening she should take

two pills the next night. If the bleeding does not occur within 7 days of taking

the last tablet the next course still begins. In the unlikely event of two

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“periods” being missed the patient should have a pregnancy test. To ensure

maximum contraceptive efficacy, oral contraceptives should be taken as near

as possible to the same time each day (i. e., at regular 24-hour intervals). Most

oral contraceptives are commercially available in a mnemonic dispensing

package that is designed to aid the user in complying with the prescribed

dosage schedule; these containers should be used whenever possible.

Many сombined contraceptives are available. They may be mono-phase,

two-phase and three-phase. In modern practice the lowest effective dose of

estrogen is used to reduce the risk of thrombosis. The dose of progestogen

may be varied.

Mono-Phase

Those tablets contain the same dose of estrogen+ progestogen for 21 or

22 days of cycle, and then there is a 7-day interval without tablets.

For example:

Minovlar Ethinylestradiol 0. 05 mg + norethisterone acetate 1mg

Euginon 50 Ethinylestradiol 0. 05 mg + d-norgestrel 0. 5 mg.

Others: Ovidon, Marvelon, Minulet.

Two-Phase

Those sets contain two types of tablets: for the 1st phase (from the 5th to

15th day of the cycle) – only estrogen, or estrogen + the least dose of

progestogen, and for the 2nd phase (from the 16th to 25th day of the cycle) –

usual combination (scheme) of estrogen + progestogen.

For example:

Anteovin Ethinylestradiol 0. 05 mg + levonorgestrel 0. 05 mg

Ethinylestradiol 0. 05 mg + levonorgestrel 0. 125 mg

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Three-Phase

There are different contents of estrogen and progestogen for different

days of cycle, like in normal menstrual cycle. Usually those drugs are of low

dosage.

For example:

Tri-Regol Ethinylestradil 0. 03 mg + levonorgestrel 0. 05 mg

(6 yellow tablets) for the 1st phase.

Ethinylestradiol 0. 04 mg + levonorgestrel 0. 075 mg

(5 tablets of apricot colour) for the 2nd phase.

Ethinylestradiol 0. 03 mg + levonorgestrel 0. 125 mg

(10 white tablets) for the 3rd phase.

Others: Loginon, Trisiston, Triphasil, Ortho-Tri-Cyclen, Tri-Norinyl.

Combined hormonal contraceptives may be used in injections.

For example:

Ciclofem Estradiol sipionat 0. 05 mg + medroxyprogesterone acetate 0.

25 mg . Injection once monthly.

Mesigina Estradiol valerianat 0. 05 mg + noretindron enantat 0. 50 mg.

Injection once monthly.

Four-phase

Qlaira (Natazia) is 4 progestin/estrogen dosing combinations during

each 28-day cycle and is the first "4-phasic" oral contraceptive. It also is the

first contraceptive to contain the bioidentical synthetic estrogen estradiol

valerate, rather than ethinyl estradiol. It is composition of the colored tablets

containing one or two active substances:

2 dark yellow tablets each containing 3 mg estradiol valerate

medium red tablets each containing 2 mg estradiol valerate and 2

mg dienogest

17 light yellow tablets each containing 2 mg estradiol valerate and

3 mg dienogest

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2 dark red tablets each containing 1mg estradiol valerate Qlaira

composition of the white inactive tablets: these tablets do not

contain any active substances.

Estradiol valerate/dienogest contraceptive tablets (Qlaira or Natazia)) may be used

for the treatment of excessive, prolonged, and frequent menstrual bleeding, also may

be administered for contraception for women in premenopausal age.

Progestogen - only pills (continuous method)

Because of side effects of estrogens this method was introduced. The

pills, which only contain a progestogen, are taken daily without intermission.

Every set of drugs has 35 or 28 tablets with the same dose of levonorgestrel or

noratindron. The failure rate is higher than with combined method, but the

regime is simple for the patient. The pills, which only contain a progestogen,

are named mini-pills.

They are:

Microlut Levonorgestrel 0. 05 mg

Micronor Noratindron 0. 35 mg

Ovrette Norgestrel 0. 075 mg

A modification of this method is to inject a long-acting progestogen.

Depo-Provera. A single deep intramuscular injection of medroxyprogesterone

acetate 150 mg (Depo-Provera) is given at 3 monthly intervals.

Noristerat Noretindron-anantate 200 mg, one injection for every two

months.

In contrast to estrogen-progestin combinations, progestin-only oral

contraceptives are administered in a continuous daily dosage regimen

beginning on the first day of menstruation and continued each day of the

year. To achieve maximum effectiveness, patients should be instructed to take

the drug exactly as directed and at intervals not exceeding 24 hours. Strict

adherence to the dosage regimen is especially important during the first 6

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months of use. The drug should be taken at the same time each day and

continued daily, without interruption, whether bleeding occurs or not.

Women should be advised to contact their physician, if prolonged bleeding

occurs during oral contraceptive use.

Progestin-only oral contraceptives are generally reserved for women

who do not tolerate estrogens or in whom estrogens are contraindicated, since

progestin-only oral contraceptives are less effective than estrogen-progestin

combinations and require a high level of patient compliance. When taken

according to the prescribed regimen, progestin-only oral contraceptives

provide almost completely effective contraception. The efficacy of oral

contraceptives mainly depends on compliance with the prescribed regimen.

Unlike estrogen-progestin combinations, progestin-only oral contraceptives

must be taken daily, without interruption, to be effective.

Levonorgestrel for subcutaneous implantation (Norplant®) has been

used for prevention of conception in women who elect to use subcutaneous

progestin implants as a method of contraception. The system consists of 6

silicone capsules containing levonorgestrel that are implanted subcutaneously

in the upper arm to provide contraception for up to 5 years.

Common rules of administration of oral contraceptives

Whenever possible, the smallest dosage of estrogen and progestin

should be used. The amount of both hormones should be considered in the

choice of an oral contraceptive preparation. It is prudent and in keeping with

good principles of therapeutics to minimize exposure to estrogen and

progestin. The combination used should be one, which contains the least

amount of estrogen and progestin that is compatible with a low failure rate

and with the individual needs of the woman. Common adverse effects are

usually most pronounced during the first oral contraceptive cycle and

generally disappear or diminish after 3 or 4 cycles; there it does not appear to

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be any advantage in changing preparations during this period. If minor

adverse effects persist after the fourth cycle, a different combination of drugs

or a different dosage may be tried.

Most fixed combinations are available as 21- or 28-day dosage

preparations (conventional-cycle oral contraceptives). The 28-day

preparations contain 21 hormonally active tablets and 7 inert or ferrous

fumarate-containing tablets. In establishing an oral contraceptive dosage

cycle, the menstrual cycle is usually considered to be 28 days. The first day of

bleeding is counted as the first day of the cycle.

Administration of monophasic fixed-combination conventional-cycle

oral contraceptives usually begins on the first day of the menstrual cycle or on

the first Sunday after menstrual bleeding has started. A back-up method of

contraception (e. g., condoms, foam, sponge) should be employed for 7 days

following initiation of oral contraceptive therapy if the first dose of the oral

contraceptive is begun on the first Sunday after menstrual bleeding starts. A

back-up method of contraception is not needed if the first dosage cycle is

initiated on the first day of the menstrual cycle. Some clinicians suggest that

women switching from higher-dose preparations to low-dose preparations

may begin administration of the low-dose preparation on the first day of

withdrawal bleeding; however, if withdrawal bleeding does not occur after

discontinuance of the higher-dose preparation, administration of the low-

dose preparation should begin on the eighth day after taking the last

hormonally active tablet of the higher-dose preparation and the woman

should be advised to take additional contraceptive measures. Monophasic

fixed combinations are usually administered once daily for 21 consecutive

days, followed by up to 7 days without drugs; when the 28-day dosage

preparations are used, inert tablets or tablets containing ferrous fumarate are

administered during this latter 7-day period. Withdrawal bleeding usually

occurs within 2 or 3 days after the last hormonally active tablet has been

taken. Repeat dosage cycles begin on the same day of the week as the initial

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cycle. Repeat cycles should generally begin regardless of whether

menstruation has stopped; after several cycles of fixed-combination

preparations, menstrual flow may be considerably reduced. If a repeat 21-day

cycle is started later than the eighth day after taking the last hormonally

active tablet (or later than the next day after taking the last inactive tablet

with 28-day dosage preparations), a back-up method of contraception should

be employed until the patient has taken a hormonally active tablet daily for 7

consecutive days.

When a biphasic oral contraceptive is used, each dosage cycle consists of

2 sequentially administered fixed combinations; the first sequence consists of

10 tablets containing a fixed combination of low-dose estrogen and low-dose

progestin and the second sequence consists of 11 tablets containing a fixed

combination of low-dose estrogen and higher-dose progestin. Although

biphasic oral contraceptives consist of 2 sequentially administered fixed

combinations, they are not the same as previously available "sequential" oral

contraceptives, which consisted of an estrogen alone for the first sequence.

Administration of a biphasic oral contraceptive usually begins on the first

Sunday after or on which bleeding has started. Tablets from the first sequence

are administered once daily for 10 consecutive days, followed by once-daily

administration of tablets from the second sequence for 11 consecutive days

and then a period of 7 days without drugs; when a 28-day dosage preparation

is used, inert tablets are administered during this latter 7-day period. A back-

up method of contraception (e. g., condoms, foam, sponge) should be

employed for 7 days following initiation of oral contraceptive therapy, if the

first dose of the oral contraceptive is begun on the first Sunday on or after

menstrual bleeding starts; a back-up method of contraception is not

necessary if the first dosage cycle is initiated on the first day of the menstrual

cycle. Repeat dosage cycles begin on the eighth day after taking the last

hormonally active tablet.

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Triphasic oral contraceptives contain graduated sequences of progestin

or estrogen. With most commercially available triphasic oral contraceptives,

each dosage cycle consists of 3 sequentially administered fixed combinations

of the hormones in which the ratio of progestin to estrogen progressively

increases with each sequence. The first sequence consists of tablets containing

a fixed combination of low-dose estrogen and low-dose progestin, the second

sequence consists of tablets containing a fixed combination of low-dose and

higher-dose progestin, and the third sequence consists of tablets containing

low-dose estrogen and either an even higher-dose progestin or low-dose

progestin (i. e., Tri-Norinyl).

Triphasic oral contraceptives, in which the estrogen component

progressively increases with each sequence, also are available. The first

sequence consists of tablets containing a fixed combination of a progestin and

low-dose estrogen, the second sequence consists of tablets containing a fixed

combination of progestin and a slightly higher dosage of estrogen, and the

third sequence consists of tablets containing a progestin and an even higher

dosage of estrogen. Administration of a triphasic oral contraceptive usually

begins on the first Sunday after or on which bleeding has started or on the

first day of the menstrual cycle. Tablets from the first sequence of Ortho-

Novum® 7/7/7, Ortho-Tri-Cyclen®, or Ortho-Tri-Cyclen® are administered

once daily for 7 consecutive days, followed by once-daily administration of

tablets from the second sequence for 7 consecutive days and then once-daily

administration of tablets from the third sequence for 7 consecutive days.

Tablets from the first sequence of Tri-Norinyl® are administered once daily

for 7 consecutive days, followed by once-daily administration of tablets from

the second sequence for 9 consecutive days and then once-daily

administration of tablets from the third sequence for 5 consecutive days.

Tablets from the first sequence of Tri-Levlen® or Triphasil® are

administered once daily for 6 consecutive days, followed by once-daily

administration of tablets from the second sequence for 5 consecutive days and

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then once-daily administration of tablets from the third sequence for 10

consecutive days. Tablets from the first sequence of Estrostep® are

administered once daily for 5 consecutive days, followed by once-daily

administration of tablets from the second sequence for 7 consecutive days and

then once-daily administration of tablets from the third sequence for 9

consecutive days. The 3 sequences are then followed by a period of 7 days

without drug; when a 28-day dosage preparation is used; inert tablets are

administered during this latter 7-day period. Repeat dosage cycles begin on

the eighth day after taking the last hormonally active tablet. If a repeat 21-day

cycle is started later than the eighth day after taking the last hormonally

active tablet (or later than the next day after taking the last inactive tablet

with 28-day dosage preparations), a back-up method of contraception should

be employed until the patient has taken a hormonally active tablet daily for 7

consecutive days.

Administration of a triphasic oral contraceptive usually begins on the

first Sunday after or on which bleeding has started or on the first day of the

menstrual cycle. Tablets from the first sequence of these preparations are

administered once daily for 7 consecutive days, followed by once-daily

administration of tablets from the second sequence for 7 consecutive days and

then once-daily administration of tablets from the third sequence for 7

consecutive days.

If oral contraceptives are first taken postpartum or later than the fifth

day of the menstrual cycle, the contraceptive effect should not be relied on

until after 7 consecutive days of drug administration, since there is a

possibility that ovulation and conception may have occurred. In all patients,

additional contraceptive measures may be advisable through the first week of

the initial regimen. In determining whether to initiate oral contraceptive

therapy in the postpartum period, the increased risk of thromboembolism

during this period must be considered since use of oral contraceptives is also

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associated with an increased risk of thromboembolic and thrombotic

disorders.

Side effects and complications

Minor side effects mostly when starting medication

Nausea is common in the first cycle and can be reduced by taking the

pill last thing at night. It is due to estrogen. To minimize nausea, oral

contraceptives should be taken with or after the evening meal or at bedtime.

As vomiting or diarrhea may decrease absorption of oral contraceptives and

potentially result in treatment failures, a back-up method of contraception (e.

g., condoms, foam, sponge) should be used until the next clinician contact.

If it persists the patient should be examined to exclude pregnancy and a

change is made to a pill containing less estrogen.

Tenderness and slight enlargement of the breasts may occur, but they

usually cease after few cycles.

The “menstrual” loss is usually reduced. Intermenstrual spotting (break

through bleeding) may occur. If this persists it is usually controlled by

changing the progestogen or increasing the dose of progestogen.

An initial weight-gain of 0. 5 kg is common. This is usually lost after a

few cycles; changing to another pill sometimes decreases the weight gain.

Major complications

Hypertension may occur especially during the first year of use and in

patients over 30. The pressure must be recorded at each visit to the doctor or

clinic. If medication is stopped the pressure becomes normal.

The risk of venous thrombosis and embolism is increased in women

taking the combined contraceptives, but the risk must not be exaggerated.

Combined oral contraceptives are not advised for any woman with a history of

thrombosis or embolism.

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The first period after stopping oral contraception is often late. More

persistent amenorrhea is uncommon, and usually recovers spontaneously.

If a woman has had an estrogen depended tumor (e. g., breast cancer)

pills containing estrogens are contraindicated.

Other side effects.

Cervical erosions are common.

Vaginal candidiasis may occur.

Chloasma (facial pigmentation like sometimes seen in pregnancy) has

been reported.

Migrainous headaches may occur.

Psychological effects are difficult to assess. Depression is sometimes

attributed to the pill, but seldom with much evidence.

Postcoital hormonal contraception.

Oral administration.

The “morning after pills” can be used after unprotected coitus around

the time of ovulation. They are diethylstilbestrol 25 mg, ethinyl estradiol 0. 03

mg, norgestrel 0. 3 mg. The drugs are administered in a short-course regimen

of 2 doses (consisting of 2 tablets per dose) administered 12 hours apart.

Other short-course, postcoital contraceptive regimens usually consist of 2 or 4

tablets per dose administered 12 hours apart. Women should be advised of

the importance of taking the second dose 12 hours after the initial dose, and

to schedule the first dose as conveniently as possible (but no later than 72

hours after intercourse) so that the likelihood of missing the second dose 12

hours later is minimized (e. g., if the first dose were taken at 3 p. m., the

second dose would need to be taken at 3 a. m., which might present a problem

of compliance for heavy sleepers). The high doses of steroids just after

ovulation may disrupt the endometrium enough so that implantation of the

embryo does not take place.

Because the high dosage in the combination regimens may cause severe

nausea and vomiting in a substantial proportion of women, which could limit

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compliance with postcoital contraception, use of an antiemetic (e. g.,

meclizine, diphenhydramine, trimethobenzamide, promethazine) prior to

administration of each dose of the combination should be considered.

Administering the dose with food also has been suggested as a means of

reducing the risk of nausea and vomiting. If breakthrough vomiting does

occur within one hour after administration of a dose of the estrogen-progestin

combination despite concomitant administration of an antiemetic,

consideration should be given to repeating the dose.

Because of the short time frame of effective postcoital use (i. e., therapy

must commence within 72 hours of unprotected intercourse), clinicians

ideally should inform women of the availability of postcoital contraception

before such use is warranted, advising them to contact a clinician immediately

if the need for such contraception arises. Alternatively, women can be given

an appropriate estrogen-progestin combination in advance, with careful

instructions on how to safely and effectively use the combination for

emergency postcoital contraception; if a supply of the drugs is given to a

woman in advance, she also should be advised that postcoital contraceptives

are for emergency situations (e. g., unprotected intercourse, missed doses of

oral contraceptives (more than 2 tablets), missed parenteral contraceptive

dose [more than 2 weeks past scheduled injection], contraceptive failure) only

and should not be employed as the primary method of contraception.

Hormonal injections

Women may receive the transdermal contraceptive containing ethinyl

estradiol and norelgestromin (Ortho Evra®). The transdermal system is

applied topically to a clean and dry area of intact skin on the buttock,

abdomen, upper outer arm, or upper torso, by firmly pressing the system with

the adhesive side touching the skin. The system should be pressed firmly in

place with the palm of the hand for about 10 seconds, ensuring good contact,

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particularly around the edges. The application site should not be oily,

damaged, or irritated. The transdermal system should not be applied to the

breasts or to areas where tight clothing may cause the system to be rubbed

off. If the system inadvertently gets detached during the period of use, and is

off for less than one day, the system may be reapplied or, if necessary, a new

system (if the system is no longer sticky) may be applied; in either case, the

application schedule employed should be continued. If the system is off for

longer than one day or for an unknown duration, a new system should be

applied immediately and a new 4-week cycle should be started; a back-up

method of contraception (e. g., condoms, spermicides, diaphragm) must be

used for the first week of the new cycle. Patients should be instructed to

handle the used transdermal system carefully (e. g., fold the system in half

with the sticky sides together) and then discard the system.

This is a very effective method, provided that the patient does not fail to

take the tablet

Intravaginal administration of contraceptives

Patients receiving the vaginal contraceptive ring containing ethinyl

estradiol and etonogestrel (NuvaRing®) should be carefully instructed in the

use of the vaginal ring. The ring should be inserted into the vagina by the

patient; the manufacturer states that the exact position of the ring inside the

vagina is not critical for its proper functioning. If the ring is accidentally

expelled, it can be rinsed with cool or lukewarm water and reinserted or, if

necessary, a new ring should be inserted as soon as possible; in either case,

the administration schedule employed should be continued. If the

contraceptive ring has been out of the vagina for longer than 3 hours, a back-

up method of contraception (e. g., condoms, spermicides) must be used until

the ring has been used continuously for 7 days.

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Other hormonal contraception

Not long ago it was founded, that chronic GnRH agonist treatment,

which is usually used to facilitate treatment of hypogonadism, resulted in

down regulation of the pituitary processes responsible for gonadotropin

synthesis and release. Thus, buserelin, a GnRH analogue, when given daily

doses of 400 or 600 µg intranasally over 3 to 6 months, obtained a safe and

effective method of birth control that works by interfering with normal

ovulation. So, the main mechanism of action of chronic GnRH agonist

treatment seems to be pituitary desensitization of the processes responsible

for gonadotropin secretion. The reserve capacity for gonadotropin secretion is

rapidly reduced during repeated administration of GnRH agonists.

Intrauterine devices

These are made of radio-opaque elastic in various shapes that are

intended to prevent their extrusion from the uterus. They can be compressed

or straightened for insertion through a cannula, without anesthesia. They are

most easily inserted just after a period, or immediately after termination of

pregnancy or in puerperium. Most forms have a thread attached, which

projects through the cervix so that the presence of the device can be checked.

A normally situated device can usually be easily removed by traction on this

thread.

The action of the original devices was mechanical, presumably by

interference with the embedding of the ovum. Recently smaller devices have

been introduced, which carry drugs into the uterus. The commonest

medicated device has fine copper wire wound round the vertical limb. (Fig.

156). Copper ions are released and enter the endometrial cells, but there is no

significant absorbtion into the blood stream. Mechanism of action is:

disturbed implantation of the fertilized ovum, increased peristalsis of the

tubes etc. The device carries enough copper for 2 to 3 years of use.

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Another type of medicated device releases progesterone slowly. The

endometrium becomes atrophic, but insufficient progesterone is absorbed to

affect ovarian function.

The medicated devices are more effective than the simple varieties, and

are easier to insert as they are smaller.

Although a device is less effective than an oral contraceptive, it has the

advantage that the patient has no responsibility once it is in place. They are

useful for patients who dislike oral contraceptives, or who are incapable or

untrustworthy in their use.

Side effects

The common side effects are pain, chiefly dysmenorrhea, and increasing

menstrual bleeding. A device may be expelled by uterine contractions. Both

expulsion and symptoms are most common in the first six months of use.

Pregnancy may occur if the device is partly extruded or incorrectly

placed. If this happens the device should be removed by traction on the string.

There is a risk of infection during the pregnancy.

Occasionally an intrauterine device may perforate the uterine wall. X-

ray will show the device lying outside the uterus. The device should be

removed from peritoneal cavity with the aid of a laparoscope.

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Mechanical methods

They also may be male and female. As to female, the most common is

vaginal diaphragm (‘Dutch cap’). This is a dome-shaped rubber diaphragm

with a flexible rim that fits over the cervix, acts as a barrier to sperm. The

diaphragm is made in different sizes and the commonest size required is 50-

70 mm in diameter. The woman must be shown how to insert it so that the

cervix is covered. Spermicidal cream, (all of them are mainly Nonoxynol

based) is placed on both aspects of the diaphragm before insertion.

Spermicides should always be used with the diaphragm to improve

contraceptive effectiveness in case the diaphragm is displaced during coitus.

The diaphragm should cause no discomfort to either partner. It should be

inserted before coitus and remain in place for at least 6 hours after the last

coitus, if intercourse is repeated in that period more cream must be injected

with an applicator.

The diaphragm is less efficient than oral contraceptives or IUD unless

used strictly according to instructions, but it has no side effects

Chemical methods

Spermicidal agents are inserted into the vagina in the form of creams,

pessaries, gels or aerosols. All of these are mainly Nonoxynol based. For

example: pharmatex. One dose of spermicide must be injected before each act

of coitus. The method is not very effective. The active agents work by killing

the sperm, decreasing sperm motility, or inactivating the enzymes needed for

the sperm to penetrate the ova. Surface-active agents, for example, nonoxynol

9 and octoxynol 9 are spermicidal agents that disrupt the outer lipoprotein

surface layer of spermatozoa.

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Contraception based on time of ovulation

Natural family planning (periodic abstinence)

This method requires abstaining from coitus during the fertile period.

Ovulation usually occurs about 14 days before onset of the next menses.

Although the human ovum can probably be fertilized for only a few hours

after ovulation, sperm can fertilize the ovum for several days after entering

the cervical canal; thus, fertilization can result from coitus that occurs up to 5

days before ovulation. So, natural family planning is not very effective.

The calendar rhythm method (‘safe period’)

The period of abstention is determined by subtracting 18 days from the

shortest period of the previous 12 cycles and 11 days from the longest. Thus, if

the woman’s cycles vary between 26 and 29 days, the couple must abstain

from coitus from day 8 through day 18 of each cycle. This method of

contraception is the least effective type of contraception.

Basal body temperature

This method is more effective, requires training and a high degree of

motivation.

The woman must take her rectal temperature every morning for the

sustained rise, which indicates ovulation. Basal temperature rises about 0. 5%

after ovulation. The couple abstains from coitus for at least 48 to 72 hours

after the rise in temperature. Such graphs of basal temperature are not now

accepted as being very precise indicators, but women with regular periods can

usually identify the peri-ovulatory time with a fair degree of accuracy.

However, even with careful training, the pregnancy rate is about 10%.

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Symptothermal method

Symptothermal method is the most effective method for determining of

periodic abstinence, involves observing changes in cervical mucus (increased

cervical mucus secretion, the “spinnbarkeit” phenomenon, increased

extensibility of the cervical mucus) and in temperature as well as other

symptoms associated with ovulation.

Coitus interruptus

This means withdrawal of the penis just before ejaculation. It is widely

practiced and probably adequate for couples of low fertility, but some sperms

must enter the vagina, and withdrawal at the point of orgasm is unnatural.

Self test

1. Surgical contraception is indicated for

A. young women

B. women in reproductive age

C. women with medical contraindications to pregnancy

D. women in menopausal age

2. Which of the following is not mono-phase oral contraceptive?

A. minovlar

B. euginon

C. marvelon

D. anteovin

3. Loginоn is

A. the three-phase contraceptive

B. the two-phase contraceptive

C. the monophase contraceptive

D. the progesterone only pill

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4. Intrauterine device is contraindicated for

A. patients with isthmico-cervical insufficiency

B. patients with active sexual life

C. multiparae patients

D. patients with extragenital diseases

5. Intrauterine device is most easily inserted

A. just after a period

B. in every day of period

C. just before the beginning of menstrual flow

D. in day of ovulation

6. Microlut is

A. progesterone-only pills

B. mono-phase pills

C. two-phase pills

D. three-phase pills

7. Which of the following is not a contraceptive action of the spermicides?

A. killing the sperm

B. decreasing sperm motility

C. disrupting the outer lipoprotein surface layer

D. neutralizing vaginal acidity

8. The medicated device carries enough copper for

A. 2 to 3 years of use

B. 3 to 4 years of use

C. 4 to 5 years of use

D. 5 to 6 years of use

9. Which of the following is not a physiologic change affected by oral

contraceptives?

A. suppression of the ovulation

B. a hypoestrogenic state

C. inactive endometrium

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D. reduction of gonadotropins

10. Which of the following methods of contraception suppresses ovulation as its

primary mechanism of action?

A. medicated intrauterine device

B. postcoital norgestrel

C. barrier contraceptives

D. buserelin

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Chapter 10. TYPICAL OPERATIONS IN

GYNECOLOGY

In the treatment of certain gynecologic affections it is necessary to

invade the peritoneal cavity. This invasion of the great peritoneal sac in the

center of the body necessarily carries with it considerable risk to the patient.

On the preantiseptic days the mortality was great- so great that operation was

but rarely resorted to. By modern antiseptic and aseptic methods; however,

the mortality has been reduced to a very small percentage. But, though the

mortality of the operation is small, we must not forget that there is mortality

due directly to the operation.

The danger varies much in different cases, depending on the particular

form of disease present and on the condition of the patient at the time of

operation- but there is some danger in every case. It is well to call particular

attention to this, because some physicians seem prone to overlook, or at least

fail to give proper weight to, the fact that occasionally a patient, with

everything apparently favorable, will die; and no one can promise any patient

absolutely that she will survive. One may say, in a favourable case, that the

risk is very slight and that in all probability the patient will go through the

operation and convalescence without trouble. But though the risk is slight, it

is nevertheless a risk, and the patient or her friends must so understand it.

The operation is carried out because of some condition, which is more

dangerous – that is, in that particular case the risk of waiting is greater than

the risk of operation.

This serious decision as to whether or not to operate at a certain time is

based on many factors, including knowledge of the disease in its various

forms and of the patients ability to stand the operation and the character of

the hospital facilities immediately available. The correctness of our judgment

in making such decision improves with study and experience, and some of the

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informing experiences are bitter as we compare the action taken with the later

developments.

Preoperative preparation of patient, operative technique, postoperative

care is important to successful surgical treatment.

Preoperative Preparation

In order to reduce to a minimum the danger of the operation, careful

preparation is required.

The operation should be carried out in the clean, well arranged

operation room of a hospital, even though the patient has to be moved a

considerable distance to obtain the requisite hospital facilities.

The further preparations for the operation will be given under the

following subheads:

preparation of the patient;

preparation of sponges and dressings;

preparation of instruments and sutures;

preparation of operator and assistants.

Preparation of the patient

The patient, having been subjected to a careful general examination

including urine analysis, to exclude contraindications, is sent to the hospital

one or two days before operation that the proper preparation may be carried

out. Of course, there are cases of rapidly spreading pelvic inflammation, or of

intra-abdominal hemorrhage or injury, in which the abdomen must be

opened at the earliest possible moment. In such a case there is no time for

preliminary prepa-ration. Careful immediate sterilization is carried out and

the abdomen is then opened. But when the case is not an emergency one, the

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preliminary preparation should be made. It gives the patient a decidedly

better chance of complete and uninterrupted recovery.

When the patient enters the hospital for operation, orders are left for

her as to diet, needed laboratory work, provision of rest and sleep, bowel

regulation, preliminary preparation of the operation field, and preanesthetic

sedation. The details vary with the surgeon and with the condition of the

patient.

A general examination is made with spеcial attention to inflammation,

anemia, the circulation and the lungs. The urine is tested for protein and

sugar, and a catheter specimen is often required for microscopy and

bacteriology. Vaginal smears should be taken for microscopy and

bacteriology. Cases of severe uterine bleeding often require blood transfusion.

The rectum and the bladder should be empty before operation.

Light diet is to be given up to and including noon of the day before

operation, then liquids only, but with water in abundance. After midnight,

just preceding operation, nothing is to be given by mouth but water, and the

water may be continued to within an hour of the operation.

An enema is to be given the night before, and again the next morning.

The idea is to have the intestinal tract in as nearly normal condition as

possible, with just a good clearing out of the lower bowel just before the

operation. Experience has shown that this simple method of preparation

brings the patient to the operating table in better condition and causes less

disturbance after the operation than the prolonged dieting and purging

formerly employed.

In cases of marked habitual constipation and eases in which the bowels

are not to be moved for some time after operation, such as in repair of

complete laceration into the rectum, it is well to clear out the intestines some

days before, but avoid prolonged increased peristalsis to the operation. When

there are complications that may necessitate resection of the intestine or

365

opening of the stomach, then, of course, the usual preoperative measures for

approximate sterilization of the upper intestinal tract would be indicated.

Preliminary sterilization of the field. In the preparation of the operative

field, as in the intestinal preparation, the trend of practice has been toward

simplicity. It has been found that some of the measures formerly employed

served to irritate the skin and increased rather than diminished the chance of

inflammation. This was true particularly of the strong antiseptics applied for

long periods preceding operation. Instead of the extensive soap poultice and

the prolonged antiseptic pack, the following method, with minor

modifications, is now employed generally:

The afternoon before operation the abdomen is lathered and shaved. It

is then scrubbed with soap and, after soap is removed, with sterile water, and

then the surface is washed with alcohol. The cleansed surface is covered with

a sterile towel or sterile cotton held in place with a binder.

In most of the gynecological cases, vaginal preparation also is needed,

because part of the operation is vaginal, or the vagina is to be opened into, or

conditions may be found requiring it to be opened. On this account,

preoperative vaginal preparation along with the abdominal is made routinely,

unless otherwise ordered in some exceptional case.

Medication (syn.: premedication). Sleep is important, and it is well to

have a regular order for sodium bromide or other sedative, to be given as

needed to quiet the nervous system and avoid wakefulness.

A preanesthetic sedative eliminates the anxiety of the trip to the

operating room and starting the anesthesia, and also reduces the amount of

anesthetic required. For this purpose, promedol, 1–1. 5 mL of 2% solution,

and atropine sulphate, 0. 5–1 mL of 0. 1% solution, and dimedrol, 1–2 mL of

1% solution, given about thirty-five or forty-five minutes before operation,

intramuscularly in one syringe, are used by many. The patient is then kept

quiet with the room darkened until taken to the operating room.

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The preanesthetic sedative analgesia eliminates the preoperational

anxiety, which is so troublesome to some patients and more or less

troublesome to all. As a rule, the patient knows nothing about the trip to the

operating room and the induction of anesthesia and is surprised when she

learns that the operation is over. Also, the patients take the anesthetic more

quietly and require less for operations of the same length. Again, there is less

postoperative vomiting and distress. The dose of the drugs should of course

be adjusted to the size and condition of the patient, being somewhat less than

the above for small or weak individuals.

When spinal anesthesia is to be employed, the following preanesthetic

sedation is pre-ferred: 0.5 mL of atropine +0,5–1 mL of ephedrine

hydrochloride +1–2 mL of 1% solution of dimedrol in one syringe are given

intramuscularly one and one-half hours before the operation. The patient's

ears are stopped up with cotton, the eyes are covered, and the room is kept

quiet.

Catheterization. A convenient time and place for the catheterization is

during the preparation in the operating room immediately preceding

operation, during the vaginal preparation if made; otherwise just before the

abdominal preparation. Catheterization at that time has the added advantages

of emptying the bladder immediately before operation (instead of an hour

before, after which a troublesome amount of urine may collect in some cases)

and of avoiding disturbance of the patient while sedative sleep is being

induced.

Preparation in operating room. The final sterilization of the abdominal

field is ordinarily carried out as the patient is being anesthetized, though

exceptionally it may be advisable to complete this preparation before the

anesthesia is begun in order to save time under the anesthetic. As previously

explained, vaginal preparation also is advisable in most abdominal cases, and

this is usually completed just preceding the abdominal preparation. If the

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patient is in good preanesthetic sleep, no additional anesthesia is needed for

the vaginal preparation, which may be immediately proceeded with.

The patient's hips are drawn to the edge of the table and the feet are

supported out of the way by stirrups. The external genitals and vicinity all

round are cleansed thoroughly with soap and warm water, using gauze or

cotton balls, rinsed with chlorhexidine gluconate, iodine or bichloride or

cyanide solution, or any other anticeptics.

Catheterization is now carried out with strict asepsis, the labia being

held away and the meatus specially cleansed. The sterile catheter should be

lubricated and care should be taken to avoid contaminating the bladder

portion with soap or irritating antiseptics.

The vagina is then cleansed with soap and warm water, rinsed with

sterile water, and then with the antiseptic solution, using small pieces of

gauze or cotton and opening the vagina with a speculum. If the opening is too

small for the speculum, a finger may be used beside the sponge forceps.

If the operation is to be complete abdominal hysterectomy, some iodine

solution is applied to the vaginal vault, and removed with alcohol. If the

hysterectomy is for a condition accompanied with infective uterine discharge,

the cervix is grasped with a tenaculum forceps and the uterine cavity is

packed with a quarter-inch gauze moistened with iodine solution.

When the vaginal preparation is finished, the abdominal field is

prepared. The abdominal surface is painted with 70% of ethyl alcohol iodine

(twice) and then with 2. 5% iodine solution in spirit over the large area.

Particular care should be taken to sterilize the depth of the umbilical

depression, to rub in the solution along the line of incision, and to extend the

sterilization down over the pubes well beyond the lower end of incision.

Iodine is a skin irritant and must be removed with alcohol. The following plan

may be used: the first step is thorough application to the depth of the

umbilicus, with discarding of the swab. Then by circular motion, enlarging

from the umbilicus, the central area is sterilized down to near the pubic area,

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one or two swabs being used as needed. In the second step, with downward

and outward strikes application is made to the pubic area and adjacent thigh

surface changing swabs as necessary to avoid recontamination of sterilized

surfaces. Then, in the third step, with a fresh swab or two, application is made

to the outward portions of the abdominal field (Fig. 157), giving the complete

coverage indicated in Fig 158. The same plan is followed in the rapid removal

of the iodine with alcohol swabs. A final firm wipe is made from the umbilicus

down the median line and over the pubes.

Fig. 158. Showing the area to be painted with the antiseptic solution

(complete coverage)

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The above account is to show in general the steps and details of the

sterilization process. The chemical preparations will vary with the hospital

and the surgeon, and also as new preparations are developed and attain

popularity. For preparation in the vagina, aqueous solutions are used, for

example, aqueous solution of phemerol (1:500) or of zephiran (1:1,000).

When the sterilization of the operative field has been complete, the area

is draped with the sterile coverings, the patient's hips are elevated to the

Trendelenburg position, and the small platforms for the operator and

assistants to stand on are slipped into place (Fig. 159)

Any considerable dropping of the feet and legs increases the tension of

the abdominal wall, and is to be avoided.

Fig. 159. Preparation of operative field. The patient has been elevated

into the Trendelenburg position and the continuous-strip sponge

bag has been clamped in place. The small platforms for the operator

and assistants to stand on have been pushed into position.

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Preparation of sponges and dressings

The dressings, pads, towels, sheets, instruments trays, and basins are all

put through the steam sterilizer, and kept wrapped ready to use.

Preparation of instruments and sutures

The instruments used in abdominal operation for pelvic disease may be

grouped under three headings—regular set of instruments, regular set of

needles and sutures, and special instruments.

Regular Abdominal Set of Instruments (Fig. 160.):

14 Towel clips

12 Allis forceps (a, in Fig. 1164)

2 Knives with detachable blades (b)

1 Large curved Mayo dissecting scissors, (c)

1 Large straight Mayo dissecting scissors,

1 Curved blunt uterine scissors (d)

1 Straight blunt uterine scissors (e)

1 Curved sharp-pointed uterine scissors (/)

3 Tissue forceps with 2 to 4 teeth on each side (g)

1 Tissue forceps without teeth (h)

1 Tissue forceps, one with teeth (i) and one smooth 2 Large double-end

abdominal retractors (j)

1Large single-end wide abdominal retractor

1Deep single-end long-bladed retractor (k)

2 Flat flexible retractors, one narrow and one wide (I) 18 Curved clamps,

(m)("Small clamp") 32 Curved clamps, (n) ("Medium clamp")

4 Curved clamps, (o) ("Large clamp" or "Hysterectomy clamp")

24 Curved hemostats

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32 Straight toothed clamps, (p), may be curved

4 Hegar needle holders, (r)

2 Double-toothed uterine tenaculum forceps, (t)

2 Single-toothed uterine tenaculum forceps (x)

2 Shorter tenaculum forceps

1 Grooved director with probe point (u)

1 Tumor forceps with six teeth (v)

1 Uterine sound

1 Small wire probe with eye

1 Trocars, medium and large, with rubber tubing

Set of needles and suture materials

Heavy pure gum rubber sheeting

Rubber drainage tubing, various sizes

Rubber gloves

Fig. Fig. 160. Regular abdominal set of instruments. Showing the

characteristic appearance of most of the instruments used in the abdominal

operation

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The routine list will, of course, vary in different hospitals; certain things

frequently used in one hospital might be used only occasionally in another,

and hence would be got out only specially when called for.

Regular Needles and Suture Materials (Fig. 161):

6 Large full-curved cutting needles (a, Fig. 1165)

8 Medium Mayo needles (6), 6 No. 3, 1 No. 4, 1 No. 2

2 Slender curved intestinal needles (c)

2 Long straight trocar-point needles (d)

1 Tube 40-day No. 1 chromic catgut (e) 5 Tubes 20-day No. 1 catgut (/)

1Tubes plain No. 00 catgut (g)

1 meter of fine silk (size D) or linen (h)

8 Strands of heavy silkworm-gut (i)

Fig. 161. Regular set of needles and suture materials 'for abdominal section

for pelvic disease, showing the general appearance of the various articles.

The numbers required are given in the regular list in the text

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Have readily available other kinds of catgut or other suture material the

particular operator may wish to use.

Needles.The large full-curved cutting needle is large enough to be used

without a needle holder, and hence is timesaving in suturing the various

layers of the long abdominal incision. The cutting point is necessary in

penetrating the skin with the stay sutures, though it occasionally starts a

small hematoma in the wall.

For inside work in the pelvis and lower abdomen, such as ligating

pedicles and suturing together pedicle ends or other surfaces, round-pointed

needles are used exclusively. These tissues are soft and easily penetrated by

the round-pointed noncutting needle, while any cutting edge on a needle used

in this suture may cut into a vessel and start a serious hematoma.

Suture materials.Different operators use many different types and sizes

of catgut in pelvic abdominal work. Each of the two suture materials, silk and

catgut, has special advantages in certain situations. For decades we have used

catgut for pelvic pedicle ligatures and for buried sutures in the abdominal

wall, and have never regretted such use. The senior author recalls that when

he began his abdominal surgery, silk was the ligature material, and the later

attainment of reliable catgut for ligatures and buried sutures was a great

boon, for it largely eliminated the long-lasting sinuses and the "fishing" and

other operative maneuvers to remove the nonabsorbable silk ligatures which

kept them discharging.

It is convenient and it simplifies the suture preparations to use just two

kinds of catgut (twenty-day No. 1 and plain No. 00) in routine work, with

occasionally forty-day catgut for some special condition. The terms "forty-

day" and "twenty-day" refer to the lasting period in connective tissue, but the

lasting period is very much less on peritoneal surfaces and especially on

mucous surfaces.

The plain catgut is used, in slender intestinal needles, for suturing in

conservative work on the ovaries and tubes and for suture ligation of the

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meso-appendix and other small delicate pedicles. It is used for tying the

stump of the appendix, preceding the silk or linen inverting suture, and also

for the closing skin suture.

The twenty-day catgut is used for all the layers of the abdominal wall

except the skin.

The fine silk or lavsan or linen, as preferred, is used for the inverting

suture in appendectomy and for any emergency intestinal suturing that may

be required.

Silkworm-gut is the most satisfactory material for stay sutures in the

abdominal wall, and the thickest strands should always be chosen for use in

this situation.

Special instruments. There are a number of other instruments

occasionally used in abdominal operations for pelvic disease, because of a

special condition in the particular case or because preferred by the operator.

For example: large cyst trocar, large tumor forceps, Wertheim’s parametrial

clamps, and instruments for extra-gynecologic work.

Preparation of operator and assistants

Everything that is to come in contact with the operative field must be

sterilized. The hands and forearms of the operator and assistants must be

disinfected as far as possible, and should then be covered so that there is no

chance of direct contact of the operative field with the skin of the hands or

arms, for the skin cannot be absolutely sterilized. Again, the operator and

assistants must be so covered as to protect effectively the field of operation

from contamination by particles from the hair or beard, or by particles carried

in the breath.

The accomplishment of this thorough protection of the operative wound

has been the object of many decades of study and experimentation. The

present effective technique for the preparation of the operator, as well as all

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the other antiseptic and aseptic preparations, was attained gradually, by

improvements added year by year, but it is all the direct outgrowth of the

epoch-making work of Pasteur and of Lister. The following are the steps in

the preparation of the operator and assistants:

The sleeves are rolled well up above the elbows and the fingernails are

trimmed short and cleaned thoroughly.

The hands and forearms are then scrubbed carefully and vigorously, for

ten to fifteen minutes, with warm water and some liquid preparation of green

soap—using a stiff brush. Pay particular attention to the irregularities about

the nails and knuckles and to the spaces between the fingers at their junction

with the hand. Where the brush causes undue irritation of the skin, gauze is

preferable for scrubbing the arms, but a brush should be used on the hands.

Then the soap is washed off with sterile water, and the hands and

forearms are scrubbed in 80 per cent alcohol with gauze.

Then they are scrubbed in bi-chloride solution (1:2,000), with gauze.

The long-sleeved sterile gown is then put on, and the cap and face mask

are applied. As the rubber gloves are put on, the gauntlet of the glove is

brought up over the lower end of the sterile sleeve to hold it in place. The arm

is thus securely covered and there is no chance for any skin surface to come in

contact with the wound. The assistants go through the same process.

The careful and prolonged scrubbing with soap is the most important

feature in any method of hand-disinfection. This fact has long been

recognized, and many operators have discarded bi-chloride and other irritant

antiseptics and depend entirely on the soap scrubbing followed by the

scrubbing in alcohol. When carried out with care and judgment, this practice

is safe and gives good results and avoids the irritation due to bi-chloride. In

some persons, however, alcohol causes more irritation than bi-chloride.

There are a lot of methods of hand-disinfection, which are much used.

The thorough scrubbing with soap and warm water is common to all of them.

The further steps differ as follows:

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a. The "alcohol-bi-chloride" method. The various steps in this method

have just been given in detail.

b. The «pervomur (C-4 preparation)” method. The hands and forearms

are next immersed in a pervomur solution and kept there during 1 minute,

and then they are dried up with sterile gauze napkin.

c. The"cerygel"method. After the preliminary scrubbing with a soap and

brush (for 3 minutes for every hand), every hand and forearm should be

treated with cerygel gauze tampon, saturated with cerygel solution, then

thoroughly dried up with gauze napkin.

As to the choice of method of hand-disinfection, that is largely a matter

of personal preference. Any one of the above three methods, properly carried

out, will give good prac-tical hand-disinfection—i. e., from hands and arms so

prepared, infection will rarely if ever take place. The important thing is not

which method is chosen, but how thoroughly the chosen method is carried

out.

Absolute disinfection of the hands and arms is impossible by any

method, as the disinfection is necessarily confined to the superficial layers of

the epidermis. Bacteria situated in the deeper layers of the epidermis may

work to the surface during the course of the operation, hence the importance

of thorough covering of the prepared hands and arms with rubber gloves and

sterile sleeves, leaving no skin surface exposed.

Anesthesia

It may be local for minor operations (diagnostic curettage of the uterus),

for pelvic floor operations many surgeons infiltrate the tissues with local

anesthetic solutions. Peridural anesthesia, general endotracheal narcosis

should be performed for a lot of abdominal operations.

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Abdominal operations

Technique of abdominal operation

Regular Steps.

The regular steps in technique incident to every abdominal section for

gynecologic disease are as follows:

Incision.

Exploration.

Correction of pathological conditions.

Toilet of the peritoneum.

Closure of incision.

Dressing.

1. Incision

The following types of incisions are commonly used in gynecological

practice:

vertical(median, paramedian) incisions

transverse ( by Phannenstiel, by Cherny) incisions.

Median Incision. In abdominal section for pelvic disease, the incision

employed is usually longitudinal and in the median line. All parts of the pelvis

and lower abdomen may be easily reached from such a median incision, and

in practically every case exploration of the whole region should be made.

Ordinarily the incision extends from near the umbilicus to the symphysis

pubis. If there is a large tumor, the incision must be extended upward, though

at first it is usually made the ordinary size required for exploration with the

hand. As a rule, the primary incision is about 10-12 cm long. If the abdominal

wall is very thick, it must be longer; if very thin, it may be shorter. The lower

the incision is placed, the more easily the deeper portions of the pelvic cavity

may be reached, but in extending the incision low, care must be exercised to

avoid injury to the bladder.

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In cutting through the abdominal wall, it is not necessary to strike

accurately the tendinous tissue between the recti muscles. If the incision is

made a little to one side of the tendinous median line and includes some of

the rectus muscle of that side, it makes little difference. Consequently, no

time should be lost in trying to make a careful dissection exactly in the

median line.

The incision is made through the skin and with a clean knife is

continued through the subcutaneous fat and fascia, as indicated in Fig. 162. A

and the bleeding vessels in the fat are caught with forceps. The incision is

then continued through the rectus muscle with its tendinous sheath down to

the sub-peritoneal fat, as shown in Fig. 162B and Fig. 163 A.

Fig. 162. A - Making the abdominal incision. The skin and superficial

tissues have been incised, exposing the aponeurosis. The forceps are

clamped on bleeding points in the subcutaneous tissue—they do not

include the skin.B - The aponeurosis has been divided, the division being

practically in the median line, and the right rectus muscle has been

separated from the intermuscular septum. The muscle is seen to the right

and the septum to the left

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Fig. 163. A - The few remaining muscular fibers at the bottom of the wound

are cleared away by placing the two index fingers together in the center of

the wound and then separating them to the angles, as here shown. This is

not ordinarily necessary but may be helpful if there is difficulty in

identifying the deeper tissues of the wall. B - Dividing the subperitoneal

fat.

The next step is to divide the subperitoneal fat and peritoneum. The

first small opening into the peritoneal cavity should be made in the upper

portion of the incision to avoid injury to the bladder, which may be drawn up

by an underlying tumor or inflammatory mass. The subperitoneal fat is

caught up by a dissecting forceps on each side and incised between the

forceps (Fig 163 B). A deeper portion is then caught up on each side and

divided (Fig. 164A). In this process of working through the fat, it is important

to progress directly downward toward the cavity, and not to one side. Unless

this point is watched, the dissection may extend along beside the peritoneum

and thus considerable time will be lost searching for the latter, particularly in

the cases where there is a large amount of subperitoneal fat. When the

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peritoneum comes into view it is picked up with a forceps, to lift it from the

intestine. While thus raised, it is caught with another forceps, as shown in Fig.

164B.

Fig. 164. A — Continuing the division of the subperitoneal fat. After one

cut is made, deeper portions are picked up and divided, and thus the

process is continued until the peritoneum is reached. In dividing through

the fat, care should be taken to work directly downward toward the

peritoneum, and not laterally in the subperitoneal space.

B — Picking up the peritoneum, preparatory to incising it. It is first

caught and lifted from the intestine and then the lifted portion is caught

with another forceps.

The first forceps is then opened to release any underlying intestinal loop

that may have been held by it, and it is made to grasp the raised peritoneum

at another point (Pict. 165 A) This process is continued until it is evident the

raised peritoneum is clear of intestine. In some cases the peritoneum is so

thin that the absence of intestine or omentum may be determined by sight. In

other cases it may be determined by touch. The peritoneum is then divided

between the dissecting forceps (Pict 165 B), and the edges of the small

opening are grasped with artery forceps In cases of inflammation in the lower

abdomen, the intestinal coils may be adherent to the peritoneum, and

particular care is necessary to avoid injury to the intestine. This danger is

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most marked in secondary operations, where the intestine may be firmly

bound by organized adhesions to the peritoneum in the vicinity of the

incision. In such a case it is advisable to extend the exposure of the

peritoneum laterally as far as necessary to find a clear area before attempting

to open it.

Fig. 165. A.— While the peritoneum is held up with the second forceps,

the first forceps are released, so that any portion of intestine caught in

them may drop away, and then the peritoneum is again caught with the

forceps. By this process, repeated if necessary, the peritoneum may be

separated from the intestine, which is sometimes inclined to adhere to it.

B.—The peritoneum incised. Notice that the opening is made at the

upper part of the abdominal wound, in order to avoid the bladder, which

may be pushed up by a tumor or pulled up by adhesions.

The next step is to enlarge the deep portion of the incision downward

and upward to the full extent of the superficial portion. A convenient way to

complete the division of the subperitoneal fat is by blunt dissection with the

scissors, as indicated in Fig. 166 A. With the heavy blunt-pointed laparotomy

scissors this division of the fat may be quickly carried to the symphysis

without danger of injuring the bladder. The peritoneum is then lifted by the

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fingers and divided with scissors, as indicated by the dotted line in Fig. 166 B.

The divided peritoneum is then caught on each side at the lower part of the

incision and lifted out of the wound, as shown inFig. 167A. This enables the

operator to see just where the opaque bladder begins (location indicated by

dotted line in Fig. 47A, and the translucent peritoneum may be safely divided

down to it. The peritoneum at the upper angle of the wound is then divided

while the intestines are pushed away and carefully protected by the fingers

under it (Fig. 167B).

Before beginning the internal work, it is well to protect the divided

tissues of the abdominal wall by towels. The edge of a towel may be fastened

to the peritoneum of each side by hemostatic forceps, as shown in Fig. 168

A,B. Another method is to attach the edge of the towel to the opposite side of

the wound, as shown in Fig. 169A. and throw the forceps and towel over to

that side. By this maneuver the holding-forceps are covered by the towel, as

shown in Fig. 169 B. Still another method of holding the protecting towels in

place is to tuck them around the wound margins and then introduce the

retractors for holding the wound open.

Paramedian incision (syn.: rectus incision). Some operators prefer to

make the incision through the aponeurosis over the rectus muscle of one side,

usually the right. The right one is used more often as most surgeons are right-

handed. The left paramedian incision is used if the surgeon is left-handed or

the patient had several operations before. The skin incision may be made in

the median line. The skin and fat are retracted and the aponeurosis is incised

some distance from the median line, over the rectus muscle. The muscle is

then split longitudinally or retracted as preferred, and the cavity entered by

an incision immediately under the upper aponeurotic incision. The advantage

of this procedure is that it insures the interposition of a layer of muscle

between the upper and lower lines of approximation, thus giving a wide area

of union instead of the narrow one that results when the upper and lower

lines of approximation fall practically together without intervening muscle.

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The interposition of muscle to separate the peritoneal and the aponeurotic

lines of approximation in the abdominal wall may, in the opinion of the

authors, be better attained by using the median incision and, in the closure,

dividing the intermuscular septum and approximating the two muscles in the

median line by light suturing.

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385

Transverse incision. The transverse incision, known as the Phannenstiel

incision, is considered by some operators the preferable incision for pelvic

work. It is made by the following steps:

1. A transverse incision with a slight downward curve is made through

the skin and subdermal tissues, the middle of the incision crossing the

median line about (4 cm.) above the pubic bone (Fig. 170 A). The length of the

incision is 8 to 10 cm, and it lies largely within the region of the pubic hair.

The same incision is continued down through the aponeurosis to the

recti muscles but not through the muscles. The upper flap, consisting of skin,

fat and aponeurosis, is then raised, the fibrous septum between the muscles

being divided by scissors or knife (Fig. 170 B) as needed to permit this flap

being raised to the required extent. When completely loosened, the flap is

held out of the way by a retractor or otherwise.

The muscles are then separated in the median line and the peritoneum

divided to the required extent by a median incision (Fig. 171 A.). Retractors

are then introduced to give the necessary exposure (Fig. 171 B).

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It is preferable to keep the incision within the area of pubic hair when

sufficient working room can be thus secured. If necessary the incision may be

extended further on one or both sides. Transverse division of the recti

muscles is permissible when required to give sufficient working room. In fact,

some operators employ this as the routine technique, making the transverse

cut through all tissues, including the muscles and the peritoneum.

The upper flap may be held out of the way by a retractor, as already

mentioned, or by traction on the aponeurosis by means of a forceps or a

suture. When all the tissues are divided transversely, the upper peritoneum

may be rolled upward and outward, or it may be sutured temporarily to the

posterior wall of the abdomen, after the intestines have been pushed up out of

the way.

When sutured across the cavity, the peritoneal flap serves to keep the

intestinal coils out of the pelvis during the subsequent steps of the operation.

The advantages of the transverse incision are: (1) the full length of the

incision is placed where most needed, viz., over the pelvis, (2) it prevents

postoperative hernia, for the suture lines do not lie immediately under each

other but cross at right angles, and (3) the scar is hardly noticeable after the

growth of the pubic hair. The disadvantages are: (1) the extensive area of

tissue traumatized increases the seriousness of infection in the wound and

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increases the chance of oozing and hematoma, (2) proper exposure requires

persistent and strong retraction in three directions, and, (3) it is not suitable

for difficult work in the region of the umbilicus or above, which work is not

infrequently required in gynecologic cases, and the necessity for such work

may not be apparent until the abdomen is open.

Transverse incision by Cherny. It is the incision of the skin and lower

layers in transverse direction, and it is situated about 5-6 cm higher than

symphysis pubis. It may be better then Phannestiel’s incision because of its

wide opening of the abdominal cavity. But as to reparation and cosmetic view,

it is much worse.

2. Exploration

When the proper opening has been made, the hand is introduced into

the peritoneal cavity and the various pelvic organs are outlined and the

pathological conditions determined as accurately as possible. It is well to go

about the exploration in a systematic way.

The first step is to clear out the intestinal coils from the lower abdomen,

so that the pelvic organs may be seen and palpated. Having the patient in

moderate Trendelenburg posture, i. e., with the shoulders considerably lower

than the hips facilitates this step. Then with the heavy rubber sheeting,

moistened with warm saline solution, the intestines are pushed up and held

out of the field. Of course, if some of the intestinal loops are adherent in the

pelvis, the adhesions must be broken before the loops can be pushed up. In

some cases the omentum will be found adherent in the pelvis, thus covering

over and obscuring everything, even the intestinal coils. The adherent

omentum must be separated and pushed up (Fig. 172, Fig. 173). Occasionally

the margin of the omentum is so extensively or densely adherent, that it is

preferable to excise the adherent portion.

388

The omentum and intestines having been pushed out of the field, the

examination of the pelvic organs proper begins. The uterus is the central

landmark. When that organ has been recognized, the other structures, though

greatly distorted, can be identified by their relation to it. The rounded corpus

uteri can usually be easily seen and palpated and any marked abnormality

389

determined. If turned back into the hollow of the sacrum, it must be brought

forward for identification and critical palpation.

Next, the adnexa of each side are to be palpated and inspected. There

are different methods of bringing the tube and ovary up into the wound for

inspection. The most convenient method usually is to introduce the hand,

palpate the various structures, and then lift up the ovary and tube with the

fingers, as indicated in Fig. 174, first on one side, then on the other.

Another convenient method is to grasp the round ligament near the

uterus with a forceps and lift up the uterus and adnexa as shown in Fig. 175.

Care should be taken not to grasp the tube, which is more prominent than the

ligament. Still another method is to grasp the fundus uteri with a special

holding-forceps and lift the structures as shown in Fig. 176. However, this

calls for a special instrument, which unnecessarily complicates the

instrument situation.

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Other structures to be considered in the examination are the

parametrium, bladder, ureters, glands (in carcinoma), rectum, sigmoid,

appendix, cecum, ascending colon (constricting membrane) and adjacent

ileum (bands, kinks).

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Good exposure of the pelvic interior permits a better appreciation of the

pathological conditions and a more accurate correction of them. At the same

time it reduces the chance of injury to adjacent structures.

3. Correction of Pathological Conditions

After exploring the pelvic cavity and lower abdomen and ascertaining

the exact conditions present, the operator proceeds to deal with the lesion or

lesions according to established principles and technique, and perform the

operation properly.

The determination as to what is best to do is not always an easy matter.

In many cases the decision as to what to do and what not to do is the most

difficult feature in the whole case. On it rests the freedom of the patient from

subsequent serious disturbance and consequently, to a considerable extent,

her future happiness. Shall the damaged ovaries be removed or subjected to

conservative operation? Shall the chance of pregnancy be preserved by

leaving a portion of a tube, that may later cause trouble? Shall the myomas be

treated by myomectomy or by hysterectomy? Will the preservation of a

thickened and chronically inflamed uterus prove ultimately beneficial or

harmful to the patient? Is the malignant disease (uterine or ovarian, as the

case may be) really operable, judged according to the probability of

immediate and remote comfort to the patient? Is the patient's life and

comfort, in a case of old organized adhesions throughout the pelvis, best

protected by breaking up the adhesions in every direction or by removing the

obvious lesion with a minimum disturbance of adhesions? The list of

questions could be extended indefinitely but this is sufficient to call attention

to the serious problems encountered. The conscientious gynecologist must

bring to bear all possible knowledge of the physiology and pathology and

reparative powers of the organs involved, an understanding of the patient's

circumstances and wishes, and a judgment based upon close study, accurate

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observation and a sympathetic consideration of the patient's comfort and

usefulness.

Most of the questions thus encountered in the exploration may be

answered promptly and positively in the individual case. A few of the

problems present features, which have not yet been fully worked out. But the

uncertain features are being eliminated gradually, as more and more reliable

information becomes available.

To prepare for leakage. An adherent inflammatory mass or cyst may

contain pus or other irritating fluid such, for example, as in an endometrial

cyst or a dermoid. In order to prevent extensive peritoneal contamination

from leakage during enucleation, special care is needed. The first thing is to

free the omentum and intestines by breaking the light adhesions, but avoid

adhesions likely to lead to leakage from the mass.

Then cover the intestines with the rubber sheeting, spreading it out so

as to give complete protection. Then spread out a towel over the rubber

sheeting to absorb any leakage as soon as it occurs in the process of

enucleating the mass, a corner of the towel to be outside and clamped to the

abdominal sheet. The amount of free fluid in the pelvis may be held to the

minimum by using the suction apparatus as soon as leakage starts. Also, when

a fluid collection is felt and leakage seems probable, it may be advisable to

evacuate the fluid with a trocar attached to the suction tube.

Appendix. Lesions of adjacent structures may be found, either

associated with a gynecologic lesion or causing symptoms attributed to a

supposed gynecologic lesion, which was not present. The gynecologist should

of course be prepared to treat such commonly encountered lesions according

to established usage as set forth by authoritative works on those subjects.

There is one question that recurs so frequently in gynecologic work that it

merits special attention here. Should the appendix be removed in every case

of abdominal section in which the patient's condition will permit? On this

point there is decided difference of opinion among operators, and there is a

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good deal to be said on each side. Some consider it inadvisable, with the

abdomen open, to leave this structure, which may cause a second operation

and may cause the patient's death in spite of operation. Others consider it

inadvisable to open the intestinal tract in the operative field and thus run the

chance of subsequent leakage and possibly fatal peritonitis, simply to remove

a structure that is causing no trouble and may never cause trouble. The

authors have solved this problem to their own satisfaction by the adoption of

the rule that the appendix is to be removed only for a definite reason. The

accepted reasons are four in number and as a matter of fact cover most cases.

The reasons are as follows: (1) If the appendix is obviously diseased. (2) If

there have been symptoms indicating disease of the appendix. (3) If the

appendix lies in the operative field so that it is likely to be caught in the

reparative exudate. (4) If the patient requests its removal.

When the cecum and appendix are normally movable, they may be

brought sufficiently toward the median incision for convenient work. When

the structures are fixed by adhesions or congenital bands, the work must be

conducted deep in the right side, which may require strong lifting and

retraction of the right abdominal wall. Also, help may be given toward

satisfactory exposure and operating space, by keeping the patient in partial

Trendelenburg position and by pushing the small intestine to the left and

upward.

Emergency repair of injury. Injury of an adjacent structure may occur,

due to its displacement or distortion by the gynecologic lesion or involvement

in it. Such conditions, favoring injury of intestine or bladder or ureter, are

found principally with inflammatory adhesions or endometriosis, or with a

large tumor of ovary or uterus. Malignant tumors and pelvic tuberculosis are

particularly prone to involve and damage the adjacent intestinal wall or

bladder wall so that it tears on the attempt to separate adhesions.

As mentioned tinder malignant tumors of the ovary, it is well for the

gynecologist to refresh his memory in regard to the details of emergency

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repair of intestinal and urinary tract injuries when preparing to operate in a

complicated case. The emergency treatment of bladder and urethral injuries

will be found in special textbooks.

4. Toilet of the Peritoneum

Bleeding having been completely controlled, the blood and clots are

sponged out of the pelvis and, as far as practicable, the pedicle ends are

turned under and all raw surfaces covered with peritoneum. All abdominal

sponges are then removed, the intestines are permitted to come back into the

pelvis (the patient having been lowered from the Trendelenburg posture), and

the omentum is spread out in its proper place. The objects of the toilet of the

peritoneum are to remove all injurious substances, to restore the structures to

approximately their normal relations, and to prevent serious adhesions.

The prevention of serious adhesions is a problem not yet wholly solved.

In every case of operation, more or less reparative exudate is thrown out. This

splints the injured tissues and aids in repair, somewhat on the same principle

as callus about a broken bone. If everything goes well this reparative exudate

is absorbed to a greater or lesser extent. In some cases practically all of it

disappears, while in other cases a considerable portion remains as definite,

organized adhesions. In many cases where extensive adhesions remain, no

symptoms result. In other cases postoperative adhesions cause troublesome

symptoms, the most serious of which is intestinal obstruction. So it is evident

that some adhesions cause trouble and others do not.

The preventive measures have two objects: first, the prevention of all

adhesions as far as practicable and, second, the avoidance in particular of

those special adhesions which are most likely to cause serious trouble. The

first object is obtained by a rigid asepsis to prevent all infection, by the

minimum handling and roughening of the peritoneal surfaces, by the

protection of the intestines with moist gauze pads or better still by heavy

rubber sheeting by turning in of all raw ends and edges, and by the complete

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removal of all irritating materials from the peritoneal cavity at the close of the

operation.

In regard to the second object, it has been found that the adhesions of

the small intestine are the ones that are most likely to lead to serious trouble.

Consequently, as the toilet of the peritoneum is made, special care is taken to

keep the coils of the small intestine away from the irritated peritoneum in the

depth of the pelvis and away from the sutured peritoneum at the site of the

abdominal incision. The small intestines may be kept out of the depth of the

pelvis more or less by pushing the coils up and allowing the cecum and

sigmoid to come together across the pelvis (Fig. 177) or as near together as

possible. To prevent adhesions of the small intestine to the line of incision,

the omentum is to be spread immediately under the incision. Adhesions

between the omentum and the line of incision rarely cause trouble. In certain

cases the omentum may be used to assist in keeping the small intestines away

from irritated areas in the pelvis. The omentum, however, varies much in

length in different cases, sometimes being very short. Even when long, it

should not be tucked down forcibly into the pelvis, for omental adhesions

with tension will very probably cause troublesome symptoms.

The use of antibiotics and sulfanilamide in the peritoneal cavity in clean

cases has been much discussed pro and con—the risk of irritation and

contamination being balanced against the chance of inflammation in that case

and its prevention by the bactericide. Large series of carefully checked cases

will be needed to settle the matter.

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5. Closure of Incision

The peritoneal edges of the wound are lifted with forceps, so as to be

clear of intestine and omentum, and then approximated by a catgut suture.

For this purpose it is well to use a running mattress suture, as shown in Fig.

1211, locked at intervals. This type of suture prevents the turning in of the raw

edge, which would favor intestinal adhesions to the wall. However, with

special care this turning in may be avoided with the ordinary running suture,

which is more convenient and rapid in application. Another item is the

tearing of the peritoneum. In cases where there is some tension and the

peritoneum is thin or friable, it may tear with each suture, and the deeper

bites taken to bring it together only cause larger tears. This difficulty is

overcome by picking up some of the muscle along with the peritoneum in the

first row of sutures. The peritoneal sutures, and, in fact, all sutures in the

abdominal wall, are ordinarily placed with large needles that can be

conveniently handled without a needle holder. In cases where the wound is

very deep, on account of a thick wall, it may be advisable to use a needle

holder here and there in the work.

After the peritoneum is sutured, the intermuscular septum is divided by

scissors, as shown in Fig. 178 B, and the two recti muscles are brought

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together in the median line by a loosely drawn running suture. The peritoneal

and muscular suturing may be conveniently made with the same suture, by

suturing down the peritoneum, as shown in Fig. 178 A, B and up in the

muscles, as shown in Fig. 179 A,B tying the muscular portion to the upper end

of the peritoneal portion, which has been left long for that purpose.

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The silkworm-gut stay-sutures are placed so that they lie just under the

aponeurosis and emerge on the skin surface about 1/2 cm. from the wound

margin, as shown in Fig. 179 B. Three arc usually sufficient, except in the very

long incisions, where four or five may be required. The stay-sutures prevent

undue tension on the line of union during muscular activity involving the

abdominal wall. After several days the catgut sutures become somewhat

softened and a sudden strain on the wall, such as coughing or sneezing, may

damage the union by causing separation at spots deep in the depth of the

wound or by causing the whole wound to open. This danger, the reality of

which has been established by unfortunate experiences, is minimized by the

use of stay-sutures, followed immediately on their removal by strong adhesive

strapping which is to be maintained until the end of the fourth week. In that

way adequate support supplements the approximation sutures until the union

is firm enough to stand all strains to which it is likely to be subjected.

Next the aponeurotic edges are united accurately and securely (Fig.

180). This may be accomplished by a continuous suture locked at intervals, as

shown in Pict. 61 B, or interrupted mattress sutures may be used. The suture

material is of importance. It must hold long enough to permit firm union, for

on this line of union largely depends the integrity of the scar and the

prevention of hernia. Chromic catgut is generally used. A considerable

number of operators prefer silk, lavsan or linen, and an occasional one pins

his faith to silkworm-gut or silver wire. Furthermore, there are some types of

artificial catgut (dacril), which are widely used nowadays. The nonabsorbable

sutures hold indefinitely, but if any infection takes place, sinuses are likely to

persist until the infected sutures arc removed. Such unpleasant experiences

were common in former times when silk was the universal suture material.

The ideal material is a dependable long-lasting absorbable suture. The

authors for several years have used twenty-day catgut with entire satisfaction.

The matter of suture material for the abdominal wound is considered in more

detail under preparation of instruments and sutures (Fig. 160, Fig. 161)

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An additional measure to prevent postoperative hernia is to overlap the

aponeurosis, as indicated in Fig. 181. This is especially useful in patients

having an overstretched abdominal wall, with poor recti muscles.

An abdominal wall presenting wide separation of the muscles (diastasis)

requires special care in closing. More difficulty is experienced in exposing the

recti muscles and bringing them together, but it is especially important to do

so thoroughly in such a case. The excess of aponeurosis may be disposed of by

overlapping, as just explained, thus further strengthening the wall, or, if

thought preferable, it may be excised.

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The method of skin approximation varies greatly with different

operators. The skin wound may be closed by an ordinary continuous suture of

catgut or silk or linen or by interrupted sutures of these materials. The catgut

may be placed in the form of a subcuticular suture, as explained later, or

nonabsorbable material, such as silkworm-gut or silver wire or paraffined

linen, may be used for such a suture, to be drawn out after healing. Some

operators prefer clips for closing the wound, and others depend on adhesive

plaster approximation of the skin margins.

After considerable experimentation with various methods of skin

closure, the authors have returned to the simple continuous catgut suture,

applied as shown in Fig. 182. The fine suture (No. 0) is of plain catgut and

hence is absorbed as soon as its usefulness is ended,so quickly that it does not

have to be "removed" with forceps and scissors. The outer loose unabsorbed

portion is simply brushed off. This suture is most expeditiously applied with a

slender sharp needle, large enough to be handled conveniently without a

needle holder. The needle may be straight or curved, as preferred. The

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method of its application is shown in Fig 182 A and the completed suture in

Fig. 182 B. It can be applied rapidly, gives firm approximation, controls

oozing in the flaps, and is suitable for all conditions. Subcuticular suture is

shown in Fig. 183.

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6. Dressing

The skin about the wound is cleansed with saline solution, to remove

the blood, and then with alcohol and then dried. The stay sutures are then

tied over two long slender piece of gauze.

Special point

Drainage. Indications. That small percentage of cases in which drainage

is advisable includes the following classes:

Rapidly spreading inflammation of the peritoneum or acute general

peritonitis. In such cases free drainage is indicated, and, as a rule, the

freer the better.

Rupture of abscess in pelvis. This accident happens not infrequently

during the enucleation of an inflammatory mass containing pus. In

some cases the pus is not confined in any removable sac, but has

burrowed in various directions among the adherent organs. In such a

403

case, as soon as the adhesions are separated the pus flows out into the

peritoneal cavity.

Persistent free oozing from surfaces left after the enucleation of an

inflammatory mass. Here the effect desired is pressure rather than

drainage, but, as the end of the gauze used for pressure must be brought

out through the abdominal wound or through the vagina, it is usually

referred to as a drain or pack. Topical thrombin preparations now take

care of oozing in most cases.

Endometrial ovarian cysts with extensive adhesions.

Methods. The method of draining depends somewhat on the extent of

the inflammation and other conditions present. If the inflammation is limited

to the true pelvis and hysterectomy has been performed, vaginal drainage is

the preferable plan. If the cervix uteri have been removed, there is already a

satisfactory opening into the vagina. If the cervix has not been removed, it

may be split posteriorly. If the inflammation is chronic and only a safety vent

is required, small red tubing may be used. If the inflammation is acute,

immediate free drainage should be provided for using good-sized rubber

tubing. Any hemostatic gauze packing beside the tubing, should be placed so

that it may be removed without disturbing the drainage tube.

If the inflammation is severe and extensive, drainage both above and

below may be advisable—the abdominal drainage being by means of a soft

rubber tube. If the uterus is preserved, it is usually preferable to drain above

only, though vaginal drainage through a special opening in the vaginal vault

may be employed if desired.

Operations on the uterus and adnexas

Amputation of the oviduct (salpingectomy)

Indications: bag-like tumor in the tube (hydrosalpinx, pyosalpinx),

double-sided severe chronic infpammational process, without effect of

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concervative treatment, tubal pregnancy, etc. If the ovary involved into

inflammatory process it should be removed together with the tube

(adnexectomy).

Contraindication: surgical treatment is contraindicated in cases of

tuberculous disease of tubes and ovaries, because separation adhesions may

lead to development of intestinal fistula, peritonitis.

The operation may be very difficult in cases of large bag-like tumor

formations (pyosalpinx), progressive chronic inflammations due to a lot of

adhesions in abdominal cavity.

Anesthesia: general endotracheal narcosis is the most preferable in this

operation.

Stages of the operation are the following:

1. Disinfection of the skin.

2. Longitudinal or transverse incision of the anterior abdominal

wall.

3. Introduction of a dilator and shielding of the intestinal loops.

4. Gripping of the uterine tube by a hand and its elevation.

5. Placement of Kocher’s forceps on the mesosalpynx and the

uterine end of the oviduct.

6. Excision of the uterine tube, suturing and ligation of stumps.

7. Peritonization of stumps. (Fig. 67)

8. Cleaning of the abdominal cavity in case of purulent formation

(pyosalpinx, ruptured tumor-like formations), it is necessary to

perform the drainage of abdominal cavity with special sterile

polyvinyl tube, setting in one or both iliac areas.

9. The surgical nurse’s report about the accountability of all

instruments and napkins;

10. Suturing of the abdominal wound.

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Operative treatment of ectopic pregnancy

Ectopic pregnancy is a significant health problem for women of

reproductive age and warrants an urgent well planned therapeutic strategy. It

can be a life threatening condition and is the leading cause of first trimester

mortality for women living in the developed world. The long term sequelae of

ectopic pregnancy are infertility. Critical decisions need to be taken during

the initial management of a woman with ectopic pregnancy to ensure safety

and to optimally preserve future fertility.

Ectopic pregnancies can be managed surgically either by laparotomy or

laparoscopy. Most cases should be managed laparoscopically as best practice

The traditional treatment in this stage is abdominal operation and

removal of the pregnant tube (in tubal pregnancy) as soon as the diagnosis is

fairly certain (see chapter 11). Abdominal salpingectomy (Fig. 184, Fig. 185)

as well as abdominal salpingotomy traditionally were used for surgical

treatment of non-interupted tubal pregnancy.

406

Currently ectopic pregnancies can be managed surgically either by

laparotomy or laparoscopy. Most cases should be managed laparoscopically

as best practice. The obvious benefit of laparoscopic surgery was

demonstrated convincingly in these trials – shorter operation times, less

blood loss, shorter hospital stays and lower analgesic requirements. It has

been standard teaching in the past that laparotomy should be used for women

with a haemoperitoneum. This is no longer true in the case of the experienced

laparoscopic surgeons with good operating facilities. However, in general

terms the surgical procedure that will prevent further blood loss most quickly

should be used, and in many centres laparotomy may still be the preferred

choice.

The two procedures usually performed on tubal ectopics are

salpingectomy and salpinsgotomy. In some cases with an isthmic ectopic

pregnancy, a segment of the tube can be removed which will leave sufficient

tubal length for reanastomosis at a later stage, since these cases have a poorer

outcome with conventional salpingostomy. A laparoscopic salpingostomy is

the removal of the ectopic pregnancy, by dissecting it out of the tube, leaving

the Fallopian tube in situ in an attempt to preserve fertility on that side. Fig.

186, Fig. 187.It is used for surgery of non0interrupted tubal pregnancy.

407

408

Pelvic hematocele. The typical example of pelvic hematocele is tubal

abortion. In these cases the hemorrhage has long since ceased and the

collection of blood low in the cul-de-sac is well shut off from the general

peritoneal cavity by plastic exudate and adhesions. The embryo and

membranes have probably escaped from the tube, either through a rupture in

the wall or through the end of the tube by "tubal abortion," and perhaps have

been largely absorbed. Practically all that remains is the blood in the pelvis

with the exudate and adhesions around it. This forms a tender mass low in

the culdesac back of the uterus.

In such a case the tclassic, traditional surgery was to perform urgent

laparotomy and salpingectomy, removing of blood clots and tissues of the

ovum from uterine cavity, and drainage of the uterine cavity. (Fig. 188).

Laparoscopic salpimgectomy is the benefit for managhement of such

cases today (Fig. 189).

409

410

Resection of the ovary

Indications: retention cyst of the ovary, Stein-Leventhal syndrome,

endometriosis of the ovary.

Stages of the operation are the following:

1. Disinfection of the skin.

2. Longitudinal or transverse incision of the anterior abdominal wall.

3. Introduction of a dilator and shielding of the intestinal loops.

4. Fixation of the ovary with fenestrated forceps.

5 Pathologically altered tissue of the ovary excision (with a scalpel). (Fig. 192).

6. Suturing of the ovary (with catgut).

7. Revision of the abdominal organs.

8. The nurse’s report.

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9. Cleaning the abdominal cavity

10. Suturing of the abdominal wall (drainage should be performed in case of

endometriosis of the ovary)

11. Catheterization of the bladder

Removal of para-oophoritic cyst

Indications: para-ophoritic cyst.

Main stages of the operation are the following:

1. Disinfection of the skin.

2. Longitudinal or transverse incision of the anterior abdominal wall.

3. Introduction of a dilator and shielding of the intestinal loops.

4. Inspection of the organs of abdominal cavity and uterus especially their

topography.

5. Dissection of the anterior layer of broad ligaments (between clamp and

contraclamp).

412

6. Enucleation and removal of a cyst with the help of swab and scissors. (Fig.

193)

7. Placement of a catgut suture on the incision in the broad ligaments.

8. Nurse’s report.

9. Cleaning the abdominal cavity

10. Suturing of the abdominal wall.

11. Catheterization of the bladder

Supravaginal amputation of the uterus

There are two main types of amputation of the uterus: with or without

appendages (ovaries and tubes). The most preferable type is amputation

without adnexa. But if there is a serious damage of the ovary (or ovaries) due

to hemorrhage, inflammatory process, cysts and tumors etc, the injured ovary

(or ovaries) should be removed.

413

Indications: myoma of the uterus, endometriosis, injuries of the uterus

(perforation during artificial abortion), etc.

Main stages of the operation are the following:

1. Skin disinfection;

2. Longitudinal or transverse incision of the anterior abdominal walls;

3. Introduction of a dilator and inspection of the pelvic organs;

4. Placement of a tenaculum forcepts into the uterus and its elevation into the

wound;

5. Shielding of the intestines;

6. Application of forceps to the round ligament of the uterus, proper ligament

of the ovary, and the uterine end of the oviduct, dissection of each of those

ligaments between two forceps, and suturing of the stumps.

If it is amputation with appendages, one should apply forceps to the round

ligament, suspensory ligament, then follows dissection, ligation. Then the

tissue between forceps should be dissected;

7. Dissection of the vesicouterine fold of the peritoneum and displacement of

the bladder with a gauze swab;

8. Application of the forceps and ligation (after suturing) of vascular bundles

on both sides.

9. Dissection of the uterine corpus from the cervix; (Fig. 194).

10. Suturing of the cervical stump;

11. Peritonization;

12. Cleaning the abdominal cavity;

13. The surgical nurse’s report about the accountability of all instruments and

material;

14. Suturing of the abdominal wall;

15. Catheterization of the bladder.

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Extirpation of the uterus (abdominal hysterectomy)

Indications: tumors of the uterus (large myoma, cancer, sarcoma),

endometriosis, unexplained repetitive uterine bleedings, ovarian tumors. This

operation is most preferable in patients after 40 years of age.

Main stages of the operation are the following:

Stages 1-3 are the same.

4. Placement of a tenaculum forcepts into the uterus and its elevation into the

wound; (Fig. 195)

5. Shielding of the intestines;

6. Application of forceps to the round ligament of the uterus, proper ligament

415

of the ovary, and the uterine end of the oviduct, dissection between two

forceps of each of those ligaments, and suturing of the stumps. (Fig. 196).

If it is extirpation with appendages, one should perform application of forceps

to the round ligament, suspensory ligament of the ovary (lig.

infundibulopeolvicum), then follows dissection, and ligation of the

formations;

7. Dissection of the vesicouterine fold of the peritoneum and displacentment

of the bladder with a gause swab. (Fig. 196);

8. Application of the forceps and ligation (after suturing) of vascular bundles

on both sides;

9. Dissection and ligation of the uterosacral ligaments;

10. Additional separation of the bladder;

11. Dissection and ligation of the uterine vessels on both sides;

12. Separation of the uterus from the vaginal fornices. The moment the vagina

is opened, the surgical nurse gives the surgeon a narrow gauze band 30 cm

long moistened with 70 per cent alcohol in the middle, which the surgeon

introduces into the vagina with the help of a long forceps; the latter is

immediately discarded after the operation. (Fig. 196);

13. Suturing of the vagina ;

14. Peritonization (Fig 197);

15. Cleaning the abdominal cavity;

16. The surgical nurse’s report about the accountability of all instruments and

material;

17. Suturing of the abdominal wall;

18. Catheterization of the bladder.

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Conservative myomectomy

Indications: subserous myoma of the uterus.

Main stages of the operation are the following:

1. Disinfection of the skin;

2. Longitudinal or transverse incision of the anterior abdominal wall;

417

3. Introduction of a dilator and shielding of the intestinal loops;

4. Fixation of the uterus by one of the nodes with a tenaculum forceps;

5. Shielding of the abdominal cavity;

6. Dissection of the uterine wall above (may be around) the node (with

scalpel) with haemostasis using Kocher’s forceps;

7. Grasping of the exported node with a tenaculum forceps ; (Fig 198)

8. Enucleation of the node with scissors and gauze swab;

9. Ligation of bleeding vessels;.

10. Suturing of the bed of the tumor (interrupted catgut sutures in 2 layers);

11. Peritonization;

12. Cleaning the abdominal cavity;

13. The surgical nurse’s report about the accountability of all instruments and

material;

14. Suturing of the abdominal wall;

15. Catheterization of the bladder.

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Transvaginal Operations

Preparation of operative field

The preliminary preparation of the operative field the day before has

already been mentioned. The preparation in the operating room is usually

made after the patient is anesthetized and in position for operation, though it

may be made before anesthetization if preferred. With good pre-anesthetic

sedative sleep, the preparation and often also the vaginal operation

(curettage, cervix work) can be carried out without additional anesthesia,

provided the work be conducted gently and quietly.

In arranging the patient for vaginal operation, the arms are folded over

the abdomen and each hand is caught with a gauze loop about the wrist, the

other end of the muslin strip being tied around some convenient projection

on the opposite side of the table. This method of hand tying protects the arms

from slipping over the edge of the table and also restrains the hands as

needed.

With the patient's hips drawn to the end of the table and the feet

supported out of the way by stirrups (Fig. 199.), the external genitals are

cleansed thoroughly with green soap and sterile water, using gauze or cotton

balls, then cleansed with sterile water, and then with the antiseptic solution.

419

Catheterization is then carried out with strict asepsis, the labia being

held away and the meatus specially cleansed. The sterile catheter should be

lubricated and care should be taken to avoid contaminating the bladder

portion with soap or irritating antiseptics. After the catheterization, the

vagina is cleansed with soap and water and then with the antiseptic solution.

The soap scrubbing is the most important part of surface sterilization.

As already mentioned under abdominal preparation, the other antiseptics

employed vary greatly in different institutions and at different times.

Tinctures of these and other of the newer chemicals are used for skin

disinfection, but are irritating to mucous membranes. Instead of the usual

swabbing method of application for skin sterilization, spraying has been

employed.

It is well to extend the preparation of the operative field over a wide

area. When the vaginal opening is large enough, a vaginal speculum or

retractor is introduced to facilitate the vaginal disinfection. When the opening

is too small for the speculum, a finger may be introduced alongside the gauze-

carrying forceps to spread out the vaginal folds.

When the antiseptic preparation is completed, the pad and towels are

removed, the hips are brought down well, the flat electrode is placed if there is

to be conization, and the feet are elevated in preparation for draping. In

placing the patient in position for the vaginal operation, the feet in the

stirrups should be raised high, as shown in, and then swung slightly outward

by a small twist of each support. When this is carried out correctly, the

patient's feet are slung high out of the way, giving plenty of room for the

assistants to stand immediately by the operative field where they can see what

is being done and assist to the best advantage. At the same time the feet and

legs are supported without troublesome pressure back of the knees. Of course,

for stout patients with very wide hips the usual towel padding is required

between the lower part of the leg supports and the hips. A point of importance

in arranging patients in position for operation is to watch for any stiffness of a

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joint. Such an ankylose or painful joint is usually mentioned by the patient in

giving the history. In some cases, however, the patient does not mention this

incidental condition: hence in arranging the patient it is important to proceed

gently so that if there should be any unmentioned stiff joint, it will be noticed

and due allowance made to avoid strain.

After the patient is arranged in position, the sterile combination sheet is

applied with the steps. A waste basin is placed on the floor where it will catch

blood and soiled sponges, the operator's stool is pushed into position, the

assistants step into place, and the instrument table is pushed close to the right

side of the seated operator so that he can conveniently pick up and lay down

the few instruments ordinarily used.

Catheterization in the operating room immediately preceding operation

is advisable as part of the routine preparation. It gives an entirely empty

bladder, which tends to prevent injury in extensive pelvic operative work and

also facilitates accurate examination in those cases requiring deep palpation

under the anesthesia. Catheterization in the operating room has the

advantages that it is carried out under better antiseptic precautions and with

less trouble and loss of time than in the patient's room, and also prevents

troublesome accumulation of urine between catheterization and operation. In

the exceptional cases where catheterization is not advisable, a word in time to

the preparation-assistant will eliminate it.

Another point of importance in vaginal work is to arrange the sterile

coverings about the vaginal opening in such a way that the rectum will be kept

covered. Unless such care is exercised in the various manipulations in the

course of the operation, the rectum may become exposed sufficiently to

permit contaminating contact of sutures or instruments or the operator's

gloved fingers.

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Operations on the cervix and vaginal walls

Cervical electroconization

Indications: cervical erosion, erosive ectropion of the cervix.

Main stages of the operation are the following:

1. Disinfection of the external genitalia and vagina with any antiseptic

solution (not alcohol);

2. Introduction of a special vaginal speculum (without electroconductive

material);

3. Fixation of the cervix with tenaculum forcepts;

4. Excision of the abnormal site with the electroconizer;

5. Treatment of the wound with 5% solution of potassium permanganate;

6. Removal of the instruments.

Conical excision of the cervix (after Sturmdorf)

Indications: glandulomuscularis hyperplasia of the cervix due to chronic

cervicitis without any effect of concervative treatment.

Main stages of the operation are the following:

1. Disinfection of the external genitalia and vagina.

2. Exposure of the cervix with the aid of a speculum.

3. Fixation of the anterior and posterior labia of the cervix with a tenaculum

forcepts ;

4. Dilatation of the cervix with Hegar's dilators (up to No. 8);

5. Circular incision of the cervical mucosa (with a scalpel);

6. Placement on the cervix of two catgut guy sutures;

7. Excision of a cone from the cervix;

8. Hemostasis;

9. Placement of two main sutures from catgut No. 6 (the nurse should give the

surgeon threads 25-30 cm long);

10. Placement of additional sutures on the cervix (catgut No. 4);

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11. Treatment of the cervix with iodine tincture and removal of the speculum;

12. Tamponade of the vagina (liquid petrolatum, synthomycin liniment). (Fig.

200).

High amputation of the uterine cervix

Indications: elongation of the cervix, pronounced deformation of the

vaginal part of the cervix due to previous ruptures, scars, glandulomuscularis

hyperplasia of the cervix.

Main stages of the operation are the following:

1. Disinfection of the external genitalia and vagina;

2. Exposure of the cervix with the aid of a speculum;

3. Fixation of the anterior and posterior labia of the cervix with a tenaculum

forcepts;

4. Dilatation of the cervix with Hegar's dilators (up to No. 8);

5. Circular incision of the cervical mucosa (with a scalpel), reaching

submucous layer;

6. Bringing down of the cervix downwards (by tightening with forceps);

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7. Dissection of the cervix for two parts (anterior and posterior);

8. Amputation of the anterior part of the cervix;

9. Ligation of separated cervical mucosa of anterior part with the endocervix;

10. Amputation of posterior part of the cervix;

11. Ligation of separated cervical mucosa of posterior part with the

endocervix;

12. Treatment of cervical stump with iodine tincture and removal of the

speculum;

13. Tamponade of the vagina (liquid petrolatum, synthomycin liniment).

Cervical biopsy

Indications: histological study of the cervical tissue in case of malignant

and pre-malignant diseases of the cervix.

Main stages of the operation are the following (Fig. 201):

1. Disinfection of the external genitalia and vagina;

2. Exposure of the cervix with the aid of a speculum;

3. Fixation of the cervix with a tenaculum forcepts;

4. Excision of the abnormal site of the cervix;

5. Placement of interrupted catgut sutures (catgut No. 3);

6. Treatment of the cervix with iodine tincture;

7. Marking of the material and sending it to a laboratory.

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Plastic surgery on the anterior vaginal wall (anterior colporrhaphy)

Indications: prolapse of anterior vaginal wall.

Main stages of the operation are the following:

1. Disinfection of the external genitalia and vagina;

2. Exposure of the cervix with the aid of a speculum and its fixation with a

tenaculum forcepts (two pairs);

3. Infiltration of tissues with 0. 25 per cent solution of novocaine;

4. Dissection of the anterior vaginal wall and separation of the edges of the

vaginal flap (with a scalpel);

5. Separation of the bladder from the cervix (with scissors and a gauze swab);

6. Placement of purse-string catgut sutures (catgut No. 3-4) on the bladder

fascia;

7 Settling of the bladder into the purse-string suture with a finger ;

8. Placement of a continuous catgut suture on the vaginal wall ;

8. Excision of the excessive portion of the vaginal wall flap;

9. Catheterization of the bladder;

425

10. Treatment of the suture with iodine tincture and removal of the

instruments.

Plastic surgery on the posterior vaginal wall and the muscles of

the pelvic floor (colpoperineorrhaphy)

Indications: long-standing rupture of the perineum, prolapse of

posterior vaginal wall, prolapse of rectum.

Main stages of the operation are the following:

1. Disinfection of the external genitalia and vagina;

2. Placement of Kocher's forceps on the edges of the would-be flap;

3. Infiltration of tissues with 0. 25 per cent solution of novocaine;

4. Dissection of the vaginal wall and perineal skin;

5. Separation of a flap

6. Dissection of scars with a scissors and the fascia in the lateral corners of the

wound and exposure of the levators;

7. Placement of 2-3 interrupted sutures (catgut No. 6);

8. Placement of a continuous catgut suture on the vaginal wall;

9. Ligation of sutures on the levators;

10. Placement of buried sutures (catgut No. 3) on the superficial muscles;

11. Placement of silk sutures on the perineal skin;

12. Treatment of sutures with iodine tincture.

Manchester operation

Indications: prolapse of the uterus and vagina.

Main stages of the operation are the following:

1. Disinfection of the external genitalia and vagina;

2. Fixation of the cervix with a tenaculum forcepts;

3. Probing of the uterine cavity;

4. Infiltration of tissues with 0. 25 per cent solution of novocaine;

426

5. Incision of the anterior vaginal wall and a circular incision of the mucosa

around the vaginal portion of the cervix (with a scalpel);

6. Separation of the vaginal flap;

7. Separation of the bladder and rectum (with a scissors and a gauze swab);

8. Placement of two Kocher's forceps on the cardinal ligaments, dissection of

the ligaments and their suturing with catgut No. 4;

9. Dilatation of the cervix with Hegar's dilators (up to No. 8) and amputation

of the cervix (with a scalpel);

10. Placement of semi-purse-string sutures on the bladder fascia (catgut No.

3-4);

11. Excision of the excessive portion of the vaginal flap;

12. Fixation of the cardinal ligaments to the stump of the cervix with two

catgut sutures;

13. Placement of a continuous catgut suture on the vaginal wall;

14. Placement of sutures to form the anterior and posterior labia of the cervix

(catgut threads 25-30 cm long);

15. Catheterization of the bladder;

16. Treatment of sutures with iodine tincture (followed by

colpoperineorrhaphy as described above);

17. Placement of intravaginal tampon with petrolatum liquid or synthomycin

liniment.

Minor gynecological operations

Artificial (induced, justifiable, therapeutic) abortion

Indications: grave extragenital diseases, bad living conditions, suspicion

to congenital malformations of the fetus, hereditary diseases, etc.

Artificial abortion may be performed in term of gestation 6-12 weeks

depending on medical or social indications.

Main stages of the operation are the following:

427

1. Disinfection of the external genitalia and vagina;

2. Exposure of the cervix with the aid of a speculum;

3. Fixation of the cervix with a tenaculum forcepts;

4. Paracervical anaesthesia;

5. Probing of the uterine cavity;

6. Dilatation of the cervix with Hegar's dilators (up to No. 10-12, sometimes

to13-

14) (Fig. 202).

7. Destruction of conceptus with small curette or fenestrated forceps (Fig.

203);

8. Curettage of the mucosa of the uterine cavity;

9. Removal of the instruments and treatment of the cervix with iodine

tincture;

10. Marking of scrapings and sending the material to a laboratory.

428

Separate Curettage of the Uterine Cavity

Indications: histological study of the endometrium in case of malignant

and pre-malignant diseases of the uterus, disturbances of menstrual cycle,

etc.

Main stages of the operation are the following:

1. Disinfection of the external genitalia and vagina;

2. Exposure of the cervix with the help of a speculum and fixation of the

cervix with a tenaculum forcepts;

3. Para-cervical anesthesia;

4. Probing of the uterine cavity;

5. Dilatation of the cervical canal with Hegar's dilators;

6. Curettage of the uterine mucosa;

7. Removal of the instruments and treatment of the cervix with iodine

tincture;

8. Marking of scrapings and sending the material to a laboratory.

Puncture of the abdominal cavity through the posterior vaginal

fornix

Indications: suspicion to interrupted ectopic pregnancy, perforation of

the uterus, pelvioperitonitis or general peritonitis, to determine the character

of the exudation of tumor-like formations of appendages, etc.

Main stages of the operation are the following (Fig. 204)

1. Disinfection of the external genitalia and vagina;

2. Exposure of the cervix with the aid of a speculum;

3. Fixation of the cervix with a tenaculum forcepts ;

4. Puncture of the abdominal cavity;

5. Treatment of the cervix and the site of puncture with iodine tincture.

429

A course of the postoperative period and care for patients

When the operation is over and the patient has recovered from narcosis,

she is transferred to an intensive care unit since such patients require a

particularly thorough observation, care, and not uncommonly intensive

therapy.

The equipment of the postoperative room should meet the following

requirements: the beds should allow for the possibility to create the necessary

position (horizontal, with the elevated head or foot end), and there should be

apparatuses for observing the patient's status (tonometer, electrocardiograph,

etc.), as well as items necessary for caring for the patient and drugs.

The medical personnel working in the postoperative room should have

at their disposal a mouth opener, tongue holder, glasses or mugs, bedpans,

hot bags, ice bags, jars, colonic tubes, gastric probe, Esmarch's irrigator, and

clean bed linen. The room is equipped with a centralized supply of oxygen for

oxygen therapy.

430

A special cabinet should contain sterile systems for fluid and blood

transfusion, syringes, needles, sterile material, and sets of drugs including

cardiac means (camphor, caffeine, corglycon, strophanthin), different groups

of NSAIDS (meloxicam, acetaminophen), opioid analgesics (morphine,

promedol), haemostatic means, and drugs exerting a contractile action on the

uterus (calcium chloride, methylergometrine, syntocinon, oxytocin,

mammophysin, etc.), as well as fluids for intravenous infusion (5 per cent

glucose solution, isotonic saline) and means for providing urgent care

(adrenaline, insulin, hydrocortisone, etc.).

A nurse responsible for providing care to patients should always be

present in the room. Before the patient is brought in from the surgical theatre

it is desirable that the bed be warmed up by means of hot bags (it is

particularly important for elderly patients and persons with a heavy blood

loss). Having put the patient into the bed, place hot bags at her feet. To

prevent burns, these bags should be warm rather than very hot; they are

wrapped into a towel or placed onto the blanket. Put an oil-cloth bag with

sand on the abdomen (on the area of sutures), and then 2-3 hours later

replace it with an ice bag. An ice bag is wrapped into a cloth. It is removed for

15-20 min after 1-2 hours. An ice bag should preferably be applied for a

period of 24 hours after which it is employed only when special indications

warrant it (inflammatory process, obese abdomen, tendency to bleed). The

patient is placed on her back, without a pillow, with her head turned laterally.

These measures may prevent tongue prolapse and aspiration of the vomit.

In the postoperative period the patient needs a particularly thorough

observation, especially in the first postoperative hours when she is still

heavily sedated.

The nurse should check regularly the patient's respiration, pulse, the

state of the bandage, and vaginal discharge (following vaginal operations and

uterine extirpation). Paleness, tachycardia, weak pulse, and a drop in arterial

pressure may suggest internal bleeding and shock.

431

Tongue prolapse and aspiration are witnessed with difficult breathing

and cyanosis. If this is the case, turn the patient's head aside, support the

lower jaw, and give her oxygen.

If the patient has stopped breathing, repeated intubation is indicated to

perform artificial ventilation of the lungs. If the nurse notices any changes in

the patient's state, she should immediately report her observations to the

doctor.

A sedated patient (her consciousness not fully recovered after narcosis)

may fall off the bed, so it is advisable that she is tied to the bed with the help

of a wide cloth bandage, which is fixed above the blanket (at the level of the

hips) during the first postoperative hours.

It is important to remember about the necessity to control postoperative

pain since it interferes with deep breathing, which aggravates lung ventilation

and cardiac activity. Analgesics(particularly narcotics) should be

administered by the doctor. The method of choice is promedol administered

in combination with analgin and diphenhydramine hydrochloride (narcotics

may cause side-effects, for example, vomiting).

Vomiting during the first 1-2 postoperative days may be related to post-

narcosis intoxication. Vomiting debilitates and depresses the patient, leads to

dehydration, and may be associated with aspiration of the vomit. Therefore,

the doctor should institute disintoxication (infusion) therapy and

administration of anti-emetic means (metoclopramide, promethazine). If

vomiting persists after this period, it may indicate serious complications

(peritonitis, intestinal obstruction), which call for special intervention.

Nausea observed after the operation may be due to fasting (the patient may be

given some broth on the third day) or reaction to the administered drugs

(antibiotics, narcotics, etc.). Sometimes, the patient complains about

intensification of nausea after an injection of a definite drug (the doctor

should be informed about this).

432

The postoperative period is not uncommonly associated with metabolic

disorders (water, electrolyte, protein, carbohydrate), which may be linked

with fasting, operative trauma, and blood loss and is expressed in decreased

diuresis, nausea, vomiting, fever, weakness, bloated abdomen (intestinal

paresis), and other symptoms. These alterations are the greater, the more

extensive was the operation and the heavier was the blood loss. For 2-3 days

such patients should be given infusion therapy (blood transfusion, protein

preparations, blood substitutes, vitamins). If there are no contraindications

and vomiting, the patient should be fed, which will help to normalize

metabolism.

Nutrition and water regimen. If the patient is fully conscious and does

not suffer from vomiting, she can be given water 3-4 hours after surgery and

tea with lemon and mineral water by the end of the first day. Taking meals

fairly soon after the operation activates the function of the alimentary organs.

Following laparotomy (with the exclusion of operations on the intestine), the

patient is given sweet tea and cranberry water on the first day; raw egg, broth,

and yoghurt on the second day; liquid porridge, broth, omelette on the third

day. Beginning from the fourth day, the diet is gradually expanded.

After vaginal plastic operation the patient receives only liquid food

(broth, tea, yoghurt, fruit drink) within the first four postoperative days. On

the fifth day the patient is given a raw egg, porridge, and strained soup. The

diet is gradually expanded beginning from the 6th-7th postoperative day.

Oral hygiene. It is very important from the standpoint of stomatitis and

parotitis prevention. If the patient is unable to get up, she should be provided

with an opportunity to brush her teeth over a hand basin. In severely ill

patients the oral cavity should be treated with solution of hydrogen peroxide

or sodium tetraborate on glycerol. This is particularly important in patients

receiving antibiotics as it helps to prevent Candida-caused stomatitis.

Monitoring of intestinal function. Following planned operations

preceded by preparation, patients rarely have unassisted bowel movements.

433

So, on the 3rd day after laparotomy an enema with hypertonic (5%) solution

of sodium chloride (150-200 ml) is made.

In colitis and haemorrhoids a simple cleansing enema is recommended.

Later on, bowel movements are regulated by diet (yoghurt, prunes, dried

apricots, beets) or by prescribing plant laxative and glycerol suppositories.

Following vaginal plastic operations the intestine is emptied using of

magnesium sulphate (15 g) on the 5th-6th postoperative day, after which

bowel movements are also regulated by diet.

If the operation had to be performed urgently, without intestinal

preparation, intestinal paresis and gastric bloating may develop rather early

(by the end of the first or during the second postoperative day). Stimulation of

intestinal peristalsis is used in such cases (proserine subcutaneously, 10 per

cent solution of sodium chloride intravenously, hypertonic enema, colonic

tube).

Regulation of urinary function. Within the first 24 postoperative hours

patients are rarely capable of voluntary micturition, so, the nurse should pass

the patient's urine with a catheter at least twice daily. Occasionally, the

patient cannot urinate because she is afraid to tense her abdominal muscles

or cannot bring herself to urinate in the supine position. In such cases it is

necessary to explain to her that there is nothing to be afraid of and allow her

to sit up (if there are no contraindications). When serving a bedpan, one

should first warm it up. Sometimes, a good effect can be achieved by pouring

warm water onto the external genitalia. Patients waiting for vaginal plastic

operation should be taught how to urinate in the supine position even prior to

surgery since the normal urinary excretion may take a long time to recover

after such operations.

When urine retention is present, drug treatment may also be employed:

5-10 ml of 10-20 per cent solution of intramuscular magnesium sulphate, 1 ml

of subcutaneous pituitrin, and irrigation of the bladder with warm solution of

nitrofurazone (1:5000).

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When multiple catheterization is necessary, it is advisable to administer

furadonin and 5-NOK. After extensive extirpation of the uterus it is expedient

to introduce a permanent catheter into the bladder for 3-4 days. Following

removal of the catheter and restoration of voluntary urination, the bladder

evacuation may not be complete in these patients since the bladder tonus may

take some time to fully recover. The degree of bladder evacuation may be

determined with palpation, percussion, or catheterization (following

micturition).

After some operations one should pay particular attention to the

amount of the excreted urine. Decreased diuresis may be associated with

shock, blood loss, traumatic surgery, and sometimes with ligation of ureters.

Postoperative anuria may be a very dangerous symptom. Having noticed a

diminution in diuresis, the nurse should immediately report to the doctor

about this development.

Postoperative regimen. It depends on the patient's age, the nature of the

underlying disease, and the scope of interference, as well as on attendant

diseases.

In recent years an active mode of the postoperative management has

been increasingly introduced into the gynaecological practice. The patient is

allowed to turn from side to side by the end of the day she was operated on,

whereas some 24 hours after the operation she may vigorously move her arms

and legs and sit up in the bed. At the same time she is recommended to do

breathing exercises to improve her respiration. Patients, on whom minor

surgery was performed, especially with a transverse incision of the abdominal

wall, may get up 24 hours after the operation. Early getting of the patient on

her feet reduces the danger of pulmonary and thrombotic complications.

Patients on an active regimen show a faster restoration of normal micturition

and improvement of intestinal peristalsis. An active mode of the

postoperative management is contraindicated in patients with pneumonia,

myocardial infarction, and heart failure. If such a mode is recommended to

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patients suffering from obesity and anaemia and those with repeated

laparotomy, their abdomen should be tightly bandaged. An improvised

bandage from a clean towel may be used for this purpose. The patient herself

may sew such a bandage before the operation.

Following plastic surgery on the perineum, patients are permitted to get

up on the 8th day. In elderly patients the period of confinement to bed is

somewhat longer. Sitting is allowed after three weeks.

Management of sutures. Following laparotomy, the responsible

personnel should regularly check the bandage. If the dressing is not soaked

through or detached, it is replaced on the 3rd postoperative day. Then,

inspect the area of sutures for possible hyperemia or infiltrates, treat them

with iodine tincture, and place a dry bandage. Sutures are usually removed on

the 8th day, yet, in obese patients and following repeated laparotomies they

are removed on the 9th-10th day. Treat the perineal sutures daily with 5 per

cent solution of potassium permanganate and try to avoid wetting the area of

sutures when washing the patient's genitalia. Remove the sutures on the 5th-

6th day and continue to treat the scar with potassium permanganate solution

every day until it is completely healed.

Particularly important in the postoperative period is monitoring the

status of the cardiovascular system. Surgery, narcosis, and loss of blood and

fluid may lead to heart failure, especially within the first postoperative hours.

It is necessary, therefore, to carefully monitor the pulse (frequency, rhythm,

filling) and arterial pressure (electrocardiography when indicated). A fall in

blood pressure may be due to insufficient replacement of blood loss, pain-

associated shock, heart failure, and internal hemorrhage.

Respiratory alterations may be related to intubation, toxic action of

narcotics, and pneumonia. Following intubation, patient’s present hoarseness

and pain in the throat, which disappear spontaneously within 24 hours.

Usually the patient is brought from the surgical theatre only after normal

respiration has become established. Yet, respiration may fail again as an

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after-effect of narcotics, due to aspiration, etc. It is necessary therefore to

watch the colour of the lips and nails. The development of cyanosis witnesses

oxygen deficiency. In such cases it is necessary to give oxygen urgently to the

patient and inform the responsible physician about these symptoms.

By the end of the first day following inhalation narcosis cups are put on

the patient's chest to improve her respiration and blood circulation, on the

second day circular mustard plasters are put. Prescription of breathing

exercise and expectorants as well as alleviation of postoperative pain, improve

gas exchange and blood circulation.

After minor gynecological operations (artificial abortion, diagnostic

dilatation and curettage, cervical biopsy, and puncture of the abdominal

cavity through the posterior fornix) the patient is wheeled to the ward. Proper

care involves observation of the patient's general status (pulse, arterial

pressure, color of the skin and visible mucosa) and vaginal discharge. An ice

bag is placed on the patient's low abdomen for a period of 1-2 hours. The

nurse should immediately inform the responsible physician about the

development of bleeding or any changes in the patient's status.

Complications in the postoperative period

Early detection of postoperative complications is possible only if the

patient is very closely observed. Having noticed any deviations in the patient's

status, the nurse on duty should immediately report them to the physician so

that the appropriate treatment could be instituted without delay.

Complications on the part of the operative wound include bleeding and

hematomas, infiltrates, purulent foci, and suture failure. Bleeding and

hematomas develop during the first hours after intervention and are

manifested in soaking of the dressing and change in the patient's condition

(paleness of the skin and visible mucosa, dyspnea, syncopal status,

tachycardia, and a drop in the arterial pressure). In internal hemorrhage

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repeated laparotomy should be performed to ligate the bleeding vessels.

When the site of bleeding is in the area of sutures on the anterior abdominal

wall, it is occasionally enough to apply cold (an ice bag) or some weight (a

sand bag) onto the area of sutures in combination with hemostatic agents. If

bleeding is from the vaginal stump left after uterine extirpation, tight

tamponade of the vagina is employed. In plastic operations on the cervix it

may sometimes be necessary to place sutures on the bleeding vessels. After

bleeding has been arrested, it is necessary to replace the blood loss

(transfusion of blood and blood substitutes).

First aid in postoperative bleeding consists in application of an ice bag

on the area of sutures and abdomen and a sand bag on the area of sutures. A

nurse may also give the patient oxygen to breathe, hemostatic means and

should promptly call the physician.

Infiltrates, suppuration, and suture failure are most often related to

infection of tissues following surgery for purulent inflammatory diseases or

traumatic operations in weak and anemic patients. Patients usually present

pain, fever. The area of sutures is hyperemic and edematous. Painful

indurations are palpated, and pus may seep through the sutures. If the latter

is the case, the sutures at the area of the most severe inflammation should be

removed to ensure a better outflow of pus. Following purification of the

wound, it heals by the second intention. Simultaneously, antibacterial therapy

is conducted. Suture failure can vary in its degree from failure of sutures

placed through the skin edges to eventration. This complication is observed in

weak, emaciated or obese, and elderly patients. Signs of incipient eventration

are nausea, vomiting, and sudden profuse suffusion of the dressing with

serous fluid. Removal of the dressing reveals complete suture failure in all

layers of the abdominal wall. If the skin sutures are still intact, they hold the

intestinal loops that are readily palpated directly under the skin. Eventration

is eliminated by repeated placement of silk sutures onto the wound through

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all layers and by antibacterial and invigorating treatment. Such sutures are

removed in 2-3 weeks.

Inflammatory complications may develop not only in the abdominal

wall but also in the pelvic organs. Their usual manifestations are pain, the

presence of dense painful infiltrates, high pyrexia, and algor.

First aid in suppurative processes consists in application of an ice bag

onto the area of sutures. When eventration is suspected, the patient is not

allowed to stand or sit up. A nurse should immediately inform the physician

about her suspicions.

Appropriate preventive measures include observation of aseptic rules,

careful treatment of tissues, good hemostasis during surgery, and

prophylactic antibacterial therapy after the operation.

Cardiovascular complications may manifest themselves in the form of

shock and collapse.

Shock and collapse develop after prolonged traumatic operations

associated with heavy blood loss and are expressed in mental inhibition,

apathy (with the consciousness preserved), small rapid pulse, paleness, cold

perspiration, fall in arterial pressure, oliguria, and shortness of breath.

Having noticed such symptoms, a nurse should immediately call the

physician.

First aid consists in immediate intravenous infusion of blood

substitutes, administration of cardiac means (20 per cent camphor oil,

caffeine), and oxygen inhalation. A key method of controlling shock is blood

transfusion, as well as administration of noradrenaline, hydrocortisone,

prednisolone, and analgesics (prescribed by the physician).

Thrombophlebitis of both superficial and deep veins of the lower

extremities is not an infrequent complication of gynecological operations. In

such cases the patient complains of pain in the limb, which becomes

edematous and larger in size. Signs of hyperemia and induration appear along

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the course of the superficial veins (phlebitis may develop on the hand

following a vein-puncture made during the operation).

To manage this condition, the patient is confined to bed, her leg is

elevated, ice bags are applied to painful sites, and anticoagulants are

administered. Thrombophlebitis may cause pulmonary thromboembolism.

When small branches of the pulmonary artery are occluded, the patient

develops dyspnea, retrosternal pain, cyanosis, and tachycardia. Massive

embolism and embolism of the main trunk of the pulmonary artery may cause

instant death. Prophylaxis of this dire complication consists in thorough

preparation of the patient for the operation, tight bandage of the lower

extremities, an active management of the postoperative period, and

administration of anticoagulants (heparin, phenylin, acetylsalicylic acid, etc.).

Pneumonia is the most frequent respiratory complication. Elderly and

obese patients are at a particular risk of developing pneumonia. Congestive

manifestations linked to hypodynamia and poor lung ventilation serves as a

contributing factor. Measures intended to prevent pneumonia include

analgesics, active regimen (getting up in the early postoperative period and

breathing exercise), application of circular cups and mustard plasters, and

cardiac means. Pneumonia is treated with antibacterial drugs.

Gastro-intestinal complications are expressed in gastro-intestinal atony.

It may be attended by acute dilatation of the stomach, intestinal paresis, and

ileus.

In acute dilatation of the stomach, it is markedly distended with gastric

contents accumulating in it. The patient presents uncontrollable vomiting and

foul belching, which is accompanied by tachycardia and dehydration (dry

tongue). In such cases it is indicated that the stomach be irrigated with the aid

of a thin probe which is introduced through the nose (the probe is profusely

treated with petrolatum). Using Janet's syringe, introduce alkaline solution

into the stomach and actively aspirate its contents. Continue irrigation until

pure water is aspirated and leave the probe in the stomach for 10-12 hours.

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Allow the patient to drink and periodically irrigate the stomach with small

amounts of fluid.

Intestinal paresis is manifested by abdominal flatulence, diffuse pain

throughout the abdomen, tachycardia, the absence of peristalsis, nausea and

vomiting, and stool and gas retention. If the above symptoms are very severe,

it is justified to speak about dynamic intestinal obstruction (ileus). Ileus may

also be due to a mechanical obstruction (adhesions, flexions, invagination).

This is associated with sharp paroxysmal pain attended by nausea and

vomiting. The abdomen becomes asymmetrical secondary to flatulence of

intestinal loops above the place of obstruction.

The diagnosis of ileus may be specified by X-Ray examination. It shows

intestinal loops distended with gas and horizontal levels of fluid.

Furthermore, you may give the patient half a glass of barium suspension and

examine its passage in 10-12 hours.

Paresis and dynamic ileus may be eliminated conservatively via

intestinal stimulation (injections of atropine and proserine, intravenous

administration of hypertonic saline, hypertonic enema, siphon enema,

paranephric novocaine blockade, and diadynamic currents on the area of the

solar plexus).

Mechanical obstruction not uncommonly requires surgical intervention.

Prolonged paresis and ileus may lead to the development of peritonitis.

Postoperative parotitis is a consequence of inadequate oral hygiene. The

patient presents pain at an angle of the lower jaw that irradiates to the ear,

swelling in this area, and fever. The treatment includes antibiotics, warming

compresses, and analgesics.

Anaesthesia-associated paralyses develop as a result of malposition of

the arms during the operation (putting them behind the head, compression

with the end of the operating table), which may injure peripheral nerves.

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Self test

1. What is better for the patient before the operation?

A. - an enema the night before, and again the next morning

B. - the prolonged dieting and purging formerly employed

C. - absence of special diet and regimen before the operation

2. The afternoon before operation the abdomen

A. - is lathered and shaved without washing

B. - is lathered and shaved, then washed with soap and sterile water

C. - should be treated with iodine solution and alcohol

D. - should be treated with dimexid solution

3. Choose correct scheme of premedication before the operation.

A. - promedol 1,5 mL + atropine 1 mL, + dimedrol 2 mL

B. - analgin 1 mL+ dimedrol 1 mL + atropopin 1 mL

C. - promedol 0. 5 mL + atropine 2 mL + dimedrol 5 mL

4. The twenty-day catgut is used for

A. - all the layers of the abdominal wall except the skin

B. - suturing of the abdominal skin

5. The silk is used for

A. - any emergency intestinal suturing

B. - for suturing in conservative work on the ovaries and tubes and for suture

ligation of the mesoappendix

6. The hands and forearms are scrubbed

A. - in 80 per cent alcohol with gauze

B. - in 70 per cent alcohol with gauze

C. - in 96 per cent alcohol with gauze

7. The most preferable type of abdominal incision in modern medicine is

A. - Phannestiel incision

B. - Cherny incision

C. - rectus incision

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D. - median incision

8. The choice of abdominal incision depends on

A. - patients condition and type of the operation

B. - the request of the operator

9. Indications for salpingectomy are as follows except

A. - hydrosalpinx, pyosalpinx

B. - severe chronic inflammation process

C. - tubal pregnancy

D. - subserous myoma of the uterus

10. What kind of operation is it in case of retention cyst of the ovary?

A. - resection of the ovary

B. - removing of the ovary with the tube

C. - extirpation of the uterus with adnexa

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Chapter 11. ACUTE ABDOMEN IN GYNECOLOGIC

PRACTICE

Acute abdomen means such a state, which may lead to severe

complications and even death. Acute abdomen in gynecologic practice may be

due to:

internal (intraperitoneal) bleeding, caused by interrupted ectopic

pregnancy, injuries of pelvic organs, etc;

Failure of blood supply of abdominal organs (torsion of the pedicle of an

ovarian tumor or a subserous myomatous node);

acute inflammation in abdominal cavity including the peritoneum.

In all these cases rapid and correct diagnosis and therapeutic measures

save the patient’s life.

Ectopic pregnancy

Normally, the fertilized egg moves along the tube to enter the uterus

and to implant in its mucosa. But the conditions for the movement of the egg

may be disturbed and the fertilized ovum may implant elsewhere to cause

extrauterine or ectopic pregnancy.

Ectopic pregnancy includes those implanting in the uterine cervix

(cervical pregnancy), tubes (tubal pregnancy), the ovary (ovarian pregnancy),

or the abdomen (abdominal pregnancy). Abdominal pregnancy may be

primary (fertilized ovum is implanted in the abdomen from the very

beginning), and secondary (at the beginning the ovum was fertilized in the

tube, and after tubal abortion it begins to be fertilized in the abdomen). (Fig.

102)

Definition. Ectopic pregnancy is an implantation of the fertilized ovum

outside the uterus. The trophoblast can successfully be implanted in any

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tissue with an adequate blood supply. But the most common site for an

ectopic pregnancy is the fallopian tube (98 %), but other sites are the ovary,

cervix and abdominal cavity.

Incidence. The frequency of ectopic pregnancy is about 1 in 200

pregnancies.

Classification. Ectopic pregnancy is classified according to: the location

(tubal, ovarian, abdominal, pregnancy in the cervix and others); the clinical

stage (ongoing or non-interrupted, and interrupted); the type of termination

(tubal abortion, rupture of the tube).

Etiology of ectopic pregnancy

Risk factors for ectopic pregnancy include:

Fallopian tube damage

o Previous tubal surgery (including female sterilisation) and pelvic

surgery including Caesarean section and ovarian cystectomy

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o Previous abdominal surgery including appendicectomy and bowel

surgery

o Confirmed genital infection and pelvic inflammatory disease, commonly

caused by chlamydial infection

Infertility

o Documented tubal disease

o Assisted reproductive technology

o Endometriosis

o Unexplained infertility

Contraceptive failure

o Progestogen-only contraception

o Intrauterine contraceptive device

Cigarette smoking – including past exposure.

Age >35 years

Previous ectopic pregnancy

Previous spontaneous abortion or induced abortion

Ectopic pregnancy is more common in women attending infertility

clinics even in the absence of tubal disease. In addition, the use of ART

increases the rate of ectopic pregnancies. In vitro fertilisation (IVF) is

associated with an ectopic pregnancy risk of 2–5% and it may be higher than

this where there is tubal disease. Indeed the first IVF pregnancy, before the

first IVF live birth, was a tubal ectopic pregnancy.

Tubal Pregnancy

Clinical presentation of tubal pregnancy depends on clinical form:

interrupted or non-interrupted (ongoing).

Non-interrupted (ongoing) tubal pregnancy can terminate by the type

of tubal abortion and by the type of rupture of the uterine tube. Patient with

ongoing tubal gestation have all the changes of early physiological gestation.

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The ovum implants in the endosalpinx and begins to grow into the muscular

wall. The growing ovum distends the attenuated and loosened walls of the

tube, which become a spindle-like. The patient displays presumption and

probably signs of gestation (change of appetite, nausea, excessive salivation,

menstrual delay, breast engorgement).

The diagnosis is difficult, diagnostic tests for ectopic pregnancy include:

o a urine pregnancy test;

o ultrasonography;

o beta-hCG measurement;

o occasionally, diagnostic curettage

While collecting the history, one can identify factors of risk for the

development of ectopic pregnancy. Physical examination reveals breast

engorgement. Gynecological examination can find cyanosis of the vaginal

walls and cervix, softening of the cervical isthmus, uterine engorgement and

disparity between the size of the uterine body and gestational age. Tumor-like

ovoid formation may be laterally and behind the uterus. The fornices are free,

cervical displacements are not painful. In patients with complicated

gynecological anamnesis, presence of risk factors, transvaginal ultrasound is

useful to assess whether a pregnancy is in the uterine cavity. The presence or

absence of an intrauterine sac is the key diagnostic marker for ectopic

pregnancy. US should be done in accordance with β-hCG level in blood

serum. In 1985, the concept of a "discriminating level of β-hCG" was

introduced to isolate the concentration of β-hCG in serum when pregnancy

should be visible in ultrasound scanning.

For TVUS, the discriminatory level of β-hCG (also known as the

discrimination zone) is 1500 IU / L. The yolk sac, if present in the uterine

cavity, should be identified in TVUS if the hCG level is 1500IU / L or more.

The absence of the yolk sac in the uterine cavity, despite the fact that a

discriminatory level of 1500 IU / L or more in TVUS basically means an

ectopic pregnancy.

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For TAUS, the discrimination zone of hCG is 6500IU / L and more.

Thus, in the transabdominal ultrasound study, the absence of an intrauterine

gestational sac at a β-hCG concentration of more than 6500 IU / L confirms

an ectopic pregnancy. β-hCG levels may assist in interpreting ultrasound

findings. In a uterine ongoing pregnancy, the minimal rate of increase in β-

hCG is 66% in 2 days, peaking at a level greater than 100,000 mIU per mL

(100,000 IU per L). In ongoing ectopic pregnancy the level of β-hCG will also

increase, but without doubling every two days. A rapid decline in β-hCG

concentrations over 2 days, commonly by 21–35% or more, is indicative of a

spontaneous abortion or a resolving ectopic pregnancy. In cases where an

ectopic pregnancy is suspected and ultrasound is inconclusive, a diagnostic

laparoscopy may be required.

An alternative to diagnostic laparoscopy may involve a repeat

ultrasound examination, particularly when β-hCG concentrations are close to

1500 IU/l. Other strategies include alternative diagnostic tests, such as serum

progesterone or an endometrial biopsy, or empirical medical treatment as the

patient may well have an ectopic pregnancy. If β-hCG concentrations are

falling but an ectopic has not been excluded, consideration should be given to

performing serial β-hCG measurements until levels become undetectable, as

rupture can still occur. In selected cases of Pregnancy of Unknown location,

an endometrial biopsy may be taken and analyzed for the presence or absence

of chorionic villi. Their absence in the presence of a static β-hCG is suggestive

of an ectopic pregnancy.

Management of ongoing (non-interrupted) tubal pregnancy

Ectopic pregnancy may be managed surgically, medically or expectantly.

Around 70% of ectopic pregnancies with β-hCG level , 1000 mIU\mL resolve

spontaneously. It is important to remember the risks of ruptured ectopic

pregnancy. The best indicator of spontaneous resolution is β-hCG levels that

are falling by 15-25% every 48hours. If spontaneous resolution is suspected,

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the patient will be monitored with 48hourly bloods looking for a continuous

decline in β-hCG of at least 15% each two days. If this rate stops declining or

β-hCG levels start to rise then medical or surgical treatment should be

considered.

Medical management of ectopic pregnancy. Medical treatment is

useful for patients with an unruptured tubal ectopic pregnancy who are

haemodynamically stable and have minimal symptoms. Methotrexate is a

folic acid antagonist that targets rapidly dividing cells and arrests mitosis. In

ectopic pregnancy, the drug prevents the proliferation of cytotrophoblast

cells, reducing cell viability and β-hCG secretion and thus progesterone

support for the pregnancy. This facilitates the resolution of the ectopic

pregnancy and tissue remodelling. Methotrexate is most successfully used

when the patient is asymptomatic and the beta HCG levels are lower than

3000 IU/L. The woman should be counselled that there is a failure rate

associated with medical therapy and tubal rupture may still occur in 7% of

cases.

Single dose treatment of IM methotrexate using 50mg/m 2 (most

patients require 75 – 90 mg) is effective in most cases. Β-HCG levels can be

performed on day 4 and 7 after methotrexate therapy and a minimum of 15%

drop in beta HCG would be considered acceptable between day 4 and 7.

Approximately 10% of women will require surgical intervention, although

most of these are for slowly falling β-hCG levels rather than for acute tubal

rupture. The Beta HCG levels should decrease by approximately 50% every 48

hours after the salpingotomy procedure.

Another option for the treatment of ectopic gestation is the multi-dose

protocol and direct injection of methotrexate into the ectopic pregnancy. The

multi-dose regimen consists of methotrexate treatment on Days 1, 3, 5 and 7

to a maximum of four doses and leucovorine ‘rescue-therapy’ at a dose of 0.1

mg/kg on alternate Days 2, 4, 6 and 8. This treatment may be more

appropriate for patients who present with a larger adnexal masses and greater

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initial β-hCG levels (>5000 IU/l). Direct injection of methotrexate into the

ectopic sac, either laparoscopically or with ultrasound guidance, limits

systemic toxicity or maintains a higher therapeutic level. However, local

injection has no significant advantage in most patients and is accompanied by

a risk of provoking tubal rupture.

Contraindications to the use of methotrexate include:

o the size of embryo is .3 cm

o fetal cardiac activity, β-HCG greater than 15 000 IU/l,

o free fluid in the cul – de - sac,

o documented hypersensitivity to methotrexate,

o breastfeeding,

o immunodeficiency,

o alcoholic or other liver disease,

o anaemia, leucocytopenia, thrombocytopenia,

o active pulmonary disease,

o peptic ulcer disease,

o renal or hepatic dysfunction

Interrupted tubal pregnancy

Tubal abortion (Fig. 206): the ovum is partially or completely

separated from the wall of the fallopian tube and begins to be expelled

through its ampullar end into the abdominal cavity. It is associated with pain,

which has recurrent or continual and increased character. Pain is localized in

one of the iliac areas, irradiating into the rectum, hip, sacrum, occasionally,

into the clavicular and scapular area (lat.;phrenicus symptom). Small blood

vessels may clot, bleeding stops, and pain disappears. Expulsion of the ovum

from the uterine tube may be repeated, so termination of ectopic pregnancy

by the type of tubal abortion may be prolonged. Blood effused into the cavity

of the oviduct is gradually expelled into the abdominal cavity and then finds

its way into the rectouterine pouch, where a rectouterine hematoma may form

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(it may also be peritubal, if blood coagulates and accumulates directly around

the fallopian tube). Between attacks the patient may experience constant

gnawing pain, heaviness in the area of the lower abdomen, and the feeling of

pressure into the rectum.

Fig. 206. Tubal abortion

Diagnosis of tubal abortion is very difficult. The most prominent

symptom is anemia of a varying degree. The patient displays presumptive and

probable signs of pregnancy. Menstrual disturbances are constant. Menstrual

delay lasts from several days to 2-3 weeks with the subsequent appearance

(soon after an attack of pain) of scanty vaginal discharge of a dark-brown

color. Sometimes sanguineous discharge appears without the preceding

menstrual delay. Examination of the abdomen may reveal its bloating and the

phenomenon of the abdominal wall lagging behind respiration-associated

movements. Percussion elicits dull sounds in sloping places. Gynecological

examination reveals cyanosis of the mucosa, scanty dark-brown discharge

from the cervical canal. Cervical displacements are painful. Uterine

engorgement does not correspond to the term of the proposed pregnancy, the

uterus is softened in the isthmus area. A sausage-like formation of the doughy

consistence is palpated in the adnexal area. This formation is tender,

moderately mobile, with a vague outline. The posterior and corresponding

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lateral fornices may be flattened or may bulge out. The severity of the clinical

picture depends on intensity of internal bleeding.

Tubal rupture. Symptoms in patients with a ruptured uterine tube

(Fig. 207) are distinguished by severe internal bleeding, shock and acute

anemia. Rupture of a fallopian tube frequently occurs when the gestational

sac is localized in the isthmic or interstitial portion of the tube. The history is

characterized by the same factors of risk of ectopic pregnancy and delay of

menstruation. The clinical picture of tubal pregnancy, which terminates by

the type of rupture, is characterized by a sudden attack of a sharp pain in the

lower abdomen or in the iliac area with irradiation into the rectum, hip,

shoulder-blade. The patients soon become adynamic and find it difficult to

answer the questions. Any signs of internal bleeding appear, for example,

severe paleness, cyanosis of the lips, and cold sweat. The pulse is frequent,

blood pressure may be low. The abdomen is drastically bloated, the patient

spares it during breathing. Percussion and palpation of the abdomen are

tender. Percussion elicits dull sounds in sloping places. Palpation elicits

pronounced tenderness of the abdomen, the Shchotkin - Blumberg symptom

is positive. Gynecological examination reveals painful cervical displacements,

the overhanging of the posterior and lateral fornices. Palpation of the

posterior fornix is very painful ("Douglas's cry"). The uterine body is usually

enlarged, softened and tender. To one side of the adnexal area one can

palpate dough-like mass with a vague outline, occasionally pulsation may be

felt. Clinical features of this disease are so characteristic that the diagnosis is

not difficult, as a rule.

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Fig. 207. Tubal pregnancy: rupture of the tube.

However, other clinical conditions are likely as well and should be ruled

out:

o Adnexal torsion or acute appendicitis. Although these conditions are

suggested

o by unilateral pelvis, they do not produce amenorrhea, syncope, anemia,

and early shock.

o Aborting intrauterine pregnancy. In an aborting intrauterine pregnancy,

o the external bleeding is much more severe than the pain, whereas the

reverse is true with an ectopic pregnancy.

o Corpus luteum bleeding at a normal pregnancy. Corpus luteum bleeding

usually does not produce the severity of pain or shock typical of ectopic

pregnancy. In addition, uterine bleeding is usually absent. When heavy

internal bleeding is accompanied by shock, the physician has no other

option to observe the process directly but by laparoscopy or laparotomy.

Treatment of interrupted tubal pregnancy (see also chapter 10)

Tubal pregnancy is treated surgically by removing the pregnant tube.

The patient is operated on immediately after the diagnosis has been

established, even if the condition of the patient is only satisfactory, because

the hemorrhage into the abdominal cavity may recur at any moment. If the

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clinical picture is grave, the patient is operated on urgently, with transfusion

of blood; cardiac drugs and other means to control anemia and shock are

used.

In general the ectopic pregnancy must be removed by one of the

following techniques:

- Salpingectomy. If the tube is badly damaged, the correct treatment is

removal of the affected tube. If implantation has occurred in the interstitial

portion of the tube, then it may be necessary to resect part of the uterine horn

in addition to removing the tube.

- Salpingotomy. If the ectopic pregnancy is contained within the tube, it

may be possible to conserve the tube by removing ofthe pregnancy and

reconstitution of the tube. This is particularly important when the

contralateral tube has been lost. However, there is an increased risk of

recurrent ectopic pregnancy in the damaged tube.

- Tubal compression. Occasionally when the tubal pregnancy occurs in

the fimbrial end of the tube it may be possible to squeeze out the ovum

without opening the tube, but it is essential to be certain that adequate

hemostasis is obtained.

- Laparoscopic surgery. Salpingectomy and salpingotomy can be

performed using minimal access surgery. The Beta HCG levels should

decrease by approximately 50% every 48 hours after the salpingotomy

procedure.

Some words can be added about blood reinfusion. It may be initiated

immediately after opening the abdomen (blood reinfusion is contraindicated

when much time has passed from the moment of ectopic pregnancy

termination and in hemolysis).

Cervical Pregnancy

This is a rare variant of ectopic pregnancy, which carries a considerable

risk of severe bleeding. At the beginning of this process the clinical features

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are like in the normally implanted pregnancy. Thus the patient is likely to be

diagnosed as a case of inevitable abortion.

The findings are:

The cervix is dilated and thin-walled and contains products of

conception.

A small firm uterine corpus can be palpated, resting on the swollen

cervix.

Attempts at evacuating the “abortion” cause the increase of bleeding.

(Fig. 208)

Fig. 208. Cervical pregnancy

Treatment. This is a dangerous condition. The choice is between

hysterectomy and local excision, and hysterectomy is strongly indicated if the

bleeding is heavy and not controllable. More rarely, if local excision is

attempted, the cervix must be clamped laterally to occlude the lateral vessels.

But there is a high risk of excessive bleedings in these cases, because the

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altered cervical wall has no possibility of effective contractions to arrest the

bleeding.

Ovarian and abdominal pregnancies occur rarely. Implantation of the

fertilized ovum in the ovary makes up 1% of all ectopic pregnancies. The

clinical picture of the ovarian pregnancy is similar to that of the tubal

pregnancy, but the ovarian tissue is perhaps less likely to rupture than is the

muscular wall of the tube. An enlarged ovary is found at operation and if

ectopic pregnancy is suspected, the tumor should be excised. It should be

possible to preserve the ovary.

Abdominal pregnancy usually does not continue for a considerable

period of time, but still cases have been reported on full term abdominal

pregnancy. The fetus inside the membranes grows in the space between the

internal organs, the placenta being attached to the tube, the peritoneum or

the inner organs. The pregnancy is pathological and the fetus would die. The

dead fetus macerates and undergoes aseptic disintegration or mummification.

Cases have been reported in which the dead fetus was macerated and

necrotized due to the entrance of infection from the intestine.

Considerable intraabdominal bleeding may occur in connection with

separation of the placenta.

Ovarian and abdominal pregnancies are treated surgically.

Prophylaxis of extrauterine pregnancy consists in control of infantilism

(protection of children’s health), inflammatory diseases and abortions

(contraceptives, health education), which often provoke inflammatory

diseases.

The patient operated for extrauterine pregnancy requires treatment

aimed at prevention of its recurrence.

Ovarian apoplexy

Ovarian apoplexy is hemorrhage into the ovarian parenchyma due to

follicle rupture in the ovulatory period or luteal rupture attended by damage

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to ovarian tissue and bleeding into the abdominal cavity. Most often ovarian

apoplexy occurs at the age of 16 – 30.

Etiology. The main etiological factors are inflammation of the ovary,

hormonal disturbances (increased LH secretion), injuries, overwork, etc. It

may be without any visible reason, even during the sleep.

Clinical picture. The most typical symptom is acute pain in the iliac area

spreading throughout the abdomen and irradiating to the rectum. Pain is

accompanied by dizziness, faintness, cold sweat, and nausea and vomiting.

Severity of the symptomatology is determined by the presence or

absence of intra-abdominal bleeding and its intensity (thus, two types of the

disease are distinguished: anemic and algesic). The internal bleeding is

related to skin paleness, tachycardia, and low blood pressure. The abdomen is

bloated, only weakly participating in respiration, and is painful on palpation.

Gynecological examination may elucidate overhanging of the vaginal fornices,

tenderness upon cervical displacement, the uterus of a normal size, and a

tender and enlarged ovary.

Treatment. If there are no signs of significant bleeding and the patient

feels well, conservative treatment is possible (bed rest, cold application onto

the low abdomen, hemostatic and anti-inflammatory therapy). In cases of

intra-abdominal bleeding (anemic form of apoplexy) laparotomy and ovarian

resection in the presence of hematoma or suturing of bleeding site are

performed.

The rupture of pyosalpinx, pyoovarium

An abscess of the ovary (pyo-salpinx, pyo-ovarium), or a suppurative

ovarian tumor (for example, in torsion of its pedicle), may be ruptured into

the abdominal cavity with the development of perforative peritonitis.

An abscess may rupture either spontaneously or following a physical

trauma. The main symptoms are intensification of pain, fever, increase of the

symptoms of peritoneal rebound tenderness.

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Examination of and care for the patient in such cases should be delicate.

Rupture of the abscess with effusion of pus into abdominal cavity is

followed by acute stabbing pain throughout the abdomen, collapse (rapid

weak pulse, cold sweat, pronounced paleness and cyanosis of the lips and

nails), nausea and vomiting. The abdomen is tense and very tender when

palpated. The general state of the patient rapidly worsens, the facial features

turn sharp, and breathing becomes frequent and shallow. Other findings

include a drastically bloated abdomen due to intestinal paresis, torpid

peristalsis, and flatulence. Percussion of the abdomen elicits dull sound in

slopping places due to the formation of exudate in the abdominal cavity.

Gynecologic examination reveals overhanging of the fornices and sharp

tenderness upon displacement of the cervix. The uterus and adnexa cannot be

palpated because of marked tenderness and tension of the abdominal wall.

Diagnosis. It is based on history and clinical findings.

Treatment. The treatment is surgical. Pre-expert care consists in

ensuring that the patient is not disturbed, careful transportation to hospital,

and symptomatic therapy (cardiac and analgesic drugs), as well as

intravenous infusion of blood substitutes.

Surgery consists of laparotomy, removal of the involved organ, and irrigation

and extensive draining of the abdominal cavity.

Rupture of ovarian cyst

Rupture may be either traumatic or spontaneous. Traumatic rupture

may follow torsion of a pedicle, during bimanual examination, during labor

when the cyst is impacted in the pelvis. Spontaneous rupture is not common,

especially with malignant cysts, when the epithelial tissue outgrows the

connective tissue.

Hemorrhage may occur into these cysts, and they should not be

mistaken for endometriomata. Occasionally intra-peritoneal bleeding from a

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ruptured cyst is sufficient to suggest an ectopic pregnancy and require

laparotomy. Thus the main clinical symptoms are the acute pain and

tenderness in lower abdomen, peritoneal symptoms, swelling in lower

abdomen due to internal bleedings.

Pseudomyxoma peritonei. This rare condition occasionally but not

inevitably follows the rupture of a mucinous cystadenoma. The epithelial cells

implant on the peritoneum and continue to secrete a gelatinous

pseudomucin; this material is not absorbed, or secretion is faster than

absorption; and the abdominal cavity is eventually filled with the jelly, while

the secreted cells spread over the parietal and visceral peritoneum. A reactive

peritonitis with adhesion is a sequel, and the patient must be operated for

removal of as much of the exudate as possible. The disease develops slowly

over several years, but will eventually cause the patient’s death from cachexia

or obstruction.

Self test

1. What percentage of women with a previous ectopic pregnancy can expect to

have another ectopic pregnancy?

A. -3%

B. -6%

C. -12%

D. -20%

E. -25%

2. What is the most accurate method of diagnosing an ectopic pregnancy?

A. -culdocentesis

B. -endometrial biopsy

C. -laparoscopy

D. -pelvic ultrasound

3. Which of the following sequele of pelvic inflammatory disease does not

enhance the possibility of ectopic pregnancy?

A. -altered cilia action

B. -distal tubal closure (hydrosalpinx)

C. -constriction of the tube

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4. Which of the following is not a likely reason for the establishment of a tubal

pregnancy?

A. -pelvic infection

B. -peritubal adhesions

C. -tubal anastomosis

D. -assisted reproductive technology

E. -uterine myoma

5. Which of the following symptoms is more important for the development of

cervical pregnancy?

A. -dystrophy of the endometrium due to inflammations, a lot of curettage,etc

B. -acute inflammation of the uterus

C. -threatened abortion in early stage of pregnancy

D. -cervical deformarions

6. The most typical symptoms of the ovarian apoplexy are

A. acute pain in the iliac area and internal bleeding

B. delay of menstrual flow and nausea and vomiting

C. fever

7. The most effective treatment of pyoovarium is

A. - surgical treatment

B. - conservative treatment (bed-rest, antibiotics and anti-inflammatory drugs)

C. - physiotherapy

8. Are all of the following a characteristic for the rupture of the abscess with

effusion of pus into abdominal cavity ?

A. - acute stabbing pain throughout the abdomen

B. - collapse

C. - nausea and vomiting

D. - vaginal bleeding

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Chapter 12. INJURIES OF THE FEMALE GENITAL

TRACT

Obstetric injuries

Most injuries of the female genital tract occur during childbirth. In a

normal delivery the circular fibres, which surround the external cervical os

are torn laterally on each side so that an anterior and a posterior lip of the

cervix become differentiated. As a result of stretching, the vagina becomes

more patulous, and through laceration, the hymen is subsequently

represented by irregular tags of skin, termed the carunculae myrtiformes. A

superficial laceration of the perineal skin of the first degree is common even

in uncomplicated deliveries.

In abnormal labour and when obstetrical manipulations have been

carried out, or as the result of inexpert technique, injuries of the birth canal

are frequent. Severe lacerations of the perineum are perhaps the commonest

form of birth injury. Tears of the vagina may be caused by rotation of the head

with forceps or may take the form of extension of tears either of the perineum

or the cervix. Severe lacerations of the cervix are usually caused by violent

uterine contraction at the end of the first stage of labour; others result from

the delivery of a posterior position of the occiput and some from cervical

dystocia. A vesicovaginal fistula may result from ischaemic necrosis or a

difficult forceps delivery in cases of disproportion, while a rectovaginal fistula

is the result of a complete tear of the perineum or a suture, which perforates

the rectal wall. Extensive vaginal incarceration causes fibrosis and atresia,

which may lead to dyspareunia and even apareunia.

The majority of obstetrical injuries are theoretically preventable. A case

of disproportion should be recognized antenatally and be treated in time by

caesarean section. Lacerations of the cervix and extensive tears of the

perineum, although avoidable, should be treated by immediate suturing. One

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of the worst injuries in obstetric practice is rupture of the uterus. It occurs

mostly in delivery, when obstructed labour is not diagnosed. Uterine rupture

carries a very high maternal mortality and morbidity.

Injuries of the perineum

Lacerations are 5-6 times more frequent with primiparae than with

multiparae.

It is customary to grade lacerations of the perineum into three degrees.

In the first degree the laceration is restricted to the skin of the fourchette. In

the second degree the muscles of the perineal body are torn through, while in

the third degree the tear extends backwards through the external sphincter of

the anus into the rectum and the anal canal. A rare type of tear is the central

tear of the perineum when the head penetrates first through the posterior

vaginal wall, then through the perineal body and appears through the skin of

the perineum. It usually occurs in patients with a contracted outlet.

Perineal Lacerations. First-degree lacerations, restricted to the skin of

the fourchette, have no influence upon the integrity of the pelvic floor, but if

the lacerations are not sutured after delivery, the vaginal orifice becomes

more patulous. In practice, small lacerations of the fourchette are not sutured

unless they extend to the skin of the perineum, where they are more likely to

become infected and to cause pain.

Second-degree lacerations should always be sutured carefully

immediately after delivery. The pelvic floor is weakened unless the injury to

the muscles of the perineal body is efficiently repaired. If the decussating

tissues of the levator ani muscles are torn through, the hiatus urogenitalis

becomes patulous and prolapse of the vagina and the uterus is likely to

develop, unless these lacerations are sutured immediately after delivery.

With extensive second-degree tears, the patient should be given a local,

regional pudendal block or general anesthetic, placed in the lithotomy

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position, and the torn muscles of the perineum identified and sutured

together with catgut. The torn edges of the vagina and the skin of the

perineum should then be sutured together with catgut. The essential part of

the after-treatment of perineal lacerations consists in keeping the perineum

clean. Frequent swabbing is therefore imperative during the puerperium. The

wound should be cleaned with an antiseptic solution such as Betadine after

micturition and defecation. Antibiotics are required.

Third-degree tears are much more important, because unless they are

efficiently repaired immediately after delivery, the patient becomes

incontinent of faeces and flatus. Amongst the predisposing causes of complete

tear of the perineum are forceps delivery in the persistent occipito-posterior

positions, and extraction of the after-coming head in breech presentation in

primiparae. Large heads and precipitate labours are also contributory factors,

but unfortunately the commonest cause is vigorous pulling in the wrong

direction during forceps delivery, especially with Kielland's forceps, so that no

opportunity is given for the head to be born by the natural mechanism of

extension. A properly performed episiotomy will very largely eliminate the

risk of a third-degree tear.

Incomplete tear of the perineum, repair should be performed as soon as

possible after the delivery. A practitioner should not undertake the repair of a

complete tear of the perineum single-handed. The operation should be

undertaken under anesthesia with the patient lying in the lithotomy position

in a good light, and with good assistance. The operation should be regarded as

a surgical emergency and there is no excuse for delay. As the facilities are not

available in the patient's home, she should be transferred to a hospital.

The immediate repair of a complete tear of the perineum is a relatively

simple procedure, since the muscles of the perineal body, though torn, can be

distinguished without much difficulty. The surrounding skin is first cleaned

and the operation area isolated with sterile towels. A sterile pack is placed in

the vagina and the limits of the laceration defined with tissue forceps. The

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rectum and the anal canal are first repaired with fine interrupted catgut

sutures inserted with an atraumatic needle. A few sutures are then introduced

to invaginate the torn edges of the bowel wall. The muscles of the perineal

body are now sutured together, and every effort should be made to obtain

exact anatomical reposition. Particular attention must be paid to the

sphincter ani muscle, and at least two catgut sutures should be used to draw

the cut edges together. The tears in the vaginal wall and in the skin of the

perineum are now repaired with interrupted catgut sutures. Care should be

taken to avoid tying the sutures too tightly, otherwise edema of the perineum

will develop, which may lead to severe pain and cause the stitches to cut

through. If a complete tear of the perineum is treated by immediate suture,

the end result is satisfactory if correct anatomical reposition has been

attained. If primary union of the vagina and the perineal skin is not obtained

the practitioner need not despair. The wound should be kept clean and

encouraged to granulate by frequent sitz baths. The end results are often

functionally good inspite of the initial breakdown of the suture line. The

bowels should be confined for at least five days, solid foods withheld and

intestinal antiseptics given, along with stool softeners. Systemic antibiotics

are necessary.

Treatment. The treatment of complete tear of the perineum is operative.

The technical difficulties are much greater in old cases than in those operated

upon immediately after delivery. The optimum time for operation in the case

of old tears is three to six months after delivery. If the operation is attempted

earlier than this, healing by first intention is exceptional, while if the

operation is further delayed, dense scar tissue may be deposited which adds

to the operative difficulties. Preoperative preparation is of importance, and

the patient should be kept in the hospital for several days before the

operation, during this time the bowels should be emptied by aperients and

enemas and the vagina disinfected by douching and by insertion of gauze

packs soaked in flavine 1 in 1000, or betadine lotion. The bacterial flora of the

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bowel should be controlled by phthalyl- sulphathiazole or neomycin, given in

large doses for three days before operation. The patient should be put on a

non-residual diet like milk, and fluid for two days prior to surgery. Various

techniques have been described in the operative treatment of complete tears

of the perineum, but the underlying principles are the same in all. The rectum

must be dissected from the vagina by incising the intervening scar tissue, and

by dissecting upwards in the rectovaginal septum.

Perhaps the most important step of all in the operation is to dissect the

rectum clear of scar tissue, and to mobilize it so that it can be brought down,

without tension to the anal region. The tear in the rectum and anal canal is

now repaired by excising scar tissue, freshening the cut edges and suturing

them together with fine interrupted catgut sutures mounted on an atraumatic

needle and tied within the bowel. The needles, forceps and scissors used

during this step are discarded. The wound in the bowel is now invaginated

with a layer of interrupted Lembert's sutures. Next, the deep muscles of the

perineal body and the levator ani are identified and sutured together with No.

1 catgut. It is important to ensure that the muscles are dissected clear of scar

tissue, and are mobilized. The next important step in the operation is to

suture together the torn edges of the external sphincter. These must be

carefully defined, dissected clear of scar tissue and sutured together with

three or four separate sutures. The remains of the superficial muscles of the

perineum are now sutured together with catgut and then the cut edges of the

vagina and the perineum are repaired, interrupted catgut sutures being used.

These principles are uniformly followed in the various methods described for

the treatment of a complete tear of the perineum. The modifications depend

solely upon the position of the incisions made in the vaginal walls and in the

skin of the perineum, and these, in their turn, depend not upon any particular

technique, but upon the type of complete tear, which is to be repaired.

After-treatment. The most important part of the after treatment is to

keep the wound dry. The perineum should be swabbed after micturition and

465

defecation with antiseptic solution and subsequently powdered. Betadine is

the antiseptic solution of choice these days, and it is effective. The bowels

should be confined until at least the fifth day of the operation. To achieve this,

the patient is given only intravenous fluids for the first two days and oral

fluids the next two days. On the fifth day, she receives olive oil enema. As in

all operations on the perineum, retention of urine is a common complication,

so that it may be advisable to leave a Foley's catheter for a few days in the

immediate postoperative period. Sulphathiazole or neomycin administered

preoperatively should be continued for at least a week postoperatively.

Systemic chemotherapy is necessary to prevent infection and it should be

given for a week. The end result is usually good. Another complication that

may develop is a rectovaginal fistula, which is usually the result of faulty

technique but may be due to infection.

Old-standing complete tears

Various degrees of complete perineal tears, usually resulting from

careless attempts at immediate suturing are not unusual. The rectal wall may

be torn through as high as 5 cm or more along the posterior vaginal wall, but

in most cases only the anal canal is involved. The appearance of the perineum

in the cases of old complete tear is a characteristic one. The red glistening

mucous membrane of the anal canal and rectum protrudes and fuses directly

with the vaginal wall without any of the perineal tissues intervening.

Laterally, on each side, on a level with the anus, is the depression in the skin,

which corresponds to the position of the severed edge of the torn external

sphincter. Behind the anus are the radial folds in the skin, which is corrugated

by the underlying contracted subcutaneous sphincter. The external sphincter

is only present posteriorly and the absence of the sphincteric grip is

appreciated by inserting a finger into the anus.

One of the most interesting features of the complete tear of the

perineum is that it is very rarely if ever associated with prolapse, although the

466

decussating tissues of the levator ani muscles have been torn through. The

reason is that the patient continuously draws together the two levator ani

muscles in an effort to close the bowel, so that by constant use, the tone of the

muscles becomes exceptionally good. This firmness and good development of

the levator muscles is found on clinical examination when the levator muscles

are palpated.

Symptoms. The patient complains of incontinence of faeces and flatus.

A few patients develop the tone of the levator muscles so well that they only

suffer incontinence of flatus. These women will complain of incontinence of

faeces only if they suffer an attack of diarrhea.

Rectovaginal fistula

The majority of rectovaginal fistulae result from obstetrical injuries,

usually a complete tear of the perineum, which has been imperfectly sutured

immediately after delivery. It has already been pointed out that the repair of a

complete tear of the perineum should be undertaken carefully with the

patient in the lithotomy position and under anesthesia. If, for instance, a few

sutures are placed through the lower part of the anal canal and the upper part

of the tear in the rectum is not accurately sutured, a fistulous opening may

form between the rectum and vagina. Rectovaginal fistulae may occur after

operation for old complete tears of the perineum if the wound breaks down or

if the rectum is not properly mobilized before the repair of the wound in the

rectal wall. These fistulae occur also after the operation of perineorrhaphy in

thin, elderly patients when the anterior wall of the rectum is accidentally

opened.

Other causes are tuberculosis and lymphogranuloma inguinale. In

advanced carcinoma of the cervix, when the growth has spread down the

posterior vaginal wall, a rectovaginal fistulae eventually results. Such fistulae

also occur following radiation treatment of carcinoma of the cervix or the

vagina, or following Wertheim's operation for the same condition. A fistula

467

following radiotherapy may occur three months to several years after

radiotherapy and such a fistula is surrounded by extensive stricture. A

malignant fistula is impossible to close and can only be treated by some form

of posterior pelvic exenteration or a palliative colostomy. Primary carcinoma

of the bowel can also extend forward and involve the vagina to cause

rectovaginal fistula. Congenital rectovaginal fistula is rarely seen and is the

result of mal-development of the lower part of the rectum and anal canal. In

such cases, it is customary to perform preliminary colostomy before plastic

operation.

In case of pelvic abscess when there is a collection of pus in the pouch of

Douglas, the abscess sometimes bursts into the rectum and a rectovaginal

fistula develops, particularly if the abscess is surgically opened up through the

posterior fornix. There is a form of rectovaginal fistula, which follows

infection in an anal crypt with resultant abscess formation, which bursts into

the vagina. These cases are difficult to treat surgically and good results cannot

be expected until the entire fistulous tract into the anal canal has been

excised. This necessitates division of the external sphincter, and follows the

principles laid down in the treatment of fistula-in-ano. The patient complains

of incontinence of faeces and flatus. A large fistula can easily be identified, but

a small one is very difficult to detect especially if it is surrounded by dense

fibrosis. Proctoscopy, sigmoidoscopy and injection of radio-opaque dye will

be needed to trace the fistulous tract.

Treatment. The traumatic form of rectovaginal fistula is treated by

operation. (Fig. 108) Preoperative treatment is important and the bowel

should be emptied with enema and the vagina disinfected by douches and

gauze packs soaked in antiseptic solutions such as flavine or Betadine.

Phthalyl sulphathiazole or neomycin should be given for a few days before

operation to sterilize the bowel contents.

With a small rectovaginal fistula above an intact perineal body, an

unusual event, it is sometimes feasible to excise the fistulous track and close

468

the defect successfully by a local operation. It will, however, be more

commonly found that the perineal body below the fistula is inadequate and

that the levators are not approximated. In fact, in many rectovaginal fistulae,

there is merely a thin skin bridge below the fistula and often the anal

sphincter itself is incompetent. When, in addition to these perineal defects,

the fistula is very large, the best treatment is to cut the skin bridge in the

midline and convert the fistula into a complete perineal tear. This is then

repaired exactly as described above and the results are usually satisfactory. A

high rectovaginal fistula may require a preliminary colostomy. The fistula due

to cancer of the cervix or rectum requires an exenteration operation. A fistula

following radiotherapy for cancer may be successfully closed by colpocleisis.

This operation consists of obliteration of the vaginal cavity after denuding the

entire vaginal mucosa.

Vaginal lacerations

These commonly occur following assisted instrumental vaginal

deliveries (forceps or vacuum extraction), difficult breech extractions, or

following shoulder dystocia. It is a good practice to inspect the lower genital

tract under a good light after expulsion of the placenta, identify all tears and

suture them meticulously. Sometimes a cervical tear may extend to the vault

of the vagina and cause profuse bleeding. Suturing must be done with great

care to avoid injury to the ureter. Tears extending to the base of the broad

ligament may lead to a broad ligament hematoma, which may require

recourse to a laparotomy for its evacuation.

Cervical lacerations

Minor injuries are common and need no treatment. Bilateral transverse

tears of the cervix end up as ectropions. Extensive tears involving the

sphincter of the cervix may lead to preterm deliveries or habitual painless

469

midtrimester abortions due to incompetent cervix, necessitating surgical

cerclage in future pregnancies. In women with a flat pelvis, the anterior lip of

the cervix may get caught between the fetal head and the pubic symphysis

resulting in an anterior bucket handle tear. Rarely in women with a small

gynecoid pelvis, a trial of labour may result in circumferential ischemic

necrosis of the lower part of the cervix and end up with an annular

detachment of the cervix.

Rupture of the uterus

This is almost entirely a complication of pregnancy and labour. It is

common in multiparae, usually following a neglected, obstructed delivery.

Misuse of oxytocics, or dehiscence of a previous uterine scar (cesarean

section), rarely, a haematometra or pyometra may rupture spontaneously as a

result of distension and thinning of the atrophic myometrium.

Perforation of the uterus

In the non-pregnant state, it occurs mainly during the operation of

dilatation and curettage. (Fig. 209) The perforation is more common if the

uterus is soft as in pregnancy and in malignancy. The atrophic uterus of a

menopausal woman can easily be perforated during curettage for

postmenopausal bleeding. Spontaneous perforation may also occur with

intrauterine contraceptive devices. (Fig. 210) The intrauterine coil device may

perforate the wall of the uterus, but remains within the myometrium. At times

it perforates through the entire thickness of the myometrium and either lies

freely in the peritoneal cavity or more often gets embedded in the abdominal

viscera.

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Fig. 209. Perforation of the uterus during dilatation and curettage,

and medical termination of pregnancy

Fig. 210. Diagramm showing perforation of the uterus with Cooper T

IUD

If the uterus is empty and not malignant, laparotomy may not be

necessary. Simple observation is all that is required. In presence of pyometra

and malignancy, immediate hysterectomy is strongly advised. If the

abdominal viscera, i. e. intestine prolapes through the perforation and is seen

protruding in the vagina, immediate laparotomy becomes mandatory. The

repair of the intestinal injury or resection and end-to-end anastomosis will be

471

required depending upon the extent of the damage to the intestine. If the

uterus contains products of conception, repair of the rent will suffice. If the

perforation is a large one or if the patient has completed her family,

hysterectomy is the operation of choice. Uterine injury has been recently

reported during hysteroscopic excision of the uterine septum. Excision under

laparoscopic supervision can avoid this injury. The uterine perforation can

also occur during laser ablation of endometrium through a hysteroscope in

cases of dysfunctional uterine bleeding.

Injuries due to coitus

A slight amount of hemorrhage from the torn edges of the ruptured

hymen is normal after defloration, but the hemorrhage is sometimes very

severe, particularly when the tear has spread forwards to the region of the

vestibule. The hemorrhage can usually be controlled by the application of

gauze pressure, but suturing under anesthesia is often required and blood

transfusion may be necessary.

Bruising of the vaginal wall is not uncommon in the early days of

married life, and a urethritis may result from bruising of the urethra. Such

cases (Honeymoon pyelitis) are seen frequently and it is not uncommon for

ascending pyelonephritis to result.

Lacerations of the vagina caused by coitus are occasionally seen. Violent

coitus or rape in young girls, forceful penetration in post-menopausal women

having atrophy of the vagina, or in the presence of such malformations as an

imperforate vaginal septum, extensive and serious injuries are known to

occur. These lacerations may be of variable types. It often takes the form of a

longitudinal tear of the anterior vaginal wall. Cases have been recorded where

the posterior vaginal wall has been torn through and the peritoneal cavity

opened up and both bladder and rectum may be involved in serious coital

injuries. Similar injuries may occur in patients upon whom vaginal operations

have been previously performed, especially if coitus takes place soon after the

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operation. All patients who have had a vaginal operation should be warned to

avoid coitus for two months. A similar injury can occur after the operation of

total hysterectomy, when coitus may disrupt the recently sewn vaginal vault.

Large or small bowel and omentum can prolapse into the vagina with

resulting shock and peritonitis. Severe hemorrhage follows injuries of this

kind. When the injuries are small, treatment consists in plugging the vagina,

provided thorough inspection has excluded the possibility of extensive or

internal injury. In more severe cases it is necessary to suture the laceration

under anesthesia. If the bowel has prolapsed, it is imperative to open the

abdomen so that a complete inspection of the gastrointestinal tract from the

jejunum to the rectum can be made. Damage to bowel or mesentery can then

be assessed and the correct treatment performed under-direct vision. It is

interesting to note that quite apart from the coitus or direct injury, a

spontaneous rupture of the vagina can occur in the upper posterior one-third.

The patients are usually elderly and the vagina is atrophic. The cause is

usually a violent bout of coughing or some severe strain associated with a

sudden rise in intra-abdominal pressure. The treatment is the same as for

coital injuries.

Direct trauma and vulval hematoma

Injuries to the vulva as the result of direct trauma are not uncommon.

Such accidents as falling astride gates and chairs are frequent, and usually

produce bruising of the labia majora. In more severe cases, large hematomas

develop in the labia majora, and the effused blood spreads widely in the lax

connective tissues. This is specially seen when the laceration involves the

region of the clitoris and the erectile tissue around the vaginal orifice. The

rupture of varicose veins of the labia majora sometimes causes comparable

hematomas of the vulva during pregnancy and the large swelling may

obstruct the delivery.

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One of the commonest causes of the vulvo-vaginal hematoma is the

inadequate hemostasis during suturing of episiotomy or a perineal tear. The

important complications of hematoma of the vulva are hemorrhage with

subsequent anemia and local infection. A vulvae hematoma presents a painful

tender swelling, bluish black in appearance. The patient may look pale and

she may be in a condition of shock, which is out of proportion to the clinical

blood loss. A small hematoma responds well to rest in bed, sitz bath and

magnesium sulphate fomentation. Antibiotic is given to prevent infection.

With large hematoma it is sometimes necessary to incise the swelling under

anesthesia and to turn out the clot. If the hemostasis is difficult to secure,

packing with drainage is employed, but this leads to prolonged convalescence.

The deep penetrating injuries require immediate operations, suture and

repair of the injured structure. If there is a least suspicion of visceral injury or

if the pouch of Douglas has been opened, laparatomy must be performed and

perforation of the bowel or bladder sutured. A temporary colostomy may be

necessary if the rectum has been injured.

Injuries due to foreign bodies and instruments

Vaginal.

An extraordinary variety of bizarre foreign bodies have been recovered

from the vagina including safety pins, hairgrips, pencils and small jam jars.

The patient is often mentally retarded or a young child, and in both these a

persistent and a maladorous discharge should always suggest the presence of

a foreign body.

Neglected or forgotten objects employed therapeutically. The most

frequently found is the ring pessary used for prolapse. Some of these have

remained in the vagina for many years and have become encrusted with

phosphatic deposits. These neglected pessaries can cause severe ulceration of

the posterior fornix and later vaginal carcinoma. Less traumatic are forgotten

swabs and tampons, which cause a foul purulent discharge.

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Contraceptive devices such as cervical caps and diaphragms, even a

mislaid condom when retained, can cause discharge and ulceration.

Instrumental damage caused during attempted criminal abortion.

Sound, gums, elastic bougies, hatpins, knitting needles and the like have

caused perforation of the vagina into the bladder, rectum, pouch of Douglas

and the parametrium.

Very rarely, a needle can break during suturing of an episiotomy and a

piece may remain there without causing symptoms. This is accidentally

discovered during a subsequent confinement.

Uterine.

Foreign bodies in the uterus are almost always intrauterine

contraceptive appliances such as Copper T. These are inserted in the first

place by a qualified practitioner but may be neglected or forgotten by the

patient. They cause ulceration of the endometrium and can give rise to a

serious ascending infection with inflammatory tuboovarian masses. The

foreign body may also be a cause of menorrhagia.

The other foreign body met with in the uterus has usually been

introduced in order to procure abortion. Serious intrauterine infections often

result in pelvic abscess from acute salpingooophoritis.

Perforation of the uterus may occur during dilatation and curettage, and

medical termination of pregnancy.

Perforative injuries during hysteroscopic operative procedures or

division of the uterine septum have been known. These should not be treated

lightly, the possibility of injury to hollow viscera, or vessels, must always be

borne in mind, and necessary surgical measures implemented to ensure

patient safety.

Treatment. Treatment of vaginal foreign bodies is to remove them, if

necessary under anesthesia. Simple local antiseptic douches suffice for after-

treatment. If, however, the vagina has been perforated, chemotherapy is

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indicated and, if there are signs of peritoneal infection or bowel damage, as

with criminal abortion, laparotomy may be needed.

Uterine foreign bodies should be removed under anesthesia and, if

infection is present, a swab taken and the correct chemotherapy given.

Adnexal involvement if resistant to chemotherapy, e. g. large persistent

masses with recurrent fever and constitutional upset, call for laparotomy and

their surgical removal. In young women, it is sometimes possible to conserve

the uterus and part of one ovary. When the pelvic organs are grossly

disorganized by the pelvic inflammatory disease, total hysterectomy and

bilateral salpingo-oophorectomy is the only logical answer. Fortunately, these

severe infections from uterine foreign bodies are rare.

Chemical and other burns of the vagina

The commonest cause of these is the use of strong chemicals such as

Lysol, permanganate or corrosive sublimate. The dangerous complication of

this type of burn is that during healing, extensive vaginal adhesions and

fibrosis will obliterate the canal and prevent coitus, and even cause retention

of menstrual discharge with hematometra and pyometra. Plastic

reconstruction is the only answer to this problem.

Douches administered at a too high temperature are another cause of

burn. This is culpable error on part of the operator.

During the operation of cauterization of the cervix by the cautery or

diathermy, it is quite easy to burn the vagina directly or by conduction.

Fortunately, cryosurgery has today replaced cauterization of the cervix and

burn injuries of this nature are rare. Laser therapy for cervical lesions and

vaginal cancer in situ can also cause burns.

It must be remembered that the radium inserted into the vagina for

carcinoma of the cervix always causes radiation. During the process of

healing, the vaginal vault frequently becomes obliterated by an adhesive

vaginitis and fibrosis.

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Treatment. Most vaginal burns, unless severe, heal with expectant

treatment. Those resulting in extensive scarring and atresia will require

plastic surgery.

Self test

1. What from the following symptoms should always suggest the presence of a

foreign body?

A. maladorous discharge

B. hemorrhage from the vagina

C. swelling in the lower abdomen

2. The dangerous complication of chemical burn is

A. - extensive adhesions of the vaginal canal

B. - vaginal tears

C. - vaginal hemorrhages

3. With second-degree tears, the torn muscles of the perineum should be sutured

with

A. - catgut

B. - silk

C. - metallic agraffe

4. Colpocleisis consists of

A. obliteration of the vaginal cavity after denuding the entire vaginal mucosa

B. temporary tamponade of the vagina

5. What may be a likely complication after operations on the perineum?

A. - retention of urine

B. - constipation

C. - diarrhea

6. What is the most dangerous complication in case of third-degree laceration of

the perineum?

A. the patient becomes incontinent of faeces and flatus

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B. infertility

C. chronic inflammation of genital tract

7. What may be a likely complication of the cervical lacerations?

A. - isthmico-cervical insufficiency

B. - disturbances of menstrual cycle

C. - cervical erosion

D. - cervical inversion

8. Laparotomy is the only way of treatment in cases of uterine perforation.

A. yes

B. no

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Chapter 13. MYOMA OF THE UTERUS.

ENDOMETRIOSIS. SARCOMA OF THE UTERUS

Chapter 13. MYOMA OF THE UTERUS. ENDOMETRIOSIS

LEIOMYOMA OF THE UTERUS

Leiomyomas (myomas) are the commonest of all uterine tumors.

Uterine leiomyomas are proliferative, well circumscribed,

pseudoencapsulated benign tumors composed of smooth muscle and fibrous

tissue. They are also called a fibroid, fibromyoma, myoma, fibroleiomyoma,

leiomyoma.

Incidence. Neoplasms of the uterus are almost all leiomyomas, which

may be found in nearly one woman in three over the age of 30 years. Uterine

fibroids are common, appearing in 70% of women by age 50; the 20% to 50%

that are symptomatic have considerable social and economic impact on

women’s quality of life: their health, working capacity, fertility, etc. Symptoms

of myoma are common between the age of 30 and 45. Many tumors are too

small to be palpated, and can remain asymptomatic, and are diagnosed

incidentally on clinical examination or imaging. They are present in 40% of

autopsy specimens as unexpected finding. And it is rather difficult to

determine with accuracy the true incidence of myomata. It never develops for

the first time after the menopause. They are more common in nulliparae.

Myomas are the most common indication for hysterectomy in our country.

As to its structure, it is a nonstriated muscle tumor. It develops in the

myometrium and is not encapsulated, but develops a false capsule of

compressed myometrial tissue. The cut surface is whorled, white and bulgy.

Leiomyomas may be solitary in the uterus but most frequently are multiple.

They vary in size from tiny to several cm in diameter. Some of them develop a

long pedicle and present as polyps.

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Etiology. The cause is unknown. Cytogenetic studies suggest a role of

chromosomal abnormalities (particularly chromosome 12) in the

pathogenesis of these tumors. A limited number of genetic defects

transmitted by germ cells have been associated with familial uterine fibroid

syndromes. Most notable are germline mutations causing fumarate hydratase

deficiency, which predisposes women to the development of multiple uterine

fibroids. Recent research showed the role of stem cells, somatic genetic and

epigenetic defects, and the action of estrogen and progesterone and their

cross-talk with various signaling pathways in the development of uterine

fibroids. The inciting event responsible for the neoplastic transformation is

unknown; estrogen may be necessary for expression of this mutation. Factors

that affect growth are: estrogen, progesterone, peptide growth factors.

Evidence suggests estrogen to be a promoter of myoma growth:

o myomas are rarely found before puberty and stop growing after

menopause;

o new myomas rarely appear after menopause;

o there is often rapid growth of myomas during pregnancy.

During a woman's reproductive years, myometrial smooth-muscle cells

undergo multiple cycles of growth followed by involution under the influence

of ovarian hormones or the hormones of pregnancy. These cycles make stem

cells vulnerable to the development of mutations. It can alter key signaling

pathways such as those involving β-catenin and TGF-β, which regulate cell

proliferation, survival, and senescence and the formation of extracellular

matrix, leading to clonal expansion of the stem cells within the genetically

normal myometrium. In this context, the inherent capability of myometrial

tissue to respond to estrogen and progesterone for physiologic expansion

during the luteal phase of the ovulatory cycle or pregnancy may work to the

advantage of fibroid-tumor growth. Such growth may be mediated by high

levels of estrogen and progesterone receptors in normal myometrial cells or

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by the differentiated population of fibroid cells that send paracrine signals to

the receptor-deficient fibroid stem cells for self-renewal.

Recent investigations implicate peptide growth factors – epidermal

growth factor, insulin-like growth factor – 1, platelet-derived growth factor –

in the regulation of leiomyoma growth. Estrogen may exert its effect through

epidermal growth factor.

Local factors, such as blood supply, adjacency to other tumors and

degenerative changes may account for variations in tumor volume and rate of

growth.

Classification. Myomas are classified according to their location within

or on the uterus into: intramural, submucous, subserous. (Fig. 211). Each

location is associated with different signs and symptoms.

Intramural myomas are the most common variety (70%), occurring

within the walls of the uterus as isolated encapsulated nodules of

varying size. As these grow, they can distort the cavity or the external

surface of the uterus. These tumors can also cause symmetric

enlargement of the uterus when they occur singly.

Submucous myoma –growing into the uterine cavity they present either

submucosal, pedunculated submucosal or pedunculated vaginal (10%)

myomatous nodes

o Submucous myomas are located beneath the endometrium. These

tumors grow into the uterine cavity, maintaining attachment to

the uterus by a pedicle. The pedunculated myomas may protrude

to or through the cervical os. These tumors are often associated

with an abnormality of the overlying endometrium, resulting in a

disturbing bleeding pattern.

Subserous myoma – these grow outwards from the uterus (20%).

Subserous myomas are located just beneath the serosal surface and

grow out towards the peritoneal cavity, causing the peritoneal surface of

the uterus to bulge. Subserous myoma can be:

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o Subserous.

o Pedunculated subserous (abdominal). These tumors develop

a pedicle, become pedunculated, and reach a large size

within the peritoneal cavity producing pressure symptoms,

abdominal swelling. These forms may be mobile and should

be differentiated from solid adnexal lesions.

o Intraligamentous. When myomas extend into the broad

ligaments, they are known as intraligamentary myomas

o Cervical - involvement of the isthmus and cervix, fibroids at

these sites will produce their own spectrum of symptoms

and signs.

Hystopathology. Myomas consist of whorled masses of unstriped

muscle cells, but more often they consist of muscles and connective tissue.

Secondary Pathological Changes in the Fibroid Uterus

Secondary changes may occur in fibroid. These changes occur in

alteration of circulation (either arterial or venous), postmenopausal atrophy,

or infection or may be as a result of malignant transformation.

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- Hyaline degeneration, the most common type of degeneration, is

present in almost all myomas, especially in tumors with more connective

tissue. The tumor becomes softer and the degenerated areas have a

homogenous waxy character instead of the whorl-like appearance.

Microscopically, the muscle cells become indefinite and their cytoplasm

merges with the structureless intercellular matrix.

- Cystic degeneration is the extension of hyaline degeneration with

liquefaction of some areas of the fibroid and cyst formation.

- Calcification. This more frequently occurs in the myomata of

postmenopausal women or in the subserous myoma with small pedicle. It is

practically never seen in the submucous myoma. This is associated with

circulatory impairment. In its most extreme form the fibroid is converted into

a stony mass.

- Fatty degeneration: the fatty change is associated with hyaline

degeneration and usually precedes calcification.

- Atrophy. This is noticed after menopause. The myomata become

smaller and comparatively avascular with more fibrous tissue.

- Necrosis is commonly caused by impairment of the blood supply or

severe infection. A special kind of necrosis is red, or carneous, degeneration,

which occurs most frequently in pregnancy. The lesion has a reddish hue and

is believed to be aseptic degeneration with local hemolysis.

- Infection of myoma most commonly occurs with a pedunculated

submucous leiomyoma that first becomes necrotic and then secondarily

infected.

- Sarcomatous degeneration. Malignant degeneration occurs in less

than 1% of myomas.

Associated conditions. Follicular cysts of the ovary, hyperplastic

endometrium, and endometriosis are significantly associated with myoma. All

these conditions are seen in nullipara and are due to hyperestrogenism.

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Clinical picture. The clinical symptoms of myomata are highly variable

and are dependent on the size, site and number of tumors.

Most cases of myomata are symptomless and are found in the course of

a routine pelvic examination.

The common symptoms and signs are the following:

Menstrual disturbances:

o The most common disturbances are heavy and prolonged

menstrual bleeding with increased amount and duration of flow.

In intramural myoma abnormal uteine bleeding (AUB) may be

due to increased vascularity, hyperplastic endometrium, an

increased bleeding surface because of the larger size of the uterine

cavity and associated ovarian dysfunction. Subserous tumors do

not disturb menstruation;

o Intermenstrual bleeding or a blood-stained discharge is a feature

of submucous myoma and fibroid polyps, which have become

necrotized and infected;

o Dysmenorrhea is not uncommon symptom, which is more

characterized in submucous myomata. Submucous pedunculated

tumors produce uterine contractions causing cramp-like pain in

the lower abdomen as in spasmodic dysmenorrhae.

Abdominal swelling.

o When the myoma of uterus is larger in size than the uterus at the

12th week of gestation, it can be felt in the lower abdomen.

Pressure symptoms.

o Myoma in the fundus and the body of the uterus rarely cause

pressure symptoms.

o But a cervical myoma causes bladder irritability and frequency of

micturition. Acute retention of urine can occur premenstrual due

to the compression of the internal vesicle sphincter or the urethra

against the pubic bone.

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o Occasionally a large broad ligament tumor may displace and press

on the urethra leading to hydroureter and a painful, tender

kidney.

o Constipation and difficult defecation can be caused by large

posterior myomas. Symptoms due to pressure on the pelvic veins

or nerves are exceptional.

Pain.

o Apart from dysmenorrhea, myomata can cause abdominal or

pelvic pain due to infection, red degeneration, torsion, due to

rapid tumor growing or sarcomatous change.

Sterility.

o About 40% of women with multiple uterine fibroids have

infertility. The presence of a submucous myoma may prevent

implantation due to poor deciduation or may give rise to an

abortion. The distortion of the uterine cavity, tubal blockage by

cornual myomata, associated salpingitis, endometriosis and

anovulation are also contributory causes of sterility.

Chronic posthemorrhagic anemia.

Diagnosis of myoma is not difficult and based on finding of abdominal,

vaginal and additional methods of examination.

Abdominal examination. Uterine may be palpated as irregular, nodular

tumors protruding against the anterior abdominal wall. Myomatous uterus

is usually firm on palpation; softness or tenderness suggests the presence

of edema, sarcoma, pregnancy, or degenerative changes.

Vaginal examination. The most common finding is uterine enlargement;

the shape of the uterus is usually asymmetric and irregular in outline. The

uterus is usually freely movable. In the case of the submucous myomas the

uterine enlargement is usually symmetric. Some subserous myomata may

be very distinct from the main body of the uterus and may move freely.

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Additional examination:

o blood test (hemoglobin, hematocrit, erythrocytes) is obtained in the

patient with excessive vaginal bleeding to assess the degree of loss and

account of replacement,

o coagulation profile and bleeding time are ordered in a patient with

bleeding,

o endometrial biopsy or separately uterine curettage is performed in a

patient with abnormal uterine bleeding to exclude endometrial

hyperplasia, malignization.

o ultrasonography accurately assesses uterine dimension, myoma

location, interval of growth,

o evaluation of the endometrial cavity with hysteroscopy or

hysterosalpingography.

o MRI, CT scan are also used for diagnosis of leiomyoma.

Treatment. The treatment of myomata must be adapted to each patient,

and includes nonsurgical and surgical methods. Treatment decisions are

based on symptoms, fertility status, uterine size, and the rate of uterine

growth.

In general, small asymptomatic myomas do not require treatment, but

the patient should be periodically monitored. Annual examination of these

patients is mandatory and includes:

Bimanual examination every 6- 12 months to determine uterine size and

rate of growth.

o After assurance of slow growth or stable uterine size annual

follow-up may then be appropriate. Rapid growth – a change of 4

weeks in size or greater during 12 months or less of observation –

is an indication for surgical intervention.

Additional methods of examination such as:

o TAUS and TVUS,

o X-ray examination,

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o cytological examination (Pap-testing),

o histological examination (endometrial biopsy by separate

curettage of the uterus, aspiration biopsy).

o The same about regular laboratory examination to determine Hb,

PCV, WBC, iron deficiency and so on.

Fibroids should be treated if they are associated with symptoms. Three

modalities are used to treat myomas:

o medical treatment,

o surgical treatment,

o embolization of uterine arteries

Medical treatment

Medical treatment is a temporary treatment, ideally used for patients who are

close to menopause, who are risky surgical candidates, who do not realized

their reproductive function. So, medical therapy is indicated in the following

cases:

o myoma in the late reproductive age or in premenopause;

o in case of contraindications for surgical intervention;

o before the operation to reduce uterine size and volume of

intraoperative blood loss.

Hormonal treatment of leiomyoma

o Progestogens have no stable effect on the size of leiomyoma, but

may be used in controlling the menstrual loss, especially in

anovulatory cycles, in a course of treatment of infertility, related

to leiomyoma. Progesterone is administered in the second phase

of menstrual cycle by 5 or 10 mg intramuscularly once a day for

10-12 days during 3 or 6 months; Medroxyprogesterone (Amen,

Cycrin, Provera) 10-20 mg PO qd continuously; Megestrol

(Megace) 40 mg PO qd. Use of progestins have some side effects:

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both fibroid shrinkage and enlargement have been shown; may

induce endometrial atrophy and amenorrhea.

o Combined oral contraceptive pills (COCPs) are also used.

Norgestimate/ethinyl estradiol (Ortho-Cyclen, Ortho-Prefest,

Ortho Tri-Cycle usually administered for three months, then, if

menstrual blood loss reduced, for 6 months. COCP usually

administered by:

Schedule 1 (Sunday starter)

- Begin dose on first Sunday after onset of menstruation; start that

Sunday if menstrual period starts on Sunday

- 21-tab package: 1 tab qd for 21 d followed by 7 d off medication; new

course begins on day 8 after taking last tab

- 28-tab package: 1 tab qd without interruption

Schedule 2 (day 1 starter)

- Start dose on d 1 of menstrual cycle

Patient need in further treatment of sterility treatment and special follow up.

o Gonadotrophic-releasing hormone analogues (GnRH agonist) cause

hypoestrogenism and may be used too. They are most helpful when

given preoperatively to reduce fibroid and uterine volume. Reduction in

myoma size occurs within four months of treatment and reported range

varies from 30 to 100%. Both ischemic effect and cellular atrophy play

part in the reduction of myoma size. Some of GnRHs used are buserelin,

goserelin, 3. 75-7. 5 mg monthly for 3 -4 months. Use of GnRH agonist

therapy is not recommended for longer than 24 weeks (6 months),

because of the long-term therapy is associated with rapid bone loss

(osteoporosis), with rebound growth to pretreatment size within 6

months, often increasing bleeding and pain. For these reasons and

because of the expense of these agents, GnRH agonists are

recommended for short-term use and only in selected cases; for the

treatment of large, submucous myomata to facilitate hysteroscopic

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resection; in the symptomatic perimenopausal patients who wish to

avoid surgery; and as presurgical treatment to decrease symptoms and

size.

o GnRH antagonists (Abarelix, Cetrorelix, Degarelix, Ganirelix) lead to

suppression of ovarian steroidogenesis production - immediate

pituitary downregulation. GnRH antagonists have the advantage of

flexibility in that they may be administered at any time during the

follicular phase of a treatment cycle. GnRH antagonists are

administered by either intramuscular injection (abarelix) or

subcutaneous injection (cetrorelix, degarelix and ganirelix). One

injection of Cetrorelix of 3 mg on day 8 or 9 of the stimulation cycle is

sufficient to prevent an LH surge.

o Antigonadotropic agents: Danazol may be administered in a dosage of

800 mg daily for six months.

o RU-486 (mifepristone), an antiprogestin, has been associated with

decrease in size of leiomyomas

o Androgens may cause the inhibition of pituitary function and atrophy of

endometrium. So, 30 mg of methyltestosterone (2 tablets three times a

day) during 20 days are administered for 3 months. Testosterone

propionate may be used in 25 mg intramuscularly in a day for 10

injections, with 10 days interval during 3 months. The treatment by

androgens may be used in the age older than 45 years.

Non-hormonal therapy is as follows:

- Ergometrine,ergonovine, which induces uterine contraction, from the

5th day of periods.

- Iodine electrophoresis daily a month with a break for menstrual flow.

- Nonsteroidal antiinflammatory drugs are also useful for treatment of

pelvic discomfort or pressure.

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Surgical treatment

Indications for surgery are symptomatic leiomyomas:

Excessive bleeding that interferes with normal life-style or leads to

anemia.

Chronic pelvic pain.

Rapid growth (enlargement of myoma to 3-4 weeks pregnancy size in a

year of management).

Size of the uterus is more than 12 weeks pregnancy in patients less than

40 years of age and more than 14 weeks in patients older than 40 years

of age.

Uterine growth in menopause because this may represent a

malignization of fibroid.

Submucous myoma.

Pressure symptoms on surrounding organs (micturition, urinary

retention, progressive hydronephrosis, constipation, varicosity due to

compression of pelvic vessels.

Protrusion of a pedunculated submucous myoma through the cervix.

Necrosis of myomata, torsion of pedunculated myomata and so on.

Surgical treatment may be conservative and radical.

The type of surgery to be performed depends on the age of the patient, the

nature of the symptoms, and the patient’s desires regarding future fertility.

Three classes of surgical techniques are conventional:

o laparotomy,

o operative laparoscopy,

o operative hysteroscopy.

Others: Uterine fibroid embolization, laparoscopic myolysis, MRI-guided

focused ultrasound are also currently used.

Laparotomy: this technique is indicated for large myomas, for

submucous myomas larger than 3 cm in diameter, or for myomas that,

regardless of being submucous, have a portion of the myoma that

490

compromises the myometrium so that a complete resection through the

hysteroscopy is not feasible. The classic types of operations are myomectomy

and hysterectomy (see chapter 10). Myomectomy involves the removal of a

single or multiple myomata while preserving the uterus; this procedure is

usually reserved for women who desire future pregnancy and to whom

pregnancy is not contraindicated. Myomectomy can be done through

endoscopy, by laparotomy or per vagina (in cases with submucous myoma

and polyps). If the indications for surgery are present and if the patient’s

childbearing is complete, hysterectomy may be definitive treatment for

uterine myomata. Hysterectomy may be performed on the abdominal or

vaginal route. As a rule, total abdominal hysterectomy is a satisfactory and

safe operation. Large cervical or broad ligament tumors make the operation

technically difficult and there is a risk of injury of the urethra at its

displacement. In women of approximately 45 years of age both tubes and

ovaries are usually removed along with the uterus. In those who are younger,

the ovaries are preserved unless they are diseased. Vaginal hysterectomy is an

excellent operation when the uterus is not larger than 12-14 weeks pregnancy

size, especially if the patient is multiparous.

Laparoscopic myomectomy. This technique is indicated for

pedunculated and superficial intramural myomas. Also should be reserved

for myomas with a diameter less than 6 cm.(Fig. 212). In a laparoscopic

myomectomy, thin scopes are used that contain surgical and viewing

instruments. Laparoscopy requires only tiny incisions, and has a much faster

recovery time than abdominal myomectomy. Only certain fibroids can be

removed by laparoscopy. If the fibroids are large, numerous or deeply

embedded in the uterus, then an abdominal myomectomy may be necessary.

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Laparoscopic myoma coagulation - myolysis is an alternative to

myomectomy. This procedure can be combined with endometrial ablation for

patients who have persistent uterine bleeding. Laparoscopic myomectomy is

another alternative to hysterectomy.

Robotic myomectomy. Robotic myomectomy uses a combination of

high-definition 3d magnification, robotic technology and miniature

instruments to improve a surgeon's ability to view fibroids and the

surrounding tissue, as well as enhanced ability to suture the uterus when

removing uterine fibroids and reconstructing the uterine wall. Four small

incisions are made in the abdomen to allow for slender robotic arms and tiny

surgical tools to access the uterus. Using careful techniques to continue

minimizing the bleeding, the surgeon excises the fibroid(s) from the

surrounding uterine tissue. Once the fibroid has been removed, the surgeon

uses a special device called a morcellator to cut the fibroid into smaller pieces

inside the patient's abdomen. These pieces are then removed through one of

the ports. Benefits of robotic myomectomy over abdominal myomectomy

includes less post-surgical pain, quicker recovery and return to normal

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activities. The typical recovery involves 0-1 nights in the hospital and 4 weeks

reduced activity.

Hysteroscopic myomectomy. The removal of a submucous fibroid using

hysteroscopy should be limited to small fibroids (≤3 cm) with minimal

compromise of the myometrium. With this procedure, fibroids are removed

using an instrument called a hysteroscopic resectoscope, which is passed up

into the uterine cavity through the vagina and cervical canal. Standard

resection uses an electrosurgical wire loop to surgically remove the fibroid.

Fibroids located within the uterine wall cannot be removed with this

technique. Hysteroscopic myomectomy is an out-patient surgical procedure.

Patients go home after several hours of observation in the recovery room.

Recovery time is generally only few days. There are no scars on the skin after

the procedure. Uterine synechiae development is a potential complication

after the surgery; therefore, a postoperative HSG should be part of follow-up

care.

Uterine fibroid embolization. Uterine fibroid embolization (UFE), also

known as uterine artery embolization is performed by an interventional

radiologist, a physician who is trained to perform this and other types of

embolization and minimally invasive procedures. The procedure is performed

while the patient is conscious—but sedated and feeling no pain. It does not

require general anesthesia and usually only a hospital stay of one night.

Painkilling medications and drugs that control swelling are prescribed

following the procedure. (Fig.213). UFE consists of catheterization of the

uterine artery and the injection of micro beads of polyvinyl alcohol to

selectively occlude the circulation of the fibroid. It is not intended for patients

who desire fertility.

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Contraindications for surgery: severe general diseases, severe inflammatory

diseases, and so on.

Endometriosis

Endometriosis is defined as abnormal growth of endometrial tissue

(glands and stroma) outside the uterus. The most frequent sites of

implantation are the pelvic viscera and the peritoneum. Endometriosis varies

in appearance from a few minimal lesions on otherwise intact pelvic organs to

massive ovarian endometriotic cysts that distort tuboovarian anatomy and

extensive adhesions often involving bowel, bladder, and ureter. It is estimated

to occur in 7% of reproductive age women and often is associated with pelvic

pain and infertility.

Pathology. The essential feature of endometriosis is the occurence of

endometrial tissue in ectopic situation. The displaced endometrial tissue is

respond to estrogen and progesterone cyclic changes, continues to act as it

normally would — it thickens, breaks down and bleeds with each menstrual

cycle. Because this displaced tissue has no way to exit the body, it becomes

trapped, leading to development of endometriotic implants, looking like

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small, flat patches, blebs, or flecks sprinkled on the pelvic surface. The flecks

can be clear, white, brown, red, black, or blue. The color is attributed to

hemolyzed blood from ectopic endometrium that is encapsulated by

adhesions or fibrotic tissue. These peritoneal surface lesions usually range in

size from a few millimeters to 2 cm in diameter and often are surrounded by

various degrees of fibrosis that may confer a puckered appearance.

Endometriosis implants may vary considerably in appearance. Smaller fresh

lesions may be found as clusters of nodules resembling hemorrhagic vesicles,

which have been described as “raspberry” spots (Fig. 214). Other implants

may appear as clear, nonpigmented, or slightly brown vesicles, reddish

polyps, white scar tissue or plaques, petechiae, or flamelike lesions. In the

natural evolution of endometriosis, white, scarred peritoneum or the typical

pigmented lesion is considered a late-stage manifestation of endometriosis.

All types of implants may coexist within the same patient. Occasionally, foci

of endometriosis may be found at the base of adhesions formed in response to

chronic peritoneal surface irritation by the implants. Peritoneal pockets may

also be associated with endometriosis.

The severity and course of endometriosis is highly unpredictable. Some

women may have a few endometriosis implants on the surface of the pelvis,

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the peritoneum, or pelvic organs, or they may invade the peritoneum and

grow as nodules. Endometriosis may grow on the surface of the ovary as

implants or invade the ovary and develop a blood-filled cyst called an

endometrioma, or a “chocolate cyst.” Chocolate cysts are so named because

over time the blood they contain darkens to a deep reddish-brown color.

These cysts may be as small as a pea or grow to be larger than a grapefruit.

Endometriosis may irritate surrounding tissue and produce internal scar

tissue called adhesions. These adhesions can bind the pelvic organs together,

cover them entirely, or involve nearby intestines. The adhesions may keep

fallopian tubes from picking up the egg from the ovary during ovulation.

Endometriosis also may grow into the walls of the intestine or into tissue

between the vagina and the rectum.

An “endometrioma “(the synonym of endometriosis) may be regarded

as a neoplasm, but will only survive under the influence of the ovarian

hormones. The ectopic tissue consists of both glands and stroma, in both of

which cyclical menstrual changes occur. The menstrual blood and secretion

causes secondary proliferation, and the greater part of any tumor is

adventitious tissue. Although benign, endometriosis is progressive, tends to

recur, may be locally invasive, may have widespread disseminated foci

(rare),and may exist in pelvic lymph nodes (30%).

Endometriosis occurs in the following locations (Fig. 215)

- Ovaries. Small dark endometrial “spots” appear on the surface, and the

menstrual secretion partly distends the endometrial glands and partly enters

the peritoneal cavity, where it is walled off by adhesions. A tumour mass is

formed, consisting partly of ovary, partly of adventitious fibrous tissue, and

with cystic spaces containing chocolate-coloured altered blood. The disease is

usually bilateral, and forms masses up to 10 cm in diameter.

- Uterus. Nodules (“adenomyosis”) appear in the wall, resembling

fibromiomata, except that they have no definite capsule and may show minute

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spaces containing blood. Microscopically endometrial tissue is found, with

proliferation of adjacent muscle and fibrous tissue.

- Uterine tubes. Uncommon, except in amputation stumps.

- Rectovaginal septum. A hard fixed mass of indefinite outline appears,

and may extend backwards partially to surround the rectum. Ulceration of the

posterior fornix may occur. The rectal mucosa remains intact for a long time,

but ultimately rectal ulceration and bleeding occur. Lateral extension may

involve the ureter.

- Round ligaments, both intra- and extraperitoneal portions.

- Umbilicus.

- Lower abdominal scars, especially after hysterectomy.

- Anywhere on the pelvic peritoneum. Fibrous tissues around

endometriosis of the bowel may form a ring stricture and cause obstruction.

The peritoneal surface of the bladder may be involved.

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Etiological theories. Endometriosis is an estrogen-dependent disease.

Three theories have been proposed to explain the histogenesis of

endometriosis:

Ectopic transplantation of endometrial tissue

Coelomic metaplasia

The induction theory

Transplantation theory. The most widely accepted hypothesis is that

endometrial cells are transported from the uterine cavity, then implant at

ectopic sites. Endometrial “spills” may be regurgitated through the tubes and

become implanted. Retrograde flow of menstrual tissue through the fallopian

tubes could cause intra-abdominal endometriosis (ovarian, peritoneal, tubal

endometriosis etc.); the lymphatic or circulatory systems could transport

endometrial cells to distant sites (for examplе, the pleural cavity). Retrograde

menstruation occurs in 70% to 90% of women, and it may be more common

in women with endometriosis than in those without the disease. The presence

of endometrial cells in the peritoneal fluid, indicating retrograde

menstruation, has been reported in 59% to 79% of women during menses or

in the early follicular phase, and these cells can be cultured in vitro. Also,

endometriosis is most often found in dependent portions of the pelvis—the

ovaries, the anterior and posterior cul-de-sac, the uterosacral ligaments, the

posterior uterus, and the posterior broad ligaments. Endometrium obtained

during menses can grow when injected beneath abdominal skin or into the

pelvic cavity of animals. Women with shorter intervals between menstruation

and longer duration of menses are more likely to have retrograde

menstruation and are at higher risk for endometriosis.

Coelomic metaplasia. Endometriosis may be due to metaplasia of the

coelomic epithelium from which the Mullerian system developed. This may

represent an abnormal response to estrogens; fibromyoma, cystic

endometrial hyperplasia, and ovarian follicular cysts are often associated with

endometriosis.

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Induction theory. The induction theory is an extension of the coelomic

metaplasia theory. It proposes that an endogenous (undefined) biochemical

factor can induce undifferentiated peritoneal cells to develop into endometrial

tissue.

Genetic factors population studies. The risk or endometriosis is 7 times

greater if a first-degree relative has been affected by endometriosis. Because

no specific mendelian inheritance pattern has been identified, multifactorial

inheritance has been postulated. A relative risk for endometriosis of 7.2 has

been found in mothers and sisters, and a 75% (6 of 8) incidence has been

noted in homozygotic twins of patients with endometriosis.

Endometriosis also is linked to the presence of individual human

leukocyte antigens ( 28,29 and 30).

Incidence. The incidence of endometriosis for the women of

reproductive age oscillates from 7 up to 50 %.

Clinical classification of endometriosis. A number of classifications

have been developed for endometriosis. The most widely used system was

introduced by the American Society for Reproductive Medicine (ASRM) in

1979 and revised in 1985 and in 1996.(Fig. 215, Fig. 216). The ASRM system

assigns a point score for the size and location of endometriotic implants and

associated adhesions. The new ASRM endometriosis classification for

infertility includes the morphologic appearance of the implant. There is a

form published by the ASRM to assist in the management of endometriosis in

the presence of pelvic pain. Endometriosis is classified as minimal, mild,

moderate, and severe. Mild disease is characterized by superficial implants <5

cm2 in aggregate scattered on the peritoneum and ovaries. Minimal or no

adhesions are present. Moderate forms are characterized by multiple

implants, both superficial and invasive. Peritubal and periovarian adhesions

may be evident. Severe forms are characterized by multiple superficial and

deep implants, including large ovarian endometriomas. Filmy and dense

adhesions usually are present.

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However, no staging system has been validated to correlate with the

symptoms of pain or infertility.

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The following types of endometriosis are currently distinguished:

Peritoneal endometriosis: Peritoneal implants that consist of glandular

and stromal tissue and respond to hormonal changes associated with the

menstrual cycle showing cyclic changes similar but not identical to the normal

endometrium. These implants heal by fibrosis.

Ovarian endometriosis: benign, estrogen-dependent cyst also known as

“chocolate cyst” that contains thick, old blood that happens as a brown fluid.

This result from recurrent chronic bleeding from the endometriotic implants.

In long-standing endometriomas, the endometrioric tissue is gradually

replaced by fibrotic tissue.

Deep endometriosis: this form is characterized by proliferative

fibromuscular tissue with sparse endometrial glandular and stromal tissue,

with no surface epithelium. Deep endometriosis does not show significant

changes during the menstrual cycle. Growth of endometriotic nodules is

usually found in the uterosacral ligaments, the rectovaginal space, the upper

third of the posterior vaginal wall, the bowel, and the urinary tract.

Adenomyosis: uterine endometriosis, the growth of endometriotic

implant into - and through- the myometrial layer of the uterus. Uterine

endometriosis presented with asymmetrical enlargement of the uterus.

Disseminated endometriosis: it is the growth of endometriotic tissue in

various organs in the body including at the scar site.

Clinical picture. Small lesions may be found unexpectedly at operation,

but larger lesions cause the specific symptoms.

Pain. Pain in endometriosis presents as any of the following:

o Painful menstruation (dysmenorrhea)

o Painful intercourse (dyspareunia)

o Painful defecation (dyschezia) that may be cyclic or semi-cyclic.

o Painful micturition (dysuria)

o Lower back or abdominal discomfort

o Ovulation pain

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o Chronic pelvic pain (non-cyclic abdominal pelvic pain of at least 6

months duration)

Atypical presentations include cyclic leg pain or sciatica (nerve

involvement), cyclic rectal bleeding or haematuria (bowel or bladder

invasion), and cyclic dyspnea secondary to catamenial pneumothorax.

These presentations are indicative of a more significant disease

involvement.

Infertility.

o Endometriosis is strongly associated strongly with infertility, mostly

due to pelvic adhesions or endometrial abnormalities. Moderate or

severe endometriosis markedly reduces fertility, because large pelvic

adhesions, when present, may prevent the release of eggs, block

sperm entry into the fallopian tube, and prevent the fallopian tube’s

ability to pick up eggs during ovulation. If pregnancy does occur,

there is often considerable improvement, at least for some time.

Abnormal uterine bleedings (heavy, prolonged menstrual bleedings),

and irregular bleeding occur from associated endometrial hyperplasia

or from uterine lesions.

Symptoms of intestinal obstruction may occur.

Chronic fatique and lack of working capacity.

The predictive value of any one symptom or set of symptoms remains

uncertain as each of these symptoms can have other causes (and a

significant proportion of affected women are asymptomatic).

Physical signs depend on the site of the disease:

“Chocolate cysts” (ovarian endometriosis) are tender, fixed bilateral

masses; simulating chronic salpingo-oophoritis, but without any history

of infection, fever or discharge.

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Uterine lesions cause nodular or uniform enlargement, and may be

clinically indistinguishable from fibromyoma or from diffuse

hyperplasia. Three degrees of diffuse adenomyosis are known:

o the 1st is the - germination on depth of 1 cm;

o the 2nd is the germination up to the middle of endometrium,

o the 3rd is the germination up to serous coat.

Rectovaginal lesions are tender, hard, fixed, and simulate rectal

carcinoma. In contrast to carcinoma, rectal ulceration is rare and very

late.

Local lesions (e. g. in scars) may be tender at periods.

Endometriosis of bowel may be indistinguishable from carcinoma

without histological examination, except that there are often other

endometriomatous lesions.

Diagnosis. Generally, diagnosis of endometriosis is based on the

history, the symptoms and signs, physical examination and imaging

techniques.

Physical examinations should include an assessment to determine the

position, size, and mobility of the uterus. One can feel a tender nodule

behind the cervix during a combined vaginal and rectal exam, or the

uterus may be tilted back or retroverted. One or both ovaries may be

enlarged or fixed in position. Occasionally, endometriosis implants may

be visible in the vagina or the cervix. Rectovaginal examinations are

useful in determining presence of deep endometriosis.

Other than the examination of the pelvic region, inspection and

palpation of the abdomen is also advised.

Ultrasonography is the first-line investigational tool for suspected

endometriosis. It allows detection of ovarian cysts and other pelvic

disorders such as uterine fibroids. TAUS and TVUS are used for

diagnosis of endometriosis.

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The serum level of cancer antigen 125 (CA-125) may be elevated in some

cases of endometriosis. But this is specific not only for endometriosis.

However, if the appearance of the ovarian cyst is suggestive of an origin

other than endometriosis, CA-125 and other tumor markers are

recommended.

Another serum protein, PP14, has been evaluated as a marker for

endometriosis. PP14 levels correlate with the severity of endometriosis

and decrease during suppressive medical treatment of endometriosis.

It has been traditionally believed that laparoscopy must be performed to

definitely diagnose endometriosis. Direct visualisation with

laparoscopy and histology has been regarded as the gold standard for

diagnosis. However, this view has been recently challenged as

nonsurgical diagnosis of endometriosis have proven to be highly

reliable.

In special cases, special imaging techniques such as computerized

tomography (CT ) scan, or magnetic resonance imaging (MRI) to gather

more information about patient’ pelvis may be used. These procedures

can identify cysts and help characterize the fluid within an ovarian cyst,

although an endometriotic cyst and a normal corpus luteum cyst may

have a similar appearance. These tests are useful when evaluating

women experiencing infertility and/or chronic pelvic pain.

Treatment. The treatment of endometriosis may be medical, surgical

and combined. Treatment must be individualized on the basis of age,

symptoms, desire for pregnancy, and extent of disease.

Medical treatment. Any treatment must be aimed at eliminating

pain and, if the patient desires, restoring fertility. Since ovarian hormones are

responsible for growth and activity in endometrium the immediate objective

of therapy must be to reduce their production or oppose their action.

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A variety of steroids have been employed. At the beginning these were

mainly used to induce pseudo-pregnancy, the idea being that the ectopic

endometrium would undergo decidual change, which ultimately would be

destroyed by necrosis and healed by fibrosis. The contraceptive pills in high

dosage and provera (medroxy-progesterone acetate) were reasonably

successful in relieving pain but side effects such as weight gain, depression,

mastalgia and irregular break-through bleeding made them unacceptable to

some women. However, monophasic COCPs be used, 1 tablet daily from the

5th to 25th days of cycle, or without intermission during 6-12 months.

Provera: 20-30 mg/day orally for 6 months.

Danasol is an “impeded androgen”, i. e., a steroid hormone closely

related to testosterone, which inhibits pituitary gonadotropins, is anti-

estrogenic, anti-progestational, slightly anabolic, but has very little virilizing

activity. For the palliative treatment of endometriosis in patients with

moderate to severe disease or in patients who are infertile because of

endometriosis, the usual initial dosage of danazol is 800 mg daily given in 2

divided doses. Amenorrhea and a rapid improvement in painful symptoms

are best achieved at this dosage. Subsequent dosage may be gradually

reduced, depending on the patient's therapeutic response, to a level sufficient

to maintain amenorrhea. For the treatment of endometriosis in patients with

mild disease, the usual initial dosage is 200-400 mg daily given in 2 divided

doses. Subsequent dosage should be adjusted according to the patient's

tolerance and therapeutic response. Danazol therapy for the treatment of

endometriosis should continue uninterrupted for 3-6 months; however,

therapy may be extended to 9 months, if necessary. If symptoms recur

following discontinuance of therapy, treatment with danazol may be

reinstituted.

A daily dose of about 400 mg may abolish symptoms, and after about a

year may produce complete regression and even allow pregnancy. At that

dose level, side effects include amenorrhoea, weight gain, acne and muscle

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cramps, none of them except amenorrhoea are invariably present. Increased

dosage may result in hot flushes and loss of libido, and mild but reversible

degrees of voice change and hirsutism.

Gestrinone. This is a derivation of 19-nortestosterone. It has slight

androgenic activity and is markedly anti-estrogenic and anti-progesterogenic.

It interacts with the pituitary steroid receptors and decreases gonadotrophic

secretion resulting in diminished follicular growth and anovulation. A bi-

weekly oral dose of 2. 5 to 5. 0 mg for 6 months induces amenorrhoea,

disappearance of pain and regression of the endometrial deposits. Side effects

include weight gain, acne, seborrhea and mild hirsutism.

Gonadotrophic-releasing hormone agonists (GnRH) are given

continuously to desensitize the pituitary receptors for the hypothalamic-

releasing hormone. GnRH suppresses the signals from the pituitary gland to

the ovaries that stimulate estrogen production, by doing this, also supress the

growth of endometriotic lesions. Leuprolide (Rx) recommended by 3.75 mg

IM monthly for up to 6 months or 11.25 mg IM every 3 months for 2 doses (6

months total).

Recommended duration of treatment is 6 months; may treat again for

additional 6 months, but with concomitant administration of norethindrone.

Surgical treatment. Small deposits on peritoneal surfaces, which are

found at laparotomy, may be coagulated with a diathermy needle. In women

over 40 more radical excision is advised, e. g. hysterectomy and removal of

both ovaries. Recto-vaginal lesions may be difficult to excise, and the

induction of the menopause by oophorectomy may be safer. Presacral

neurectomy is sometimes performed for the relief of pain. Operations for

intestinal obstruction are occasionally necessary.

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Self test

1. Which of the following is a typical symptom associated with an abnormally

enlarged 6-8 week myomatous uterus?

A. urinary frequency

B. constipation

C. urinary retension

D. none of the above

2. Submucous myomas may be associated with all of the following signs and

symptoms except

A. abnormal bleeding

B. reproductive failure

C. anemia

D. parasitic infections

3. Abnormal uterine bleeding associated with myomata uteri is characterized by

all of the following except

A. a gradual increase in the bleeding

B. excessive bleeding during menses of normal length

C. the development of anemia

D. irregular cycles with menorrhagia

4. All of the following statements concernimng uterine myomas are true except

A. malignant degeneration occurs in less than 1% of uterine myomas

B. myomas can be found in the fallopian tubes and vagina more often

C. myomas rarely appear or grow after menopause

D. myoma and fibroid are synonyms

5. A benign tumor from a muscular tissue is a

A. leiomyoma

B. glioma

C. lipoma

D. teratoblastoma

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6. The most frequent type of benign lesions of the uterus is

A. endometriosis

B. cervical polyp

C. trophoblastic disease

D. myoma

7. Myoma of the uterus more frequently appears

A. in the round ligament

B. in the uterine corpus

C. in the broad ligament

D. in the cervix

8. The sarcomatous degeneration of myomatous node is frequent in case of

A. subserous localization of nodes

B. intramural localization of nodes

C. submucous localization of nodes

D. any localization

9. “Chocolate cysts” are a characteristic for

A. myoma of the uterine body

B. ovarian endometriosis

C. sarcoma of the uterus

D. adenomyosis

10. What is not a characteristic for myoma of the uterine body?

A. slow growth

B. hyperpolimenorrhea

C. beginning of myoma in multiparae

D. beginning of myoma in reproductive age

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Chapter 14. BREAST DISEASES

Evaluation of the female breast is an important part of the complete

gynecologic examination. The gynecologist performs more periodic medical

checkups of women today than does any other category of physicians. Because

they see such a large number of women for regular examinations,

gynecologists need to have a thorough knowledge of the natural history,

symptoms, and characteristic, physical findings of the various benign and

malignant breast disorders; they must also be skilled in the proper techniques

of breast examination and be able to teach self-examination to their patients.

It is essential, too, that they must be aware of the high risk category of women

especially deserving of regular surveillance. The gynecologist must be

completely familiar with the screening and diagnostic modalities available,

the proper indications for their use, and their limitations.

Although the screening and diagnosis of breast carcinoma is the

responsibility of the primary gynecologist, the patient with breast cancer

should be specifically managed by a coordinated multimodality team of

oncologists with a special interest in breast cancer. Therefore the

management of breast carcinoma is not included in this chapter, and the

interested reader is referred to a number of current texts and references for

more specifics on this subject.

Embriology.Breast development of the fetus begins at approximately 35

days of embryonic life. Embryologically, the epithelial ridge differentiates to

form lactiferous ducts and alveoli. The functional components of the breast

are complete at birth but usually lie dormant until puberty. Lactation is

occasionally noted in the neonate and is due to the influence of high levels of

maternal estrogen. As the systemic estrogen levels fall, lactation abates.

Breast development and maturation comprise one of the landmarks of

puberty. The process of breast development takes place over a three- to four-

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year period, ultimately resulting in an adult breast in both form and function.

The process of breast development is under the influence of estrogen,

progesterone, and prolactin, ultimately resulting in the ability to lactate.

Anatomy. The functional unit of the adult breast is composed of

modified and specialized sebaceous glands. The breast parenchyma is located

underneath the superficial fascial layer of the chest wall and is composed of 15

to 20 lobes, arranged in a radial fashion, which drain to the nipple via a single

excretory duct (Fig. 218). Each lobe of the breast is composed of 30 to 40

lobules, which are the primary functional units. Each lobule is made up of 10

to 100 alveoli, which are lined by secretory cells. These are the secretory cells

that form milk under the influence of appropriate levels of prolactin. Milk is

transported from the alveoli by way of 2-mm collecting ducts to lactiferous

sinuses, which are approximately 5 to 8 mm in diameter. The lactiferous

sinuses ultimately drain through the excretory duct and into the nipple. The

ducts draining the lobules are supported by stroma composed of fibrous

tissue, fat, blood vessels, lymphatics, and nerves. Whereas the lobules occupy

the central portion of the breast, glandular tissue may extend toward the

axilla from the upper outer quadrant (tail of Spence). The periphery of the

breast is made up primarily of fat.

Fig. 218. Female breast anatomy

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The breasts, which weigh 200 to 300 gm during the menstruating

years, are surrounded by fascial tissue and are supported by Cooper's

ligaments. These fibrous septa extend from the skin to the underlying

pectoralis fascia. With stretching caused by enlargement of the breast during

pregnancy and lactation, and with age, Cooper's ligaments become stretched,

resulting in diminished breast support.

Lymphatic drainage of the breast is especially important with regard to

the spread of breast carcinoma.

Examination and Evaluation of the Breast (see chapter 2). Routine

examination of the breast has its primary goal, the early detection and

improved survival of patients with breast carcinoma. Evaluation of the breast,

however, also allows recognition of more frequent, benign conditions and

often affords therapy to patients who presumed that they must suffer with

breast disease. Examination of the breast should therefore be part of the

routine physical examination, and breast self-examination should be taught

to every patient.

Breast examination should be carried out to maximize detection of

breast masses and associated changes in the breast, e. g., skin or nipple

retraction, subcutaneous edema, and nipple discharge. Examination in

several positions optimizes detection of abnormalities. The breast

examination is usually initiated in the sitting position; the breasts are

exposed, and the physician (or patient, viewing through a mirror) observes for

asymmetry of the breast. Special attention should be paid to possible skin or

nipple retraction or other skin changes, e. g., discoloration or edema. The

patient then raises her arms over her head, and the breasts are examined with

particular attention to the lower half of the breast. Elevating the arms pulls

upward on Cooper's ligaments and thereby accentuates skin retraction,

especially the lower half of the breast. The patient should then place her

hands on her hips and contract the pectoralis major muscle, again attempting

to accentuate skin retraction.

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With the patient remaining in the sitting position the breast is palpated.

Examination using the whole hand as a unit and the pulps of the fingers

rather than the fingertips affords optimal capability to detect breast lesions.

The breast is palpated in an organized systematic way, with additional

attention to the supraclavicular areas, the neck, and the axillae. Any masses or

nodules palpated are noted, and attention is paid to the mobility or fixation,

size, and consistency of the mass(es). The patient is then asked to bend

forward and, with the breast dependent, is reinspected for other skin

retraction, e. g., subareolar retraction. Skin changes, especially edema of the

skin (peau d'orange), suggest an underlying cancer, although fat necrosis or

edema from obstructed lymph nodes may also cause these changes. Red,

warm skin (erythema) suggests inflammation, mastitis, or abscess, although

inflammatory carcinoma may also present erythema and pain. The nipple is

inspected with particular attention to retraction, ulceration, and discharge

(see later in this chapter for the evaluation of nipple discharge).

The patient then assumes the supine position with her arms raised over

the head. Palpation is repeated with attempts to spread out the breast tissue

so as little as possible is palpated at any one time. Again, the breast is

palpated systematically so that no areas go unexamined, with the palpation

proceeding along the tail of Spence to the axilla. Assessment on palpation

includes an evaluation of the background consistency of the breast. On

occasion, a premenstrual patient has engorged glandular tissue that is so

dense and nodular it is impossible to assess. This patient should be re-

examined several days after the menstrual period. On the other hand,

postmenopausal women should have no cyclic change in the breast (unless

they are receiving cyclic estrogen and progesterone). Examination of the

breast in the supine position includes also a search for masses or thickening.

Characteristics suggestive of benign or malignant disease are listed in table

15.

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As the breast changes throughout a woman's lifetime, the examination

also changes. As previously noted, the menstrual woman displays increased

fullness of the breast along with engorgement of glandular epithelium, which

makes the breast more nodular and examination of the breast more difficult.

Women between 20 and 40 also tend to have an increased glandular/fat ratio

and an increased incidence of fibrocystic disease. These differences through

the menstrual cycle and throughout a patient's life should be taken into

account when the breast is evaluated.

The physician's annual breast examination is an opportune time to

teach the patient breast self-examination. Self-examination is to be

encouraged, and it is suggested that it must be performed on a monthly basis

following the menstrual period. Examination in the shower when the breast is

covered with soap increases tactile sensation by decreasing skin friction. The

patient should also be informed that repeated examinations allow her to

become familiar with her breasts, and she may therefore notice changes

sooner than her examining physician. Patient teaching information, written

material, videotapes, and models for practice examinations are widely

available.

Table 15

Findings on Breast Examination Suggesting Benign or Malignant

Conditions

Condition

Mass Nipple discharge Skin changes

Benign Soft Smooth Regular borders Not fixed

Clear or milky Bilateral

None

Malignant

Hard Irregular Fixed to skin or chest wall fascia

Bloody Unilateral

Skin or nipple retraction Peau d'orange changes of skin

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Recognition and management of common breast disorders

Although carcinoma of the breast is the most significant breast disease

from the standpoint of the patient's overall present and future health and

well-being, patients come to the physician far more frequently because of a

variety of other benign breast disorders. Many of these disorders require

some form of evaluation and therapy for relief of symptoms; and in almost all

cases the possibility of malignancy must be excluded. This section

concentrates on the evaluation and management of such benign breast

conditions.

The therapy of breast carcinoma is constantly undergoing evolution,

and the student is referred to other current oncology textbooks for more

detailed discussions as to the appropriate surgical, medical, and

radiotherapeutic management of breast carcinoma. Because the gynecologist

most frequently sees patients with benign conditions and usually does not

manage patients once breast cancer is diagnosed, the benign conditions are

discussed in more detail in this section.

Fibrocystic changes

Fibrocystic changes of the breast are the most common benign breast

conditions encountered in the pre-menopausal woman. The older terms

fibrocystic breast disease, chronic cystic mastitis, and mammary dysplasia

have been replaced by the term fibrocystic changes. (Fig. 219) This condition

is not a true disease or pathologic condition; it is an exaggerated response of

breast tissue to fluctuating hormone levels. Therefore these changes are found

most frequently in women 20 to 50 years of age or, if estrogens are

prescribed, during menopause. The exact incidence is difficult to establish in

life, but pathologic findings suggest that at least 50 percent of autopsy breast

specimens contain fibrocystic changes. Some studies have suggested that one

514

in three premenopausal women have clinical evidence of fibrocystic changes,

and approximately 50 percent of these women have significant symptoms.

Fig. 219. Mammography: fibrocystic changes of the breast.

The etiology of fibrocystic changes is not clear. Proliferation and

hyperplasia of the lobular, ductal, and acinar epithelium is noted along with

proliferation of fibrous tissue in the breast. Because these tissues are under

the influence of estrogen and progesterone, it is hypothesized that this

condition is an exaggerated response of these tissues.

Symptoms of fibrocystic disease are usually worst during the

premenstrual days of the menstrual cycle. The patient usually experiences

cyclic bilateral breast pain with engorgement, increased density, increased

nodularity and tenderness, and occasionally a nipple discharge. Some

patients note a dominant cyst that may increase during the premenstrual

period.

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Examination of the patient usually reveals a lumpy nodularity more

prominent in the upper outer quadrants of the breasts. The breasts may feel

rubbery with solid areas, microcysts, or macrocysts. The diagnosis is usually

based on these clinical signs and symptoms, although it may also be

established by biopsy findings. Biopsy may show adenosis and fibrosis, ductal

ectasia, apocrine metaplasia, papillomatosis, and intraductal epithelial

hyperplasia. These conditions are in general not associated with an increased

risk of breast cancer. On the other hand, findings of ductal hyperplasia with

atypia or apocrine metaplasia with atypia are associated with an

approximately fivefold risk of developing subsequent breast cancer. Another

type of diagnosis is mammography Treatment of fibrocystic breast disease

depends on the severity of symptoms. Initial therapy should include good

breast support with a firmly fitted brassiere worn both day and night. If a

dominant mass is noted on palpation or on mammography, biopsy should be

performed.

Premenstrual use of diuretics and salt restriction may be of some help in

reducing edema and breast fullness and tenderness. The complete elimination

of methylxanthines from the diet has been reported to reduce breast

symptoms in some patients, although the results of this therapy are debated

by others. If tried, caffeine (including colas, coffee, tea, and chocolates) must

be eliminated from the diet. The use of oral contraceptives and progesterone

helps some patients minimize their breast symptoms.

In patients with severe fibrocystic breast symptoms, danazol may be

tried. For the symptomatic management of fibrocystic breast disease, the

usual dosage of danazol is 100-400 mg daily given in 2 divided doses for four

to six months. Dosage should be individualized according to severity of the

disease and the patient's response to treatment. Since ovulation may not be

suppressed when danazol is administered at this dosage, an effective

nonhormonal method of contraception is recommended during therapy with

the drug. Regular menstrual patterns, irregular menstrual patterns, and

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amenorrhea each occur in approximately one-third of patients receiving

danazol at a dosage of 100 mg daily. Irregular menstrual patterns and

amenorrhea occur more frequently when higher dosages are used.

Approximately 90 percent of patients experience a decrease in

symptomatology and decreased palpable nodularity with this regimen In most

patients, breast pain and tenderness are substantially relieved during the first

month of therapy, and eliminated in 2-3 months, but elimination of

nodularity usually requires 4-6 months of uninterrupted therapy. If

symptoms recur following discontinuance of therapy, treatment with danazol

may be reinstituted.

Unfortunately, danazol is costly, and this factor must be balanced

against the benefits the patient may experience. Alternative methods of

therapy for patients who have failed the above treatments include the use of

bromocriptine 5 mg per day or the antiestrogen tamoxifen.

Finally, in patients with severe symptoms who are unresponsive to

medical management, subcutaneous mastectomy with breast implant may be

advised. Usually, these patients are experiencing severe pain and have

undergone multiple biopsies of breast lesions. This therapy is also appropriate

in patients who have been found on biopsy to have evidence of the pre-

malignant conditions cited above.

Benign breast tumors

Fibroadenomas. Fibroadenomas are by far the most common breast

tumor and, although they may occur at any age, are most frequently seen in

women in their late teens and early twenties. They are rarely painful or

symptomatic in any way; the patient simply discovers a lump. Fibroadenomas

do not change during the menstrual cycle and are usually easily distinguished

from fibrocystic changes. Usually the mass (with an average size of 2. 5 cm) is

a firm, non-tender, rubbery-feeling, smoothly rounded, mobile, slippery

nodule most often found in the periareolar area. Its characteristic "feel" on

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physical examination is almost diagnostic. It is most often solitary, although

occasionally (15 to 20 percent of patients) multiple lesions are present in one

or both breasts. It is sometimes difficult to distinguish fibroadenomas from

cysts. In these situations, needle aspiration is a reasonable first step of

evaluation. If the mass cannot be aspirated, surgical removal is indicated.

Because fibroadenomas persist and sometimes continue to enlarge, local

excision of these well encapsulated tumors is the treatment of choice. Most

often these procedures can be performed under local anesthesia.

Cystosarcoma phylloides. Cystosarcoma phylloides has been firmly

established as a giant, rapidly growing fibroadenoma, and approximately 25

percent of the lesions are malignant. They comprise the most common

sarcoma of the breast. The correct diagnosis is usually suggested by a rapidly

growing large, hard, lobulated mass in the breast, usually during the fifth

decade, without evidence of adjacent soft tissue or axillary involvement. Wide

local resection and sometimes mastectomy may be required because of the

large size of the benign cystosarcoma phylloides. When a microscopically

verified, truly malignant cystosarcoma phylloides is encountered, radical

mastectomy is the indicated treatment because it may be accompanied by

axillary lymph node metastases.

Intraductal papilloma. Intraductal papilloma is the second most

common benign breast tumor and the most frequent cause of bloody

discharge from the nipple. A papilloma most often arises in the lactiferous

sinus of the milk system, which is usually situated approximately at the

areolar margin. Intraductal papillomas are most often found in

perimenopausal women. The symptomatic intraductal papilloma may or may

not be large enough to be palpable, but the lobular duct system containing it

can usually be localized by the systematic periareolar point-by-point pressure

maneuver. A mammogram can also be helpful when localization is difficult.

Proper treatment is removal of the breast segment from which the

discharge has been demonstrated to arise or which contains the palpable

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mass. Removal is important both to exclude the possibility that a much less

common intraductal papillary adenocarcinoma is responsible for the bloody

discharge and to put an end to the symptoms, which are a nuisance to the

patient.

Miscellaneous preast tumors. A variety of less common benign breast

tumors include lipomas, fibromas, sweat gland adenomas, hamartomas, and

hemangiomas. All of these lesions require local excision for definitive

diagnosis and treatment. Granular cell myoblastoma of the breast, a rare

benign tumor, is significant primarily because it sometimes presents all the

clinical signs of early breast cancer; even on cut section of the breast

specimen, it may grossly resemble a scirrhous carcinoma. As is true for solid

breast masses, biopsy and microscopic examination are essential to establish

a correct diagnosis and are usually the only way a granular cell myoblastoma

can be recognized as a benign lesion.

Postpartum mastitis is usually recognized as a localized, exquisitely

tender, edematous, erythematous region, usually of one breast. Treatment

goals are aimed at emptying the obstructed segment, which may be

accomplished by nursing, manual breast expression, or breast pumping. Ice

packs may reduce swelling, thereby allowing the duct better drainage.

Antibiotic therapy should also be employed, using a broad-spectrum

antibiotic aimed at the treatment of skin bacteria. Ampicillin and

erythromycin are the drugs most frequently selected for initial therapy.

Nonneoplastic lesions of the breast

The breast, by virtue of the fact that it is covered with skin, may develop

any of the skin changes or diseases noted elsewhere on the body. Because

these diseases are numerous, they are not discussed in this chapter, and the

student is referred to comprehensive dermatology textbooks for descriptions

and treatments of these diseases.

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Sometimes mimic carcinoma may be caused by local breast trauma or

inflammation. They must be distinguished from malignancy, thus they are

discussed in more detail. Trauma to the breast may cause local tissue

swelling, subcutaneous bleeding, erythema, and pain. The collection of blood

in the subcutaneous tissues (hematoma) may cause additional localized

swelling, which ultimately becomes more apparent as an evolving ecchymotic

area. Treatment can usually be expectant, with spontaneous and

uncomplicated resorption usually occurring. Local application of heat and

mild analgesics may be necessary. On rare occasions, evacuation of a large

hematoma by aspiration or incision and drainage may be required.

Trauma may also cause fat necrosis, although the traumatic incident

may not be noted or remembered by the patient. The evolution of tissue

trauma with fat necrosis may ultimately lead to physical findings that closely

simulate breast cancer. As the traumatized area heals and repairs, fibrosis of

the subcutaneous tissue occurs, leading to fixation to the skin and ultimately

skin retraction. Because breast trauma is usually superficial, fibrosis and

fixation to the chest wall rarely occur. This subcutaneous scar may evolve into

dense fibrosis and a palpable mass or into a cystic cavity with calcification of

the walls. Even mammographic findings may be indistinguishable from those

of malignancy, and therefore excisional biopsy is invariably necessary to

establish the correct diagnosis.

Phlebitis of the thoracoepigastric vein (Mondor's disease) may also be

caused by local trauma or occur after cosmetic or diagnostic breast surgery.

The phlebitis of the superficial vein is progressive and painful, ultimately

resulting in a tender, fibrous cord underneath the skin. Skin retraction and

dimpling often occur, and the inexperienced clinician may mistake the

condition for some of the changes associated with breast cancer. However,

because of its superficial and linear nature, Mondor's disease must be

included in the differential diagnosis. Most often, the phlebitis resolves with

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symptomatic therapy of heat and anti-inflammatory agents such as aspirin or

ibuprofen. Surgical intervention or anticoagulation is not necessary.

Infections in the nonpuerperal state are infrequent; and when they do

occur, the diagnosis of an inflammatory carcinoma must be considered.

Chronic subareolar abscess may occur in women in their thirties and forties.

These recurrent abscesses often drain spontaneously and ultimately may

cause areolar fistula. Obstruction of the ducts, leading to inflammation and

secondary infection, may be initially treated with heat, analgesics, and broad-

spectrum antibiotics. However, for chronic recurrent abscesses, surgical

removal of the duct and fistula tract is advised. It should be kept in mind that

inflammatory carcinoma of the breast may suggest the possibility of cellulitis

and breast abscess, and vice versa. That is, a breast abscess with surrounding

cellulitis may simulate inflammatory carcinoma, even to the cutaneous

thickening and the characteristic peau d'orange of the breast skin infiltrated

by an underlying carcinoma. Rarely, an ordinary noninflammatory type of

breast carcinoma becomes infected with or without prior ulceration of the

tumor and presents a confusing picture until biopsy clarifies the situation.

The most common causes of breast inflammation, cellulitis, and abscess

are associated with postpartum events. During the first one to three days after

delivery, breast engorgement is noted in most women, typified by swelling,

edema, and breast discomfort. A low- grade fever may be associated with this

diffuse process in both breasts. With adequate, firm breast support and ice

packs, the engorgement usually resolves within a few days. If the woman

wishes to breast-feed, it should be encouraged to reduce engorgement.

Obstruction of a duct during the postpartum period predisposes to infection

best cosmetic outcome. If a chronic infection in an old abscess cavity persists,

excision of that portion of breast may be required.

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Breast cancer

Breast cancer is the most common invasive cancer in women, and the

second main cause of cancer death in women, after lung cancer.

Risk factors:

Personal history of breast cancer

o Women who had breast cancer in the past have a higher risk of

developing breast cancer again. The new breast cancer can

develop in the same breast as the first cancer or in the other

breast. Women who had ductal carcinoma in situ (DCIS) or

lobular carcinoma in situ (LCIS) have a higher risk of developing a

second breast cancer, but most women who had these cancers do

not develop breast cancer again.

Family history of breast and other cancers

o A family history of breast cancer means that one or more close

blood relatives have or had breast cancer. Some families have

more cases of breast cancer than would be expected by chance.

BRCA (breast cancer) gene mutations

o Some gene changes can increase the risk of developing certain

types of cancer. Inherited gene mutations are passed on from a

parent to a child. Only a small number of breast cancers (about

5%–10%) are caused by an inherited gene mutation. BRCA1

(breast cancer gene 1) and BRCA2 (breast cancer gene 2) are

normally found in the body. They are called tumor suppressor

genes because they appear to play a role in controlling the growth

of cancer cells. Mutations in the BRCA1 or BRCA2 genes can affect

them so they no longer control cancer growth. These mutations

are rare (1 in 500 people).

Certain genetic conditions

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o Li-Fraumeni syndrome increases the risk of developing certain

types of cancer, including breast cancer, osteosarcoma, soft tissue

sarcoma and leukemia.

o Ataxia telangiectasia (AT) is caused by a mutation of the ATM

gene. This gene is responsible for repairing damaged DNA.

Certain families with a high rate of breast cancer have mutations

of this gene.

o Cowden syndrome is caused by a mutation in the PTEN gene,

which is normally a tumour suppressor gene. People with this

condition are more likely to develop breast cancer,

gastrointestinal cancers and thyroid cancer.

o Peutz-Jeghers syndrome may be related to a mutation of the

STK11 (also known as LKB1) gene. This gene appears to normally

function as a tumour suppressor gene. Peutz-Jeghers syndrome

increases the risk of developing gastrointestinal, breast, ovarian

and testicular cancers.

Other gene mutations

Ashkenazi Jewish ancestry

o BRCA1 and BRCA2 gene mutations are more common in

Ashkenazi women.

Dense breasts

Dense breasts have more connective tissue, glands and milk ducts than

fatty tissue. Breast density is an inherited trait.

Reproductive history

o Estrogen is the main hormone associated with breast cancer.

Estrogen affects the growth of breast cells. It plays an important

role in the growth of breast cancer cells as well. Early menarche,

late menopause are long estrogen’ influence; late pregnancy or no

pregnancy also lowers the total number of menstrual cycles a

woman has in her lifetime, and lead to longer estrogen exposure.

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Exposure to ionizing radiation

Hormone replacement therapy

o Taking hormone replacement therapy (HRT) for a long time

increases the risk of breast cancer. This is especially true for HRT

that uses estrogen plus progestin (COCP).

Atypical hyperplasia

Alcohol

Being obese

Physical inactivity

High socio-economic status

Symptoms of breast cancer. Breast cancer can have a number of symptoms,

but the first noticeable symptom is usually a lump or area of thickened breast

tissue.

Other symptoms are:

a change in the size or shape of one or both breasts

discharge from nipples (which may be streaked with blood)

a lump or swelling in armpits

dimpling on the skin of breasts

a rash on or around nipple

a change in the appearance of nipple, such as becoming sunken into the

breast.

Classification. Types of cancer are usually classified based on the location and

aggressiveness of the disease.

The most common type is ductal carcinoma, which means the original

site of the disease is within the ducts (tubes) that transport milk to the nipple.

The cancer can be classified as in situ (DCIS) which means it is not invasive

and is contained inside the duct, or as an invasive breast cancer if it has

spread outside the duct.

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Additional breast cancer types include: triple negative breast

cancer, inflammatory breast cancer, metastatic breast cancer, and other rare

forms of breast cancer.

The stages of breast cancer refer in numbers to the extent and evolution

of the breast cancer, but terms like “locally advanced” or “regionally

advanced” may also be used.

In stage 1, patients usually have invasive breast cancer, while 1A refers

to a tumor smaller than two centimeters that has spread to the lymph nodes

but not outside the breasts, and 1B to isolated cancerous patches rather than a

mass that measures 0.2 to two millimeters. Non invasive cancer, though

cancer, is concidered stage 0 (zero).

Stage 2 is when the tumor has spread to the auxiliary lymph nodes,

which can be two to five centimeters and remain localized (2A) or measure

two to five centimeters and 0.2 to two millimeters of metastasis.

Stage 3 describes a more aggressive form of invasive breast cancer and

is divided into three sub phases. Stage 4 indicates that the cancer has spread

to other organs of the body such as the lungs, the liver, distant lymph nodes,

skin, or bones.

Breast cancer screening and diagnosis. Mammographic screening is

the best available method of detecting an early breast lesion. Women with a

higher-than-average risk of developing breast cancer may be offered

screening and genetic testing for the condition.

As the risk of breast cancer increases with age, all women who are 50-70

years old are invited for breast cancer screening every three years.Women

over 70 are also entitled to screening and can arrange an appointment

through their GP or local screening unit.

The diagnosis of brteast cancer is based on anamnestic data, clinical

findings, imaging studies, biopsy with histological investigation. Breast cancer

is treated using a combination of surgery, chemotherapy and radiotherapy.

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Surgery is usually the first type of treatment, followed by chemotherapy or

radiotherapy or, in some cases, hormone or biological treatments.

The type of surgery and the treatment are depend on the type of breast

cancer. In a small proportion of women, breast cancer is discovered after it's

spread to other parts of the body (metastasis). Secondary cancer, also called

advanced or metastatic cancer, isn't curable, so the aim of treatment is to

achieve remission (symptom relief).

Self test

1. The most important aspect of examination of the breast is

A. the use of the tips of fingers in performing the examination

B. examination in the sitting position

C. the use of a circular motion to cover all quadrants of the breast

D. the amount of time spent in performing the examination

2. A dominant mass is discovered in a 30-year-old woman. Which of the

following reflects current practice in the management of breast disease?

A. a mammogram should be performed immediately

B. aspiration should be attempted as an office procedure

C. an ultrasound should be ordered

D. the patient should be looked for an open biopsy

3. Successful management of bilateral mastalgia is associated with

A. the use of Danocrine for a 6-month trial

B. abstinence from caffeine

C. the amount of time spent with the patient

D. the use of vitamin E

4. Estrogen replacement therapy

A. is essential for all postmenopausal women to prevent osteoporosis

B. is currently used by the majority of postmenopausal women

C. is widely prescribed as a result of recent controlled randomized trials

D. has not been associated with an increased incidence of breast cancer

5. Symptoms of fibrocystic disease of the breast

A. are usually the worst during the premenstrual days of the menstrual cycle

B. disappear during the premenstrual days of the menstrual cycle

C. have no changes during the menstrual cycles

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D. are usually the worst during the follicular phase of the menstrual cycle

6. The most freguent type of a benign tumor of the breast is

A. lipoma

B. fibroadenoma

C. adenoma

D. sarcoma

7. Fat necrosis of the breast may happen due to

A. traumatic lesions

B. inflammations

C. hormonal disbalance

D. congenital abnormalities

8. Chronic recurrent subareolar abscesses should be treated with

A. surgical removal of the duct and fistula tract

B. antibiotic therapy

C. physiotherapy

D. complex conservative treatment

9. Bloody discharge from the nipple is the common symptom of

A. intraductal papilloma

B. Mondor's disease

C. chronic subareolar abscess

D. postpartum mastitis

10. One of the most common types of breast lesion is

A. fibroadenoma of the breast

B. intraductal papilloma

C. cystosarcoma phylloides

D. fibrocystoma

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Chapter 15. PREMALIGNANT DISEASES OF THE

VULVA AND VAGINA. CANCER AND SARCOMA OF

THE VULVA AND VAGINA

There are a lot of atrophic and hypertrophic conditions caused by a

number of stimuli. The lesions are characterized by shrinking, whitening or

reddening exclusive to the skin of the vulva. These include background

processes and true precancerous lesions. Background processes present

abnormal conditions of the skin, which may lead to the development of

precancerous conditions or cancer of the external genital organs. These

lesions do not have a uniform microscopic appearance.

Precancerous (premalignant) conditions of vulva are diseases which can

exceed into carcinomas and are called preblastomatoses.

Background diseases of the external genitalia and vulva

Background diseases include chronic dystrophic processes without

cellular displasia and cellular atypia, characterized with proliferation,

atrophic changes, without invasion. Background vulvar disease present any

chronic, dystrophic recurrent skin damages.

Background lesions of the vulva, or Nonneoplastic epithelial disorders of

vulva and mucosa, according to classification system for "Epithelial Vulvar

Disease", include:

o Lichen sclerosus

o Squamous hyperplasia

o Other dermatoses

o Mixed neoplastic and nonneoplastic disorders

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Lichen sclerosis

The cause of this condition is not known. This condition occurs

frequently in postmenopausal women. This is a systemic atrophic dystrophy,

which occurs on the vulva and perineum. The affected areas appear whitish

and glistening with clear margins. The affected skin has a “cigarette-paper”

appearance. During the acute phase these areas may be red and purple. The

affected area on the vulva extends to the anus in a shape of Figure 8 causing

involutional adhesion of labia minora to the labia majora, thus burying the

clitoris and causing shrinkage of the introitus. (Fig.220). The leading

symptom is intense itching. If secondary infection occurs, ulceration and

contractures may follow resulting in dyspareunia and dysuria. Histologically

there is a thin inactive epithelium and loss of elastic tissue.

Fig. 220. Lichen sclerosis of the vulva.

Prognosis: areas of dysplasia or malignancy may develop in this lesion.

Other outcomes:

o Symptom improvement

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o Disease remission

o Disease recurrence

o Disease complications

o Non-compliance with treatment

o Incidence of squamous cell carcinoma

Diagnosis is based on:

o Physical examination

o Biopsy

o Immunology (autoantibody screen, if indicated)

o Microbiology (swabs, not routinely recommended)

o Assessment of complications of lichen sclerosus, including malignancy,

scarring, sensory abnormalities (dysaesthesia), and psychosexual

problems

Histological examination (biopsy) is advisable to exclude atypical

changes. Patients under routine follow-up will need a biopsy if:

o there is a suspicion of neoplastic change, i.e. a persistent area of

hyperkeratosis, erosion or erythema, or new warty or papular

lesions;

o the disease fails to respond to adequate treatment;

o there is extragenital lichen sclerosus (LS), with features suggesting

an overlap with morphoea;

o there are pigmented areas, in order to exclude an abnormal

melanocytic proliferation;

o second-line therapy is to be used.

An autoantibody screen to look for associated autoimmune disease is

useful if there are clinical features to suggest an autoimmune disorder. In

particular, thyroid disease is common in women with LS.

Swabs are indicated in erosive disease to exclude herpes simplex

or Candida as additional complicating problems. Retesting for these

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infections may be necessary in disease that flares or fails to respond to

treatment.

Complications:

Squamous cell carcinoma (SCC) - surgery has to be individualized

according to the tumour size and location, particularly in early invasive

disease.

Scarring

o Introital narrowing - this is rare, but, if significant and causing

dyspareunia or difficulty with micturition, surgery may need to be

considered.

o Pseudocyst of the clitoris- occasionally, clitoral hood adhesions

seal over the clitoris and keratinous debris builds up underneath

forming a painful pseudocyst. This requires a subtotal or total

circumcision).

o Stenosis of the urethral os - if this results in an impaired urinary

stream, referral for urological assessment is advisable.

Sensory abnormalities: dysaesthesia

o Vestibulodynia and Vulvodynia - These conditions may occur

after an inflammatory condition of the vulva or vestibule.

Typically, the patient remains symptomatic despite objective

clinical improvement or resolution of the skin lesions.

Neuropathic pain does not respond to topical corticosteroids, and

treatment must be directed to the eradication of the neuronal

sensitization. Initially, 5% lidocaine ointment is recommended,

with the addition of pain-modulating oral medication, such as a

tricyclic antidepressant or gabapentin, in unresponsive cases.

Psychosexual problems

o Women who have any chronic genital disorder will often lose their

interest in sexual activity, leading to problems with sexual

dysfunction.

531

Treatment. Better personal hygiene and using cotton underwear would

reduce the vulval moisture.

The recommended and accepted first-line treatment is the very potent

topical corticosteroid clobetasol propionate 0.05%. The regimen

recommended for a newly diagnosed case is clobetasol propionate 0.05%

ointment applied once daily, at night, for 4 weeks, then on alternate nights for

4 weeks, and then twice weekly for a further 4 weeks, before review. The

rationale for once-a-day application is based on pharmacodynamic studies

showing that an ultrapotent steroid only needs to be applied once a day on

extragenital skin. If symptoms recur when the frequency of application is

reduced, the patient is instructed to use the treatment more often until the

symptoms resolve. They can then try to reduce the frequency again.

Oral antihistamines and topical antipruritic agents may help to relieve

itching. A local application of estrogen cream is recommended. Estrogen may

have little effect or no direct effect on the epidermis but improves the

vascularity of the underlying dermis. Topical corticosteroid such as 1%

hydrocortisone aqueous cream has a beneficial effect on hypertrophic lesions.

In atrophic lesions, treatment with androgenic steroids is found to be more

useful, for example, 2% testosterone propionate ointment twice daily for 3 to

4 weeks. Oral retinoids or vitamin A analogues have also been used for this

condition. Topical calcineurin inhibitors, Ciclosporin, Methotrexate and other

immunosuppressive agents, may be administered.

Surgical therapy for the Lichen sclerosis of the vulva has also been

reported. Cryosurgery, photodynamic therapy, phototherapy, laser ablation,

or simple vulvectomy, though rarely, is the surgical methods followed.

Follow-up. Long-term follow-up in a secondary care specialist clinic is

appropriate for patients with genital LS associated with troublesome

symptoms, localized skin thickening, previous cancer or vulval intraepithelial

neoplasia (VIN), or pathological uncertainty about VIN. Biopsies of persistent

ulcers, erosions, hyperkeratosis and fixed erythematous areas are advised to

532

exclude intraepithelial neoplasia or invasive SCC. These patients usually have

LS with a histological pattern that has features of both LS and lichen planus

with squamous cell hyperplasia. Clinically these patients seem to have an

overlap syndrome and their disease runs a relentless course despite trials of

various therapies, and a small percentage do go on to develop one or more

SCCs.

Lichen simplex chronicus

Lichen simplex chronicus (previously known as neurodermatitis) occurs

in normal skin which becomes dry, thick, scaly, white but sometimes

pigmented, and fissured in response to the trauma of constant scratching.

Lichenification is a similar change which is superimposed on another

pathology, e.g. eczema or a contact dermatitis. These lesions are usually not

symmetrical within the vulva and usually occur in areas where they are

accessible to scratching.

Treatment consists of the use of emollients or low to moderate potency

topical corticosteroids. Sometimes sedation at night is useful to stop

nocturnal scratching.

Lichen planus

The lesions of lichen planus may be seen within mucous membrane or

on cutaneous surfaces, e.g. the inner surfaces of the wrists and lower legs.

These cutaneous lesions are usually red or purple flat topped nodules or

papules with an overlying white lacy patterned appearance (Wickham’s

striae). Involvement of the vulva is usually with areas of pruritus with white

patterned areas which are sometimes elevated and thickened (hypertrophic

lichen planus) or may appear red and raw with features of erosion; changes

within the mouth upon buccal mucosa or involving the gingival margin may

frequently be seen. The areas of change on the vulva may extend into the

vagina and subsequent desquamation will leave scarring, stenosis and

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adhesions. Histology will show liquefactive degeneration of the basal

epidermal layer, long and pointed rete ridges, with parakeratosis and

acanthosis, and a dense dermal infiltrate of lymphocytes close to the dermal

epidermal margin. When the condition is severe treatment can be difficult,

requiring systemic steroids, azathioprine, or other immune modifying agents;

these may include cyclophosphamide, cyclosporin although the results are not

always consistent. Lesser symptoms particularly those externally on the vulva

can be managed with the application of topical corticosteroid.

Squamous hyperplasia

Squamous hyperplasia represents inadequate proliferative reaction of

vulvar epithelium on influence of plenty of irritating factors. It can develop in

any age, but more frequent than all registers in pre - and postmenopausal

periods. Microscopic signs include an acanthosis and hyperkeratinization.

Papillomatous structures usually absent, that distinguishes squamous cell

hyperplasia from acuminate condilomas.

Principles of diagnosis and management are similar to the Lichen

sclerosis.

Vulval ulceration

Vulval ulceration may be infective (syphilis chancroid, genital herpes,

HPV – vulval warts, lymphogranuloma venerum), aphthous or associated

with Behqet’s syndrome, Stevens-Johnson syndrome, dermatitis artefacta,

benign mucous membrane pemphigoid, pyoderma gangrenosum, Crohn’s

disease, and toxic epidermal necrolysis. (Fig. 221) These conditions are

uncommon. Sometimes the diagnosis can be made clinically but occasionally

biopsy will be necessary and may require immunofluorescent techniques, e.g.

benign mucous membrane pemphigoid is associated with immunoglobulin G

(IgG) deposition within the area of the basement membrane. The

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management include treatment of underlying condition with local application

of antipruritic, moisturizing agents.

Fig. 221. Genital Ulcers: ulcers caused by genital herpes

Other dermatoses

This group of nonneoplastic epithelial disorders of vulva and mucosa

include contact dermatitis, eczema, psoriasis, which are not precancerous

conditions, but may have features of chronic, recurrent diseases with signs of

dystrophic or atrophic changes, proliferation without invasion and cellular

atypia.

The main features of recommended management is local application of

moisturizing cream or mild to moderate topical corticosteroids. Sedation at

night is useful to stop nocturnal scratching.

True precancerous lesions of vulva

The term” precancer” was chosen intentionally as it has a broad,

generic connotation that changes are present in the tissue which indicate that

a lesion, if not removed, will, with a high degree of likelihood, progress to

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invasive carcinoma. The majority of true precancerous lesions of the vulva are

of epidermal origin. Less commonly they will arise from epidermal

appendages (e.g. hidradenoma, sebaceous adenoma), the mesoderm

(fibroma, lipoma, neurofibroma, leiomyoma, lymphangioma, haemangioma)

or from the greater or lesser vestibular glands (adenofibroma, adenoma. The

description of squamous vulvar precancerous lesions is based on the concept

of vulvar intraepithelial neoplasia (VIN) and incorporates a three grade

evaluation of the intensity of dysplastic changes (low-, intermediate- and

severe grade). There is little doubt that the intraepithelial neoplasms of the

female lower genital tract should, when they are high grade, be considered to

be precancerous. The prospective follow-up studies of such lesions have

established without a doubt that this categorization is appropriate. The use of

the term "precancer" for the low-grade lesions is problematic, however,

because it is now apparent -particularly for the uterine cervix -that some of

the epithelial changes which include the morphological features of neoplasia

may, in fact, be acute human papilloma virus (HPV) infections of the

epithelium and that the majority of such lesions will not progress to high-

grade intraepithelial neoplasia nor to invasive cancer. In the low-grade lesions

it is difficult, without HPV testing and typing, to predict the biological

behaviour of the epithelial change, but the term "precancer" has still to be

used because of the potential for such lesions to progress to high-grade

intraepithelial disease and, subsequently, to invasive cancer.

Classification of vulvar intraepithelial neoplasia

Squamous vulvar intraepithelial neoplasia (VIN):

o VIN I, mildest form

o VIN II, intermediate

o VIN III, most severe form including carcinoma in situ of the vulva

Non-squamous intraepithelial neoplasia

Extramammary Paget's disease

Tumors of melanocytes, non invasive

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Squamous Vulvar Intraepithelial Neoplasms

Vulvar intraepithelial neoplasia (VIN) is graded as VIN 1 (mild

dysplasia), VIN 2 (moderate dysplasia), or VIN 3 (severe dysplasia or CIS) on

the basis of cellular immaturity, nuclear abnormalities, maturation

disturbance, and mitotic activity.

In VIN 1, immature cells, cellular disorganization, and mitotic activity

occur predominantly in the lower one third of the epithelium. x Dyskeratotic

cells and mitotic figures occur in the superficial layer.

In intermediate grade (VIN 2) 2/3 of the epithelial lining has dysplastic

changes. Other typical features are presence of immature cells, as well as

cellular disorganization, and mitotic activity. Additional cytopathic changes of

HPV infection, such as perinuclear halos with displacement of the nuclei by

the intracytoplasmic viral protein, thickened cell borders, binucleation, and

multinucleation, are common in the superficial layers of VIN, especially in

VIN 1 and VIN 2. These viral changes are not definitive evidence of neoplasia

but are indicative of viral exposure. Most vulvar condylomas are associated

with HPV-6 and -11, whereas HPV-16 is detected in more than 80% of VIN

cases by molecular techniques.

In VIN 3, immature cells with scanty cytoplasm and severe chromatinic

alterations occupy most of the epithelium, it is also known as vulvar

carcinoma in situ. (Fig. 222). VIN 3 can be unifocal or multifocal. Typically,

multifocal VIN 3 presents with small hyperpigmented lesions on the labia

majora. Some cases of VIN 3 are more confluent, extending to the posterior

fourchette and involving the perineal tissues. The term bowenoid papulosis

(bowenoid dysplasia) has been used to describe multifocal VIN lesions

ranging from grade 1 to 3. Clinically, patients with bowenoid papulosis

present with multiple small pigmented papules (40% of cases) that are

usually less than 5 mm in diameter. Most women with these lesions are in

their 20s, and some are pregnant. After childbirth, the lesions may regress

537

spontaneously. However, the term bowenoid papulosis is no longer

recommended by the ISSVD.

Fig. 222. VIN3 – carcinomain situ of the vulva.

Etiology. The cause of squamous neoplasia of the vulva is still unknown.

It was associated with syphilis and other granulomatous lesions, herpes

simplex viral infection, obesity, diabetes mellitus and poor hygiene. Many

authors have commented on the role that recurrent irritation appears to play,

and some have implicated previous pelvic irradiation. There is also an

association with HPV (HPV 16,18 and 31), immunosuppression , etc. VIN is

seen in patients of a wide age range, being reported in teenagers as young as

14 years and in women of 80 years of age (mean 40-45 years).

Clinical features. Most will present with pruritus, burning, and pain,

but up to 20% may be asymptomatic. Examination may reveal multicentric or

confluent areas of different size, colour including white, red and brown,

ulcerated and warty lesions, However, sometimes the lesions will only become

apparent on colposcopic examination with application of acetic acid.

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Any part of the vulva may be involved, most commonly the perineal

skin, the periclitorial area and labia minora; approximately one-third will

have extension to involve the perianal area. requiring the anus to be examined

too.

Diagnosis. The diagnosis is always based on a careful inspection and a

targeted biopsy and histopathology, with disorderly maturation, abnormal

mitoses, basal and parabasal pleomorphism, and koilocytosis in many lesions.

Treatment. Spontaneous regression of lesions can occur in young

women and observation may well be all that is required in young or pregnant

patients unless they are symptomatic. Nevertheless, all patients need in

careful follow up.

Popular treatment modalities include:

topical chemotherapy,

carbon dioxide (CO2) laser ablation,

surgical excision.

For medical therapy, reported to be effective in at least some cases of VIN,

following are recommended:

Imiquimod cream, applied 3 times weekly for 12 to 20 weeks. This

result in red inflamed and eroded tissue often accompanied by

considerable discomfort.

5-fluorouracil (5-FU) cream, applied twice daily for several weeks. This

causes quite severe chemical dermatitis (several weeks) of the vulva

which takes some 5-6 weeks before healing starts and the results are

generally disappointing; thus, will not be tolerated by all women. It is

less effective than imiquimod cream.

Photodynamic therapy (PDT) requires specialised equipment and can

also be very painful.

The mainstay of treatment is to remove all affected tissue with a margin

of apparently unaffected tissue. This may be done by surgical incision.

Sometimes a complete vulvectomy is undertaken because of the extent of

539

disease or because of several independent areas of VIN. The carbon dioxide

laser may be used with treatment success greater than 90%. The depth of skin

and appendage removal in VIN is 1 mm in non-hairy and 2 mm in hairy skin

assigned as appropriative for successful treatment. Rarely, skin appendage

involvement to a depth of 4.6 mm may occur.

Paget’s Disease of the vulva

The vulva is one of the sites for extramammary Paget’s disease. Paget's

disease of the vulva predominantly affects postmenopausal white women, and

the presenting symptoms are usually pruritus and vulvar soreness. The lesion

has an eczematous, erythematous, or scaly appearance macroscopically with a

clearly demarcated and slightly elevated edge. The lesion usually begins on

the hair-bearing portions of the vulva. It may extend to involve the mons

pubis, thighs, and buttocks. Extension to involve the mucosa of the rectum,

vagina, or urinary tract also has been described . The more extensive lesions

are usually raised and velvety in appearance.

The clinical manifestations consist in varying degrees of pruritus,

burning and tingling of the involved vulval areas. The histologic picture shows

little or no alteration of the general pattern of maturation of the epidermis.

Superficial keratinization is present. The epidermis contains distinctive clear

cells (Paget’s cells), which are large, round or oval and have a pale cytoplasm.

The diagnosis is based on histology. Most cases of vulvar Paget's disease are

intraepithelial. Because these lesions demonstrate apocrine differentiation,

the malignant cells are believed to arise from undifferentiated basal cells,

which convert into an appendage type of cell during carcinogenesis. The

“transformed cells” spread intraepithelially throughout the squamous

epithelium and may extend into the appendages. In most patients with an

underlying invasive carcinoma of the apocrine sweat gland, Bartholin gland,

or anorectum, the malignant cells are believed to migrate through the dermal

540

ductal structures and reach the epidermis. In such cases, metastasis to the

regional lymph nodes and other sites can occur.

Management involves identification of any underlying or associated

malignant lesion, and wide excision. Prognosis is influenced by the nature

and stage of the associated neoplasm, if present. Paget’s disease will recur in

about one-third of those without associated neoplasm, due to the multicentric

distribution and difficulty in ensuring complete excision of the lesions.

Background diseases of the vagina

Vaginal background lesions are non-neoplastic processes, represent any

chronic mucosa damages, characterized with dystrophic changes without

cellular dysplasia and cellular atypia, proliferation, atrophic changes, without

invasion. Recurrent dystrophic or proliferative process is a background for

development of dysplasia, and the risk of neoplastic appearance cannot be

excluded.

Clinical picture consist in varying degrees of pruritus, burning,

discharge, dyspareunia.

The diagnosis is based on:

Evaluation of previous history (duration of chronic diseases,

irrespective for treatment, recurrence of process)

Physical examination

Microbiology (swabs, not routinely recommended)

Assessment of complications of chronic vaginitis, including scarring,

sensory abnormalities (dysaesthesia), and psychosexual problems

(dyspareunia).

Aceto-white colposcopy

Targeted biopsy with histological examination

These diseases may be presented with patches of white or red color,

often named leukoplakia or erythroplakia. A cornification of multi-layered flat

541

epithelium, thinning of superficial layers of epithelium with the phenomena

of cornification are typical findings in these cases. Erythroplakia has the

appearance of bright red spots with a brown tint, sharp-edged scopes and

brilliant surface.

Clinical picture consist in varying degrees of pruritus, burning,

discharge, dyspareunia.

Treatment consists of:

Oral antihistamines and topical antipruritic agents

Local application of estrogen cream

Topical corticosteroid

In atrophic lesions: androgenic steroids (2% testosterone propionate

ointment twice daily for 3 to 4 weeks.

Oral retinoids or vitamin A analogues have also been used for this

condition.

Surgical excision or cryolysis of pathological foci is more effective.

True precancerous lesions of the vagina

Precancerous conditions of the vagina are diseases which can exceed

into carcinomas and are called preblastomatoses. Vaginal intraepithelial

neoplasia (VAIN) may be extensions onto the vagina from the primary

cervical intraepithelial neoplasia(CIN), or they may be satellite lesions

occurring mainly in the upper vagina. Because the vagina does not have a

transformation zone with immature epithelial cells to be infected by HPV, the

mechanism of entry of HPV is by way of skin abrasions from coitus or tampon

use. As these abrasions heal with metaplastic squamous cells, the HPV may

begin its growth in a manner similar to that in the cervical transformation

zone.

VAIN can occur in just one area of the vagina, but it more often affects

several different areas at once (multifocal).

Classification of VAIN:

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Three degrees (stages) of VAIN are distinquished: VAIN 1, 2, and 3.

In VAIN 1, a third of the thickness of the cells in the vaginal skin are

abnormal,

VAIN 2 - two-thirds of the thickness of the surface layer of the vagina is

affected.

AIN 3 - the full thickness of the surface layer of the vagina is affected. It

is also known as carcinoma in situ, or stage 0 vaginal cancer

Causes of VAIN:

HPV is a very common infection. Types 16 and 18 are most commonly

associated with VAIN.

Other factors that depress the body's immune system also need to be

present for VAIN to occur. These include Herpes simplex virus (HSV),

Cytomegalovirus, smoking, inherited immunity problems, particular

medicines (for example those taken after transplant surgery), and some

rare bone marrow and blood disorders.

Clinical features. VAIN doesn't cause any symptoms. Most women are

diagnosed with it while having medical tests for other reasons.

VAIN can’t be detected by the naked eye.

VAIN can be detected by the presence of abnormal cells in a Pap-tests

Diagnosis. Most useful method of VAIN diagnosis is a targeted biopsy

with histologic examination. Typically, the lesions are located along the

vaginal ridges, are ovoid in shape and slightly raised, and often have surface

spicules. VAIN 1 lesions usually are accompanied by a significant amount of

koilocytosis, indicating their HPV origin. As the lesions progress to VAIN 2,

they have a thicker acetowhite epithelium, a more raised external border, and

less iodine uptake. When VAIN 3 occurs, the surface may become papillary,

and the vascular patterns of punctation and mosaic may occur. The more

coarse the punctation or mosaicism, the more severe is the dysplasia.

Treatment.

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Local ablation treats VAIN by removing or destroying the abnormal

cells in the vagina. This can be done in two ways:

o Carbon dioxide (CO2) laser treatment. A laser is directed at the

abnormal cells and destroys them. This procedure is usually

carried out under a general anesthetics.

o Diathermy treatment. This treatment is sometimes used to

remove the abnormal cells. It’s done under local anesthetics. A

thin wire uses an electric current to destroy the affected area.

Surgery may be recommended if there is any possibility of there being

undetected cancer in the vagina.

o It may also be used if VAIN comes back after previous treatment.

o Surgery may involve removing part or all of the vagina (partial or

total vaginectomy).

Other modalities are:

Radiotherapy

Chemotherapy cream (topical fluorouracil 5FU in multifocal lesions is

used)

Follow-up: colposcopy twice a year.

Cancer and sarcoma of external genitalia and vagina

Vulvar cancer

It more often occurs in elderly women and is localized in the area of

clitoris, labia majora and minora, and Bartholin’s gland. Vulvar cancer is

uncommon, the incidence varying from 0.5 to 2 per loo ooo women per year.

Histological variants of vulvar cancer.

Squamous cancers account for 90% of malignant vulvar

neoplasms and 5% of all female genital cancers. They metastasize

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to the local lymph nodes, primarily the superficial and deep

inguinal nodes and they may be involved bilaterally. They usually

present with a nodule or ulcer and may cause pruritus or soreness

and pain. Bleeding and an offensive odor may be present with

larger lesions.

Verrucous carcinomas and basal cell carcinomas are squamous

variants and rarely if ever metastasize locoregionally and

therefore management is primarily aimed at local disease control

by whichever route affords the lowest morbidity. Verrucous

carcinomas present as slow growing wart-like lesions with a

tendency to local recurrence after excision.

Malignant melanoma of the vulva accounts for 10% of all vulvar

malignancies. The overall 5-year survival ranges between 8 and

50% and appears to be worse than for cutaneous melanomas

elsewhere. The single most important prognostic indicator in this

disease is the depth of invasion. Non-vulvar cutaneous melanoma

is usually staged according to the depth of histological

involvement. As some observers question the presence of a

papillary dermis in vulvar skin, absolute depth might be the best

compromise and invasion greater than 1.75 mm has such a high

risk of recurrence that even the use of radical surgery with

bilateral block dissection is unlikely to improve survival.

Adenocarcinomas of the vulva are exceedingly rare and are more

likely to represent metastases from another site.

Sarcomas are very uncommon and in general are biologically

similar to soft tissue sarcomas at other sites. Generally there is

poor prognosis after the appearance of regional or distant relapse.

Wide local excision appears to offer the best chance of preventing

local recurrence. Elective treatment of the regional nodes is not

indicated and there is no advantage in resecting metastatic nodes.

545

The role of adjuvant radiation and chemoradiation has not been

assessed largely because of its rarity.

Metastatic tumours are rare and account for about 8% of all vulvar

neoplasms. Cervix, endometrium and renal carcinomas have been

the most frequently documented primary sites.

Carcinoma of Bartholin’s gland is also rare and may be either

squamous, adenocarcinoma or an adenoid cystic carcinoma. They

occur more often in younger, premenopausal women and overall

have a survival of about 35% at 5 years.

Vulvar cancer is divided into infiltrative and nodular (with possible

ulceration).

Stages of lesions:

I – lesions 2 cm in size confined to the vulva or perineum;

II – tumor 2 cm in largest dimension confined to the vulva or

perineum, no nodal metastasis;

III – tumor of any size with adjacent spread to the lower urethra, the

vagina, or the anus or with unilateral regional lymph nodes metastasis;

IV – tumor invаding any of the following: upper urethra, bladder,

rectum, pelvic bone, or bilateral regional nodes. In stage IV distant metastasis

occur.

Itching, pain, leucorrhea, and sanguineous discharge occur rather

rarely. The final diagnosis is established after biopsy and histological

examination. (Fig. 223).

Treatment. The objectives of managing the primary lesions are to

remove the cancer, minimize the risk of local recurrence and preserve as

much function as possible. These objectives have initially been addressed by

modifications of the surgical approach and more latterly by considering

combined modality management, especially combinations of surgery and

radiotherapy. The site, size and relation of the lesion to important functional

546

structures will determine the most appropriate method to treat the vulvar

lesion.

Two broad categories of patient can be identified at the outset: those

who have small unifocal vulvar lesions with no clinical evidence of nodal

involvement (early disease), and those who have more advanced vulvar

disease and/or clinical evidence of nodal involvement (late disease). Radical

vulvectomy is excessive treatment for the majority of unifocal and early

cancers. Wide local excision is usually sufficient for the majority of TI and T2

tumors.

The elderly woman with extensive or multifocal disease with an

associated symptomatic maturation disorder such as lichen sclerosus might

well gain an overall benefit from radical vulvectomy with subsequent grafting.

Conversely, the young woman with a clitoral cancer might initially be

managed by radiotherapy, reserving surgery for failed local control. These

types of cases form the basis for local management of advanced vulvar

lesions. The prime objective is to maximize local control, closely followed by

consideration of further function and cosmesis in that particular woman.

Combined radiotherapy is also used. External beam megavoltage

radiotherapy is the treatment most frequently applied as an adjuvant in

women found to have two or more involved lymph nodes following groin node

dissection. The treatment field encompasses the superficial and deep inguinal

and pelvic nodes. It is in this role that radiotherapy is most frequently used in

treating vulvar cancer.

547

Vaginal cancer

Vaginal cancer is rare accounting for only 1-2% of all gynecological

malignancies. It is most often metastatic in nature. It arises as primary

squamous cancers or is the result of extension from the cervix or vulva.

Primary cancer of the vagina occurs very rarely. A wide age range (18-95

years) with the peak incidence in the sixth decade of life and a mean age of

approximately 60-65 years is typical for vaginal cancer.

The etiology is unknown, but several predisposing factors are

distinguished:

Prior lower genital tract intraepithelial neoplasia - mainly cervical

intraepithelial neoplasia (CIN) and/or cervical carcinoma.

HPV infection. This may explain the relative frequency of

multicentric lower genital tract tumors.

548

Previous gynecological malignancy. Several authors report

approximately one-quarter or as high as one third of patients as

having had a previous gynecological malignancy.

Clinical features. The symptoms depend on the stage of the tumor. The

most common presenting features are as follows:

Vaginal bleeding, accounting for more than 50% of presentations.

Vaginal discharge.

Urinary symptoms.

Abdominal mass or pain.

Asymptomatic. Approximately 10% of tumors will be

asymptomatic at the time of diagnosis. Vaginal tumors may be

easily missed at vaginal examination, particularly when a bivalve

speculum is used. Careful inspection of the vaginal walls whilst

withdrawing the speculum is necessary in order to avoid this as

otherwise the blades of the speculum may obscure a tumor on the

anterior or posterior vaginal wall.

Tumors can occur at any site in the vagina. The upper third of the

vagina is the site most frequently involved either alone or together with the

middle third in approximately two-thirds of cases. Approximately 1 in 6 will

be found to involve the entire length of the vagina. The size of tumor shows

great variation at presentation ranging from small ulcers less than 1 cm in

diameter to large pelvic masses, although the majority of tumors are 2-4 cm

in diameter. Vaginal cancer may be exophytic (looking like cauliflower) and

endophytic, with infiltration of adjacent tissues.(Fig. 224)

549

Fig. 224. Vaginal cancer.

Staging is carried out according to the FIGO classification (Table 16).

Table 16.

FIGO clinical staging of primary vaginal carcinoma

FIGO stage Definition

0 VIN 3 (carcinoma in situ)

I Invasive carcinoma limited to vaginal wall

IIA Carcinoma involves subvaginal tissue but does not extend

to parametrium

IIB Carcinoma involves parametrium but does not extend to

pelvic side wall

III Carcinoma extends to pelvic side wall

IVA Involvement of mucosa of bladder or rectum or direct

extension beyond true pelvis

IVB Spread to distant organs

550

Diagnosis. This is best performed under general anesthesia.

The site and limits of the tumor can be accurately determined and

a full thickness biopsy taken for histological analysis.

Combined rectal and vaginal examination is particularly helpful in

order to determine if there is any extension of the tumor beyond

the vagina and the extent of any spread.

Cystoscopy and sigmoidoscopy are required to exclude or confirm

the involvement of bladder or rectum.

Chest X-ray

Intravenous urogram.

More complex radiological investigations such as rectal

ultrasound scanning or MRI may be helpful in selected instances

in order to define the dimensions of the tumor.

Treatment. The majority of cases of vaginal carcinoma are treated using

pelvic radiotherapy although surgical excision is an appropriate form of

management in selected cases. Experimental chemotherapeutic regimes are

being developed both alone and in conjunction with radiotherapy for

advanced cases or recurrent disease.

Sarcomas of the vagina

Leiomyosarcomas are most frequently diagnosed with other types

reported including adenosarcoma and angiosarcoma. Sarcoma of the vagina

rarely occurs in adult women. It is more frequent in girls and is commonly

localized in the area of the clitoris, labia, and vagina. Sarcoma appears as a

limited node, growing into the underlying tissues and disintegrating with the

formation of ulcers.

Treatment. Primary therapy is surgical removal of affected organs and

subsequent radiotherapy. Adjuvant radiotherapy has been advocated for high

grade tumors or in recurrent disease. Adjuvant chemotherapy has been

utilized by some but has not been shown to confer a survival advantage in soft

551

tissue sarcomas of the extremities. The majority of women present with

discomfort and/or bleeding.

Self test

1. Which of the following is precancerous disease of external genitalia?

A. vulval fibroma

B. hidradenoma

C. vulvitis

D. leukoplakia of the vulva

2. Kraurosis of the vulva

A. usually happens in young women

B. is connected with itching

C. is not characterized with psychoemotional disturbances

D. is a hyperplasia

3. Lichen sclerosis occurs in

A. postmenopausal women

B. reproductive age

C. pubertal age

D. premenopausl age

4. Sarcoma of the vulva usually occurs in

A. postmenopausal women

B. reproductive age

C. pubertal age

D. premenopausl age

5. Vaginal cancer is most often

A. a metastatic process

B. an original process

6. Displasia of the vulva is

A. a true precancer of the vulva

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B. a background process of the vulva

C. a true malignant growth of the vulva

D. a benign lesion of the vulva

7. In case of Paget’s disease one can find

A. a red colored, well defined maculae, which may be infiltrated and inflamed

B. dry spots of a white or yellow colour mainly over the labia majora

C. thinning and fibrosis of the vulval skin, causing stenosis of the vaginal

introitus

D. cauliflower lesion of the vulval tissue

8. The affected areas appear whitish and glistening with clear margins in

A. a Paget’s disease

B. a vulval cancer

C. a leukoplakia of the vulva

D. a lichen sclerosis

9. Fibroma of the vulva is

A. a malignant tumor

B. precancerous lesions

C. a background process

D. a benign tumor

10. The final step of the diagnosis of vulval cancer is

A. the patient’s complaints and anamnesis

B. clinical findings

C. colposcopy and colpomicroscopy

D. histological data

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Chapter 16. «BACKGROUND» PROCESSES AND

PREMALIGNANT LESIONS OF CERVIX. CERVICAL

CANCER

«Background» processes of cervix of the uterus

The pathology of the cervix is one of the most frequent groups of female

genital diseases, accounting for 10-15% of all patients in gynecological

departments. Among them, background and precancerous diseases constitute

a group of increased risk of development cervical malignancies. Background

diseases of the vaginal part of the cervix are pathological processes that are

characterized by chronic recurrent course, hyperplasia of epithelial cells with

the formation of new glandular structures with preservation of epithelial

normoplasia, ie, the correct mitotic division of epithelial cells, their

differentiation, maturation, exfoliation are preserved. In the future, against

the background of ongoing hyperplasia, a real tumor process can occur.

Background processes present abnormal conditions of the congenital or

acquired nature, which may lead to the development of precancerous

conditions or cancer of the cervix. These diseases include cervical erosions,

pseudoerosions, chronic cervicitis, polyps, cervical ectropion, leukoplakia,

cervical warts.

Risk factors

Inflammatory processes

o necrobiosis of the multilayered squamous epithelium of the cervix

and its desquamation because of the inflammatory process

followed by the formation of erosion areas, the healing of which is

due to the overgrowth of cylindrical epithelium of the cervical

canal, which is not characteristic for the vaginal portion of the

cervix. In this zone pseudoerosion is formed. The human

554

papillomavirus (HPV) plays important role in the development of

dysplasia of the cervix.

Traumatic lesions of the cervix after childbirth or abortion

o leading to the violation of trophism and innervation of tissues

Hormonal misbalance:

o shifts in the metabolism of estrogens with the predominance of

estradiol and increase in oxygenated forms of 17-ketosteroids

Immune disorders:

o increase of cytotoxic T-lymphocytes, decrease of Langerhans cells

in the cervix, the degree of changes is proportional to the level of

immunosuppression

Sexual activity:

o early onset of sexual life and multiple sex partners

Involutional (age-related) changes of the pelvic organs

o as well as a decrease in total body resistance, the age-related

changes of metabolic and hormonal balance.

Smoking

o the risk of the disease increases with the increase in the number of

cigarettes per day and the duration of smoking

Hereditary factor

o the risk of cervical cancer in women with a history of family

history.

Methods of diagnostics

The following methods of diagnostics of background diseases are currently

used:

Evaluation of anamnestic data

gynecological examination (specular and bimanual examination)

laboratory study: CBC, Urinalysis, high vaginal swab for microscopic

555

and bacteriological examination, Pap-testing, Polymerase Chain

Reaction (PCR), Immunoenzyme Analysis to determine the type of

specific infectious agent, etc.

simple and extended colposcopy, colpomicroscopy, chromocolposcopy

with targeted biopsy, endocervical biopsy to exclude atypical changes,

as well as dysplasia

evaluation of the hormonal balance

TVUS;

optical coherence tomography.

Chronic cervicitis

Cervicitis is an inflammation of the cervix, acute and chronic forms are

distinguished. Typical symptoms are:

release of purulent or mucopurulent endocervical exudate in the

endocervical canal

sustained, easily induced endocervical bleeding, when the cotton

swab gently passes through the cervical os.

Noninfectious and infectious cervicitis are distinquished.

Noninfectious cervicitis can be caused by the following:

Local trauma - eg, cervical irritation caused by tampons, a cervical cap,

the string from an intrauterine contraceptive device, a pessary, or a

diaphragm

Radiation

Chemical irritation - eg, vaginal douches, latex exposure, or

contraceptive creams

Systemic inflammation

Malignancy

Infectious cervicitis may be caused by:

Chlamydia trachomatis, Neisseria gonorrhoeae,

556

herpes simplex virus (HSV).

Human papilloma virus (HPV)

Trichomonas vaginalis

Others

The development of the disease is determined by a combination of

several pathogenetic links. The signs of the inflammatory process are

expressed moderately and are localized mainly in endocervix. Mucous cervical

canal becomes edematous, thickened, folded. There is fullness of the vessels,

lymphohystiocytic inflammatory infiltrates are formed, epithelial cells secrete

more mucus. In exo - and endocervix, regenerative processes slow down and

dystrophic changes occur. In the lower layers of the mucosa, connective tissue

elements grow. The terminal orifices of the glands overlap with a flat

epithelium with the formation of retinal cysts. As the disease progresses,

connective tissue and cervical muscles are involved in inflammation.

The cellular and humoral immune system functions inferiorly: the

number of B- and T-lymphocytes decreases, T-dependent immune responses

are inhibited, and phagocytic activity is disrupted. As a result, the causative

agents of the infection are able to persist in both the cervical epithelium and

the cells of the immune system. In cervical mucus, the level of

immunoglobulins G and M decreases against the background of a high

content of IgA. Developed autoimmune processes with the phenomenon of

"molecular mimicry" between foreign proteins and proteins of their own

tissues.

Chronic recurrent cervicitis lead to hyperplasia, dystrophic, atrophic

changes, ulcerations, which are a prerequisite for cervical dysplasia. Acute

cervicitis does not require surgical treatment. When the inflammation

persists to a chronic stage, it is no longer confined to the mucosa but has

spread to the underlying tissue, whether on the exposed vaginal surface or

within the canal.

557

Chronic cervicitis is seen in women with laceration of the cervix, where

there is superadded infection with mixed vaginal flora. The endocervicitis

gives rise to an excessive vaginal mucoid discharge with an active

endocervical lining growing over to replace the squamous epithelium around

the external os to present as erosion.

Some of the mucous glands get blocked with pent up secretions, distend

these glands so, that they appear as whitish-yellow Nabothian cysts.

In the clinical picture of chronic cervicitis there are certain features,

which need individual attention. These features are eversion, erosion, cyst

formation, leukoplakia, whitish-yellow Nabothian cysts, and the sequelae of

laceration. To understand the appearance on examination and the deep

conditions to be dealt with, it is necessary to understand eversion, erosion,

and cyst formation.

Cervical eversion

In chronic cervicitis, the inflammatory infiltration causes marked

thickening of the mucosa and submucosal tissues. As these tissues become

more and more thickened, they push out in the direction of least resistance,

which is at the external-os. This rolling out (eversion) from inflammatory

infiltration is most marked in the cervix, which has been lacerated, but it is

found also in chronic cervicitis in nulliparas.

Cervical erosion. Pseudoerosion

The true cervical erosion and pseudoerosion are distinguished.

The essence of the process of erosion is most accurately indicated by the

very translation of this concept - "corroding" or "destruction." Erosion - is a

small inflammation or sore that has a bright red color. (Fig. 224) It is the

damaged epithelium of the mucosa, located in the area of the outer exit of the

cervix in the vagina. This erosion easily bleeds when touched. It is visible

558

from the side of the vagina on the cervix. This sore or wound on the vaginal

portion of the cervix can last for two weeks. If timely treatment is not

provided, erosion will pass into pseudo-erosion. So, pseudo-erosion is the

phase of chronic cervicitis. In this case, in the area of the entrance to the

cervical canal one can see the area on which the tissue has grown: normal

squamous epithelium cells of external surface of the cervix are replaced by

columnar cells from the cervical canal. These cells appear red and inflamed,

but they are not cancerous, and the cervix itself does not literally erode. At the

beginning of the development of pseuderosion, erosive glands can form, in

this case the gynecologist diagnoses glandular pseudo-erosion of the cervix. It

can be observed for several years.(Fig. 225).

When the inflammatory process ceases and the cells begin to be

replaced by the epithelium, pseudo-erosion becomes glandular-epidermal. If

the disease progresses, the erosive glands are blocked by secretion, and cysts

appear on the affected area. It is dangerous that they can be infected, so the

inflammatory process may increase.

Fig. 224.Cervical erosion

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Often this pathology is congenital and does not affect normal sexual life,

pregnancy and childbirth, which makes it possible to consider it as a variation

in the development of the female reproductive system. Assessing the

condition of the surfaces and making sure that there is no risk of tissue

degeneration or the development of inflammatory processes, the gynecologist

can completely abandon the appointment of any treatment, recommending

only regular observation. At the same time, congenital erosion can cause

inconvenience even in the period of the appearance of the first menstruation,

as well as the true, resulting from the transmitted sexual infection.

If untreated, acquired pseudo-erosion can lead to a serious

inflammatory process, infertility, dysplasia, malignant tumor. In addition, it

is worth considering that erosion is constantly recurring, so woman need to

be extremely cautious. That is why it is known as background disease.

Diagnostic points

The principal diagnostic difficulty in connection with chronic cervicitis

is the question as to whether there is or not a beginning of malignant disease.

Chronic cervicitis, in its various forms and with its long-continued irritation,

is an important factor in the development of cancer in this situation. This is

readily appreciated when we consider the persistent irritation from erosion,

eversion, and cyst formation, with the resulting proliferative cell changes in

this danger area where two types of epithelium meet.

There are no symptoms in the real beginning. As far as this form of

cancer is concerned, the so-called "early" symptoms are early only in the

symptomatic sense. They are the first symptoms noticed by the patient, but

they do not represent the early stage of the pathologic process. The

microscopic change, which constitutes the beginning of tumor does not cause

bleeding or discharge. When these symptoms appear, the cancer usually has

deep prolongations.

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Cervix cancer is usually preceded by local chronic cervicitis. There are

many things not yet known about cancer, but two known things are a). cancer

development favors in a susceptible individual chronic irritation; b). this

tendency is increased by the aging process (involution). In the cervix this

chronic irritation usually appears in the form of chronic cervicitis. Even when

marked, this causes little discomfort beyond annoying discharge, which is

easily controlled by douches. In milder cases, there may be no troublesome

discharge to call the patient's attention to this minor disturbance. In the

meantime, however, the mild inflammation penetrates into the cervical

glands and keeps up chronic irritation.

Diagnosis of pseuderosion:

Analysis of the microflora, for this is taken a smear from the urethra,

vagina and cervix to timely identify the inflammatory process.

Pap-testing

A hormone level test is performed.

Colposcopy makes it possible to completely examine the cervix under a

microscope, to reveal the structure of tissues.

Cervical biopsy with histological exam

Pseudo-erosion treatment

As a first stage of treatment, antimicrobial agents and antibiotics may be

required. In severe cases, surgical methods of treatment are used:

Diathermocoagulation is the cauterization of an electric current.

Laser surgery (carbon-dioxide laser).

Cryodestruction (cryoablation) - freezing by the action of nitrogen.

Radio wave effect.

Chemical coagulation.

Thus, a woman with pseudo-erosion should be constantly observed at

the gynecologist, only in this way serious complications can be avoided.

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Cyst formation

The formation of small retention cysts in the cervix is due to obstruction

of the ducts of normally situated glands by inflammatory infiltration and to

the formation of glandlike cavities in areas of erosion. If there has been a

laceration of the cervix, the resulting scar tissue may obstruct ducts and this

aids in cyst formation.

These retention cysts are felt as small hard nodules, like shot of various

sizes, in the cervix, and may give rise to an erroneous diagnosis of cancer. The

cervix may be honeycombed with these small cysts, producing a condition

designated as "cystic degeneration" of the cervix. The mucus in these cysts is

usually clear and presents the characteristic tenacious, stringy consistency. In

some cases a cyst may contain pus and appear as a yellow spot.

Cervical polyps

Polyp formation in the cervix is due to chronic irritation from the

persisting inflammation and discharge. In most cases the polyp represents

simply a localized and projecting portion of the thickened mucosa (mucous

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polyp). Occasionally, however, the polyp is a projecting portion of a

carcinoma, and as the distinguishing features can be determined with

certainty only by microscopic examination, all polyps should be sent for

laboratory examination. (Fig. 226).

Fig. 226. Cervical polyp.

These are often due to endocervical hyperplasia caused by endocervicitis

or, rarely, by oral contraceptives. These small, pea-sized mucus polyps, give

rise to a vaginal discharge, which may be mucoid and blood-stained. The

patient may also complain of postcoital bleeding.

Speculum examination shows pedunculated mucus polyps. These can be

easily twisted off, avulsed and sent for pathologic examination.

Leukoplakia

Leukoplakia is the term applied to certain small white areas occasionally

seen on the cervix. They are smooth and there may be several ones, differing

in size and shape. (Fig . 227). If the patch is wiped off, it is likely to return in a

few days. Leukoplakia, like other forms of chronic irritation in the cervix, is

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important because of its relation to the development of carcinoma in this

location. The white color is due to abnormal proliferation of certain cells of

the epithelial layer, the types of proliferation differing somewhat in different

cases. In some cases the type of proliferation borders very closely on the

malignant one.

Leukoplakia of the cervix should be promptly removed, the same as any

other area of chronic irritation. There is likely to be associated irritation in the

form of erosion or cyst formation, and the whole affected area should be

removed by electric wire-loop conization or by conical excision with the knife.

The removed tissue is of course to be subjected to thorough microscopic

investigation. In this connection it is to be remembered that when the

specimen is removed the leukoplakic color distinction disappears. On this

account it is important, before removing such specimen, to mark the

leukoplakic area with one or two small sutures just outside the boundary—

otherwise it will be missed in the laboratory.

Fig. 227. Cervical leukoplakia, front view, macroscopic.

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Laceration

Laceration of the cervix in labor is one source of infection and resulting

chronic cervicitis. Also, the laceration has much to do with the shape and

appearance of the chronically inflamed cervix. The splitting of the cervix by

the laceration allows much more rolling-out of the infiltrated tissues. This

eversion is a progressive process, and may go on till the laceration-notch is

obliterated and the cervix appears round like a ball.

Troublesome symptoms from cervix laceration and conditions requiring

treatment are due largely to inflammation. If there is no complicating

inflammation, the torn surfaces may fall together and unite, leaving only a

small notch, or they may heal over by granulation and scarring, leaving two

thin lips. In either case the condition causes no trouble and requires no

treatment. But if inflammation supervenes, there follows the interesting

series of progressive changes resulting in the conditions seen in chronic

cervicitis.

Precancerous lesions of cervix

Precancerous conditions imply processes in which hypertrophy,

proliferation, and various abnormalities in the vital activity of epithelial cells

occur. Precancerous conditions arise due to benign processes of ectopy and

metaplasia, which are observed in the epithelium. Ectopy develops when

cylindrical epithelial cells are formed from the reserve cells or the flat

epithelium is replaced by a cylindrical one that covers the area of the cervical

canal. Metaplasia is characterized by the transformation of reserve cells into a

tissue of flat epithelium. In general, precancerous conditions of the cervix

may be described as presence of various dysplasias. Dysplasia means the

presence of cells of an abnormal type within a tissue, which may signify a

stage preceding the development of cancer, also the abnormal growth or

development of a tissue or organ.

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Precancerous conditions have the potential to develop into cancer. With

a precancerous condition, abnormal changes have taken place in the cells of

the cervix. Over time, some of these precancerous changes can turn into

cancer if left untreated. It may take many years (typically about 10 years or

more) for precancerous conditions to progress into an invasive cervical

cancer, but sometimes this can happen in less time.

Precancerous conditions of the cervix occur in an area called the

transformation zone. This is where one type of lining (glandular, columnar

cells of the cervical canal) is constantly being changed into another type of

lining (squamous cells of superficial layer of vaginal portion of the cervix).

The transformation zone is an area of changing cells, and it is the most

common place on the cervix for abnormal cells to develop. These abnormal

cells can be detected on a Pap smear. The location of the transformation zone

varies among women. In teenage girls, the transformation zone is on the

immature cervix's outer surface and is more susceptible to infection than in

adult women. In older women, the transformation zone may be higher in the

cervical canal.

The transformation of columnar cells into squamous cells is a normal

process, but it makes the cells more sensitive to the effect of human

papillomavirus (HPV).

Precancerous changes in the cervix are quite common. They can develop

at any age, but they occur most often in women in their 20s and 30s.

The main risk factor for precancerous changes in the cervix and cervical

cancer development is infection with the human papillomavirus (HPV).

Precancerous conditions in the cervix are described based on how

abnormal cells look under the microscope and how severe the cell changes

are. They are grouped based on the type of cell that is abnormal.

The mainstay of cervical cancer screening for the last 60+ years has

been the Papanicolaou test. The Papanicolaou test, also known as the Pap

test or the Pap smear, was developed in the 1940s by Georgios Papanikolaou.

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It involves exfoliating cells from the transformation zone of the cervix to

enable examination of these cells microscopically for detection of cancerous

or precancerous lesions.(see Chapter 2). Precancerous conditions in the

cervix are described based on how abnormal cells look under the microscope

and how severe the cell changes are. They are grouped based on the type of

cell that is abnormal.

The current classifications of precancerous lesions of cervical squamous

epithelium is based on new findings on HPV-related carcinogenesis; the key

assumption in this context is that two early genes of HPV (E6 and E7) trigger

neoplastic transformation of the squamous epithelium. These types are

referred to as transforming HPV infections. After constant expression of E6

and E7 oncogenes the oncoproteins encoded by E6 and E7 bind to cell cycle

proteins, leading to loss of cell cycle control. Mutations gradually accumulate

and cells become genetically unstable. HPV represents a family of double-

stranded, circular DNA viruses that can infect skin or mucosal cells, including

the anogenital region and the oral cavity, and may be transmitted easily via

sexual intercourse or direct contact. More than 100 types of HPV exist, 12 of

which can involve the anogenital region and are considered "high risk" or

oncogenic in nature. These include HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52,

56, 58, and 59. Of these, HPV 16 is responsible for the largest number of CIN

3 and cervical cancer cases, and HPV 16 and 18 combined are thought to be

responsible for nearly 70% of all cases of cervical cancer. Although HPV is a

necessary factor in the development of cervical dysplasia that can eventually

lead to cervical cancer, most women infected with HPV will not develop

cervical dysplasia. The presence of high-risk HPV DNA is accompanied by

cytologic abnormalities approximately one third of the time. Whether an HPV

infection will progress relates to the persistence of the infection and also

possibly to the immune response and smoking status of the woman.

Classification of precancerous lesions of the cervix. Since the Pap

smear was introduced in 1943, a number of methods have been developed to

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classify the results. The two methods commonly used today are the CIN

Grading System and the Bethesda System.

CIN Grading System for Cervical Dysplasia uses term cervical

intraepithelial neoplasia (CIN). Cervical intraepithelial neoplasia refers to

new abnormal cell growth. Intraepithelial refers to the surface layers of the

cells. The CIN System grades the degree of cell abnormality numerically, CIN

1 is the lowest and CIN 3 is the highest.

The Bethesda System to Stage Cervical Dysplasia is a system of terminology

for reporting the results of cervical cytology. It was developed in 1988, revised

in2001 and 2014 and is now widely used in the world. It uses the

term squamous intraepithelial lesion (SIL) to describe abnormal changes in

the cells on the surface of the cervix. Squamous refers to thin, flat cells that lie

on the outer surface of the cervix. An intraepithelial lesion occurs when

normal cells on the cervical surface are replaced by a layer of abnormal cells,

and these changes are classified as high grade or low grade. Precancerous

conditions of the cervix occur in an area of transformation zone. This is where

one type of lining (glandular, columnar cells) is constantly being changed into

another type of lining (squamous cells). The transformation of columnar cells

into squamous cells is a normal process, but it makes the cells more sensitive

to the effect of human papillomavirus (HPV). And so, abnormal

(precancerous) changes may happen in both glandular, columnar cells of the

cervical canal and squamous cells of superficial layer of vaginal portion of the

cervix.

The abridged Bethesda system (2001) presented in table 17.

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Table 17

The 2001 Bethesda system (Abridged)

Specimen adequacy

Satisfactory for evaluation (note presence/absence of endocervical/

transformation zone component)

Unsatisfactory for evaluation...(specify reason)

o Specimen rejected/not processed (specify reason)

o Specimen processed and examined, but unsatisfactory for

evaluation of epithelial abnormality because of (specify reason)

General categorization (optional)

Negative for intraepithelial lesion or malignancy

Epithelial cell abnormality

Other

Interpretation/result

Negative for Intraepithelial Lesion or Malignancy

o Organisms

-Trichomonas vaginalis

-Fungal oganisms morphologically consistent with

Candida species

-Shift in flora suggestive of bacterial vaginosis

-Bacteria morphologically consistent with Actinomyces

species

-Cellular changes consistent with herpes simplex virus

Other non-neoplastic findings (Optional to report; list not

comprehensive)

o Reactive cellular changes associated with

- inflammation (includes typical repair)

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-radiation

- intrauterine contraceptive device

o Glandular cells status posthysterectomy

o Atrophy

Epithelial Cell Abnormalities

Squamous cells

o Atypical squamous cells (ASC)

- of undetermined significance (ASC-US)

- cannot exclude HSIL (ASC-H)

o Low grade squamous intraepithelial lesion (LSIL)

encompassing human papillomavirus/mild dysplasia/cervical

neoplasia (CIN) 1

o High grade squamous intraepithelial lesion (HSIL)

encompassing moderate and severe dysplasia, carcinoma in

situ; CIN 2 and CIN 3

o Squamous cell carcinoma

Glandular cell

o Atypical glandular cells (AGC)

- Endocervical

- Endometrial

- Glandular

o Atypical glandular cells, favor neoplastic

o Endocervical adenocarcinoma in situ (AIS)

o Adenocarcinoma: Endocervical endometrial, extrauterine, NOS

Other (List not comprehensive)

Endometrial cells in a woman ≥40 years of age

(http://www.svgo.es/sites/default/files/Bethesda%202001pdf.pdf)

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Interpretation of the results of cytology and description of the results are

presented in Table 18, Table 19.

Table 18.

Abnormal squamous cells

Bethesda system Also includes Description

Atypical squamous cells

(ASC)

Cells do not appear

normal.

Atypical squamous cells

– undetermined

significance (ASC-US)

Cells do not appear

completely normal.

It is uncertain what the

cell changes mean.

This is considered a

mild abnormality

Atypical squamous cells

– cannot rule out high-

grade squamous

intraepithelial lesion

(ASC-H)

Cells do not appear

normal.

It is uncertain what the

cell changes mean, but

a high-grade lesion

cannot be ruled out.

This may have a higher

risk of becoming

precancerous.

Low-grade squamous

intraepithelial lesion

(LSIL)

mild dysplasia / CIN 1:

older terms

There are early changes

to the cells.

This is considered a

mild abnormality.

High-grade squamous

intraepithelial lesion

(HSIL)

moderate or severe

dysplasia/ CIN 2 or

CIN 3 (older terms)

There are marked

changes to the size and

shape of the cells, and

cells are considered

abnormal and have the

potential to develop

into cancer

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carcinoma in situ (CIS)

Cancer cells are found

only in the surface layer

of cells lining the cervix

but have not spread

into the deeper tissues

of the cervix or

surrounding tissue

(non-invasive or pre-

invasive).

Squamous cell

carcinoma

Cancer

Table 19

Abnormal glandular cells

Bethesda system

Also includes

Description

Atypical glandular cells

(AGC)

endocervical dysplasia

atypical hyperplasia

endocervical glandular

atypia

cervical intraepithelial

glandular neoplasia

(CIGN) grade 1 or 2

Cells do not appear

normal.

This is considered a

significant abnormality.

Adenocarcinoma in situ

(AIS)

endocervical AIS

CIGN grade 3

Cancer cells are found

in the glandular tissue

of the cervix

(endocervix) but have

not spread into the

deeper tissues of the

cervix or surrounding

tissue (non-invasive or

pre-invasive).

Adenocarcinoma Cancer

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Treatment. Conservative treatment is indicated in younger women and

in mild degree. Surgical procedures that preserve the uterus and may permit

future childbearing include cryosurgery (freezing), laser surgery, loop

electrosurgical excision procedure (LEEP) or cold-knife conization.

Cryosurgery, laser surgery, and LEEP can be performed in the out-patient

office or short procedure facility, often with local anesthesia. A cold-knife

conization is a more extensive operation that involves removal of part of the

cervix under general anesthesia. Not all patients can be adequately treated

with cryosurgery, laser surgery or LEEP. This decision depends on the extent

and appearance of the disease upon examination.

Women treated with conservative surgery require lifelong visits to their

doctor to ensure that recurrence of cervical disease can be detected in the

precancerous state or early while the cancer is still curable.

If the precancerous disease is more extensive or involves

adenocarcinoma in situ (AIS), and the woman has completed childbearing, a

total hysterectomy may be recommended. During a total hysterectomy, the

entire uterus (including the cervix) is removed. In addition, a bilateral

salpingo-oophorectomy, which is the removal of the ovaries and fallopian

tubes, may be performed. The decision to perform a bilateral salpingo-

oophorectomy depends on the woman’s age and whether the ovaries are still

functioning.

A total hysterectomy and/or a bilateral salpingo-oophorectomy are the

most extensive surgical options used for precancerous disease and require

general anesthesia and a hospital stay.

Cervical Cancer

Cervical cancer is the most commonly occuring tumour of the female

genital organs. Most commonly this disease occurs at the age of 40-49 years.

The rate of the disease is much higher in parous women. The most typical

background for the development of cervical cancer is cicatricial deformation

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and ectropion of the cervix postpartum, as well as dysplasia of the cervix

(severe form).

Exophytic, endophytic, and mixed forms of cervical cancer are

distinguished.

In the exophytic form the tumorappears as a cauliflower and is

positioned on the cervical surface. Occasionally, it may be rather large (Fig.

228).

In the endophytic (Fig.229) form the tumour grows into the depth of the

cervix, which results in cervical enlargement. A deep crater-like ulcer forms

upon disintegration of the tumour. In terms of the histological structure

squamous cell cancer and glandular cancer of the cervix are differentiated.

The former originates from the squamous epithelium covering the vaginal

portion of the cervix, whereas the latter originates from the mucous

membrane of the cervical canal (it is encountered less frequently).

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The process spreads via the lymphatic pathways, cellular tissue of the

true pelvis, and blood.

Classification of Cervical Cancer by the Degree of Its Propagation

Stage 0: preinvasive cervical cancer.

Stage I: only the cervix is involved (micro-invasive cervical cancer):

Stage IA micro-invasive tumor not extending more than 3 mm beyond

the basement membrane and not invading capillary or lymphatic channels;

Stage IB the growth is confined to the cervix extending more than 5 mm

beyond the basement membrane, the horizontal spread is more than 7 mm

(invasive cancer).

Stage II: the tumor extends beyond the cervix, but does not extend onto

the pelvic wall.

Stage IIA parametrial variant (infiltration of the parametrium from one

or two sides without the involvement of the pelvic wall);

Stage IIB vaginal variant (infiltration of the vagina, but not the lower

third);

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Stage IIC uterine variant (the tumour spreads to involve the uterine

corpus)

Stage III: tumor has extended onto the pelvic wall:

Stage IIIA parametrial variant (infiltration of the parametrium from one

or two sides, which involves the walls of the small pelvis);

Stage IIIB vaginal variant (the tumor involves the lower third of the

vagina);

Stage IIIC regional metastatic variant (involvement of the regional

pelvic lymph nodes)

Stage IV:tumor has extended beyond the true pelvis or has clinically

involved the mucosa of the bladder or rectum.

Stage IVA vesicular variant (spreading of cervical cancer onto the

bladder);

Stage IVB rectal variant (spreading of cervical cancer onto the rectum);

Stage IVC metastatic variant (spread to distant organs, distant

metastases).

Most commonly cervical cancer metastasizes into the lungs, liver, bones,

kidneys, and some other organs.

There is also another classification known as the TNM staging where T

denotes a primary tumour, N - involvement of lymph nodes, and M -

metastases.

In the preinvasive stage of cervical cancer (stage 0, carcinoma in situ)

there is no growth into the underlying tissues, and altered "cancer" cells are

found only within the epithelium. The presence or absence of invasion and its

depth are established only upon histological study.

Clinical picture. Characteristic symptoms of cervical cancer are acyclic

sanguineous discharge, leucorrhea (often with threads of blood), and pain

with a further spreading of the tumour. Pre- and microinvasive cervical

cancer is characterized by dull gnawing (often nocturnal) pain in the lower

abdomen, rapid fatiguability, and irritability. Progression of the disease may

576

be associated with life-threatening bleeding. When the process spreads onto

the bladder and rectum, one observes corresponding symptomatology in the

form of persistent cystitis, constipation, etc. Compression of ureters by a

cancerous infiltrate may be linked with dysuria and hydro- and pyonephrosis.

Early detection is very important.

Diagnosis of cervical cancer. When collecting the history, one should

pay attention to the status of menstrual, secretory, and reproductive functions

and to peculiarities of the parturition, which might have associated ruptures

of the cervix and the subsequent formation of an ectropion. Not uncommonly

it can be ascertained that the patient has long been suffering from

unresponsive cervical "erosion" which developed after the delivery (as a rule,

it is an erosion-affected ectropion of the cervix).

Speculum inspection of the cervix should be performed carefully in view

of possible injury to tissues and bleeding. The revealed picture may be varied.

For example, one can see minor changes on the cervix in the form of "erosion"

or greyish easily disintegrating tumorous formations of the "cauliflower" type,

which bleed readily upon touching (exophytic form). Patients with cancer of

the cervical canal exhibit no particularly visible alterations. The mucous

membrane covering the vaginal portion of the cervix is lustrous, as if tense,

whereas the cervix itself is barrel-shaped (endophytic form). Sanguineous

discharge may appear from the cervical canal during examination. The

spreading of the cervical cancer onto the vagina is associated with effacement

of the folds and a certain whitishness of its walls.

Rectovaginal and rectoabdominal examinations help to specify the

propagation of the process onto the parametrial cellular tissue and walls of

the vagina and small pelvis. The neoplastic process is characterized by dense

infiltration, occasionally (in stage III) reaching the walls of the true pelvis and

limiting cervical mobility.

577

Schiller's test makes it possible to specify borders of abnormal sites of

the cervix that remain negative when treated with Lugol's solution. Yet, this

test is not specific for cervical cancer.

Cervical cancer may also be recognized by a characteristic colposcopic

pattern: corkscrew-like vessels are positioned on the periphery of reddish

millet-like growths with hemorrhages. In cases of crater-like ulceration one

can visualize pyonecrotic overlying formations.

Expanded colposcopy helps to elucidate the most suspicious sites for

cervical biopsy with subsequent histological examination of the obtained

tissue. Biopsy should be extensive and performed by making a wedge-like

excision of the pathologically altered site of the cervix within the healthy

tissue. In addition, curettage of the mucous membrane of the cervical canal is

performed.

Cervical cancer should be differentiated from tuberculosis, syphilis,

protruding submucosal myoma through the cervical canal, and cervical polyp.

As a rule, histological examination of the excised tissue of the tumor makes it

possible to diagnose the case.

Treatment. It depends on the stage of the disease. In stage 0 of cervical

cancer in patients under 50 years electroconization of the cervix or

amputation of its vaginal portion (Sturmdorf operation) is conducted. In

patients over 50 years of age and in those with attendant uterine myoma

extirpation of the uterus without the adnexa is indicated.

In stage I the treatment is usually combined (surgery and radiotherapy):

extended extirpation of the uterus with the adnexa (as proposed by

Wertheim) in combination with radiotherapy before and after the operation.

In stage II combined radiotherapy is employed. Multimodality

treatment is used rarely, (when the tumor has spread onto the uterus—uterine

variant).

In stage III only combined radiotherapy is usually performed.

In stage IV only symptomatic treatment is actually possible.

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Combined radiotherapy involves alternation of external distance

radiation and intraluminal gamma-therapy. The net focal dose is 15-20 Gr.

The prognosis is favourable at the initial stages of the disease: in stage I

it is 75-85 per cent, in stage II - 60-65 per cent of five-year survival.

Urgent care is necessary for patients with cervical cancer in cases of

bleeding linked to an expanded neoplastic process. Bleeding may become

profuse and life threatening. If this is the case, a gynecological nurse or

midwife, even in the absence of a doctor, should conduct a very careful

speculum examination to exclude the presence of an injury to the vagina or

protrusion of a pedunculated submucous myoma through the cervix.

Upon the detection of a "crater-like ulcerated" cervix or growths in the

cervical area of the "cauliflower type" with bleeding vessels it is necessary to

tightly insert tampons into the vagina, with the internal end of a tampon

soaked with hydrogen peroxide or calcium chloride solution. The tampon is

left in place for 6-8 hours after which it is carefully removed. If the bleeding

continues, tamponade should be repeated. Simultaneously, acute anaemia is

treated (transfusion of blood and blood substitutes, as well as other types of

anti-anaemic therapy are carried out).

Self test

1. Which of the following may be established as background process of cervix?

A. acute cervicitis

B. chronic cervicitis

C. isthtmico-cervical incompetency

D. cervical pregnancy

2. Cervical dysplasia is characterized by

A. intensive proliferation of atypical cells

B. ectopy of columnal epithelium

C. endocervical atrophy

D. proliferation of cervical muscles

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3. In Shiller’s test a failure zоne is

A. white in colour

B. brown

C. red

D. unaltered

4. Prior to examination with the colposcope the cervix is swabbed with

A. acetic acid

B. Lugol’s solution

C. chlor zinc iodine

D. iodine water

5. In colposcopic examination the area of suspected dysplaia is

A. white in colour

B. brown

C. red

D. unaltered

6. ”Background” diseases of cervix of the uterus are all of the following except

A. eversion

B. erosion

C. cervical polyps

D. cervical dysplasia.

7. Cervical dysplasia is

A. background process of the cervix

B. precancerous process of the cervix

C. initial stage of malignancy

D. typical malignant lesion of the cervix

8. Epidermoid cancer takes place in case of

A. ovarian cancer

B. cervical cancer

C. cancer of uterine body

D. cancer of fallopian tube

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9. In case of cervical cancer the most frequent hystological type is

A. epidermoid cancer

B. glandular neoplasm

C. solid carcinoma

D. sarcoma

10. In case of profuse bleeding due to cervical cancer the urgent care means

A. vaginal tight tamponade with subsequent surgical intervention

B. vaginal tight tamponade

C. cryosurgery of the cervix

D. conservative hemostatic treatment

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Chapter 17. PREMALIGNANT DISEASES OF THE

ENDOMETRIUM. CANCER OF THE UTERUS.

SARCOMA OF THE UTERUS

Precancerous diseases of the endometrium

Hyperplastic diseases of endometrium are identified as precancerous

diseases in our country. Endometrial hyperplasia is of clinical significance

because it is often a precursor lesion to adenocarcinoma of the endometrium.

It is known that both endometrial hyperplasia and adenocarcinoma are

estrogen dependent conditions; the development of malignancy is

proportionate to the duration of estrogen exposure. Estrogenic stimulation of

the endometrium, unopposed by progestins, causes proliferative glandular

epithelial changes. This finding, due to prolonged hormonal exposure, is

biologically distinct from true precancerous lesions and true neoplasia.

Making the distinction between hyperplasia and true precancerous lesions or

true neoplasia has significant clinical effect because their differing cancer

risks must be matched with an appropriate intervention to avoid

undertreatment or overtreatment.

The classification of endometrial hyperplasia has had numerous

terminologies. Terms that have been used include "adenomatous

hyperplasia," "atypical hyperplasia," and "carcinoma in situ." Some, but not

all, of these lesions represent endometrial carcinoma precursors. The

diagnosis of these proliferative lesions is poorly reproducible because it is

difficult to distinguish between non-neoplastic proliferations and neoplastic

proliferations, and it is difficult to determine endometrial invasion in a

nonhysterectomy specimen. As a result, any proliferative process of

endometrium in addition to the frequent occurrence of hyperplasia of the

endometrium in association with subsequent cancer of the uterine body is a

marked reason for intensive inspection of the patient.

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Classification systems.

The WHO94 classification was the most commonly used system

since 1994. This system characterizes the glandular architectural pattern as

simple or complex and describes the presence or absence of nuclear atypia.

Simple hyperplasia - Increased number of glands but regular glandular

architecture

Complex hyperplasia - Crowded irregular glands

Simple hyperplasia with atypia - Simple hyperplasia with presence of

cytologic atypia (prominent nucleoli and nuclear pleomorphism)

Complex hyperplasia with atypia - Complex hyperplasia with cytologic

atypia

Endometrial intraepithelial neoplasia classification - The

endometrial intraepithelial neoplasia (EIN) classification system was

proposed by an international group of gynecologic pathologists in 2000.

The EIN system defines two classes of endometrial changes: benign and

intraepithelial neoplasia.

●Benign endometrial hyperplasia (EH, non-neoplastic)

o Changes typically observed with anovulation or other etiology of

prolonged exposure to estrogen. The morphology of EH varies from

proliferative endometrium with a few cysts (persistent proliferative

endometrium) to bulkier endometria with many dilated and

contorted glands that in other systems have been designated as

"cystic glandular hyperplasia," "mild hyperplasia," or "simple

hyperplasia."

●Endometrial intraepithelial neoplasia (EIN)

o Endometrial precancers. Epithelial crowding in EIN displaces

stroma to a point at which stromal volume is less than

approximately half of total tissue volume in nonsecretory

endometrium, and typically cells appear morphologically clonal and

distinct from the surrounding endometrium.

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World Health Organization classification — The 2015 WHO

endometrial hyperplasia classification system has only two categories:

●Hyperplasia without atypia (non-neoplastic)

●Atypical hyperplasia (endometrial intraepithelial neoplasm)

Morphological distinguishing

Normal proliferative endometrium exhibits no crowding of glands

within the stroma (<50 percent ratio of glands to stroma). Normal secretory

endometrium may have >50 percent gland-to-stroma ratio. Although

secretory phase glands exhibit crowding, they are organized, and cells

comprising the glands are spaced and are not mitotically active.

Benign endometrial hyperplasia is characterized by a proliferation of

endometrial glands resulting in a greater gland-to-stroma ratio (>50 percent)

than observed in normal proliferative endometrium. The proliferating glands

vary in size and shape, and cells may have cytologic atypia. Mitoses are

typically present in the glandular cells.

Endometrial intraepithelial neoplasia (EIN) is defined as when the

volume of glandular crowding is greater than the stromal volume, the

presence of cytologic alterations, a lesion larger than 1 mm, and exclusion of

mimics or carcinoma.

It is sometimes difficult to distinguish a precursor lesion (EIN) from

endometrial carcinoma. Atypical hyperplasia or EIN is distinguished from

grade 1 endometrial carcinoma by findings that suggest invasion, including:

invasive pattern of glands infiltrating reactive stroma (the most definitive),

cribriform glands, or confluent growth (lack of stroma between glands).

Marked nuclear atypia, especially in the context of atrophic background

endometrium, may be present in either endometrial intraepithelial serous

neoplasm or "intraepithelial carcinoma," which is frequently associated with

invasive serous carcinoma.

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Etiology. Endometrial hyperplasia results from continuous estrogen

stimulation that is unopposed by progesterone. This can be due to

endogenous estrogen or exogenous estrogenic sources. These diseases

develop in the presence of impaired hypothalamic-pituitary-ovarian

interrelationships and may be accompanied by abnormal uterine bleedings.

Those are:

Chronic anovulation associated with polycystic ovary syndrome

(PCOS).

Obesity, which contributes to unopposed estrogen exposure due to

chronic high levels of estradiol that result from aromatization of

androgens in adipose tissue and conversion of androstenedione to

estrone.

Endometrial hyperplasia and cancer, which are the result of

estradiol-secreting ovarian tumors, such as tumors of granulosa

cells.

Other risk factors include obesity, nulliparity, early menarche, and

late menopause.

Clinical picture. A major symptom of precancerous change of

endometrium is acyclic uterine bleeding. Bleeding may be sudden and profuse

in nature or occur as prolonged and scanty sanguineous discharge. Both

variants of uterine bleeding are linked with weakening of the patient; anemia

is frequently found. Bleeding is more frequent after menstrual delay lasting

from 6-8 weeks to several months. Cyclic bleeding occurring at the time of

expected menstruation and continuing for a long time is also possible.

Sanguineous discharge in postmenopausal women should always be

considered a sign of precancerous state or cancer of the endometrium.

Women with precancerous diseases of the endometrium are often

characterized by neuroendocrine and metabolic disorders (obesity, diabetes

mellitus, essential hypertension), prolonged menstrual disturbances,

impaired fertility, and delayed menopause (after 50-52 years of age).

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Diagnosis of endometrial hyperplasia. Endometrial hyperplasia is a

histologic diagnosis made based upon the results of evaluation of an

endometrial biopsy, endometrial curettage sample, or hysterectomy

specimen.

Tissue sampling should be performed in women with risk factors who

present with symptoms of abnormal vaginal bleeding or discharge. This

includes:

women older than 35 years with abnormal bleeding,

women younger than 35 years with bleeding and risk factors,

women with persistent bleeding,

women with unopposed estrogen replacement, tamoxifen therapy,

and hereditary nonpolyposis colorectal cancer (HNPCC) cancer

syndrome.

women with atypical glandular cells (AGC) Pap smear or

endometrial cells in Pap smears of women older than 40 years

when out of synch with menstrual cycle.

If insufficient tissue is obtained on suction curettage, or if a patient

continues to have abnormal bleeding, a formal D&C with histilogy is

recommended.

Imaging studies are also used for diagnostics:

TVUS can visualize the endometrium and the thickness of the

endometrium can be measured

Magnetic resonance imaging and computed tomography areuseful

for obtaining preoperative data on the extent and depth of

myometrial invasion by endometrial carcinoma rather than in the

primary diagnosis of endometrial carcinoma and its precursors

Hysteroscopy can be used in any woman with abnormal uterine

bleeding in whom an intrauterine abnormality is suspected

The accurate diagnosis of hyperplasia type is vital for appropriate

treatment based on risk of cancer without over or under treatment.

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Treatment and management. Treatment depends on degree of

hyperplasia, the patient's symptoms such as severity of bleeding, surgical

risks, and wish for future childbearing. Management depends on whether the

underlying disease is primarily hormonal (non-neoplastic endometrial

hyperplasia) or intrinsic premalignant disease (EIN).

Hyperplasia without atypia (non-neoplastic) responds well to

progestins. Changes in the hormonal environment, such as the administration

of progesterone, help control bleeding and prevent the progression of cancer,

reducing the degree of cytological atypia. The duration of progestin

administration is crucial for inhibiting endometrial mitotic activity; this is

important because control of endometrial growth is primarily related to

control of epithelial mitotic activity.

Clinical management of EIN is usually hysterectomy. There is a clinical

need for nonsurgical alternative therapies in women who wish to retain

fertility, or are poor surgical candidates. Medical hormone therapy may be

given to women whose general health is unsuitable to withstand surgery. High

dose progestin therapy can succeed in ablating some EIN lesions, but,

because of the high concurrent cancer rate and unpredictable response, must

be accompanied by careful clinical surveillance.

Recommended regimen for non-neoplastic endometrial hyperplasia:

Medroxyprogesterone acetate (MPA), 10 mg orally, or micronized

progesterone, 300 mg orally, once a day for 14 days per month for 3

months. Such cyclic regimens lead to withdrawal bleeding; a biopsy

specimen is obtained at the end of the progestin therapy at 3–4 months.

o Complete responders (reversal of endometrial hyperplasia to

progestational-type endometrium) should be maintained on cyclic

progesterone therapy or, if appropriate, combined cyclic or

continuous HRT.

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o If a partial response is obtained, another 3-month trial with MPA,

10 mg orally four times per day, or megestrol acetate, 80 mg, for 3

months may be carried out.

o Nonresponders and patients with intractable breakthrough

bleeding may have transabdominal hysterectomy.

Recommended regimen for endometrial intraepithelial neoplasia:

Progestin therapy for premenopausal women with EIN calls for larger

doses of MPA, 100 mg orally daily; megestrol acetate, 160 mg; or 1

g/week of MPA intramuscularly for 12 weeks.

Another option of hormonal therapy for endometrial hyperplasia

with or without atypia is medicated intrauterine device (IUD) such as the

LNG- (levonorgestrel) releasing intrauterine system (Mirena®, Bayer

Healthcare Pharmaceuticals, Inc. Wayne, NJ, USA). In general, EH

responds better (90–100%) than EIN (67–88%) to intrauterine LNG. In

addition to the powerful progestational effect of Mirena on the

endometrium, adverse events (side effects) that are commonly experienced

by patients with oral progestational therapy are considerably reduced. This

is because the systemic absorption of LNG is considerably reduced

compared to oral progestational therapy. The biopsy specimen should

show progestational-type endometrium with marked stromal

decidualization. Careful follow up surveillence, including repeated biopsy

at approximately 6 month intervals until several are free of disease is

advised to ensure complete ablation. Induction of ovulation should follow

the progestational therapy.

Any progestin should be adequate for treatment of hyperplasia

without atypia or for maintenance after resolution of atypical hyperplasia.

Patient should be sampled to assess for response every 3 to 6 months for

regression to normal endometrium. If there is inadequate response in 6

months, consider increasing dose or changing progestins. Continued

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surveillance after regression of the lesion is recommended every 6-12

months if risk factors persist. Repeat biopsy is also indicated for recurrent

abnormal bleeding or discharge. Prevention of recurrence include use of

daily or cyclic progesterone, indwelling levonorgestrel IUD, along with

weight loss for obese patients.

Surgical treatment.

Surgery (i.e., transabdominal hysterectomy) with or without bilateral

salpingo-oophorectomy is recommended for women who have persistent

benign endometrial hyperplasia but are symptomatic (abnormal uterine

bleeding) and women in the postreproductive age group with EIN.

Total hysterectomy is indicated for endometrial intraepithelial

neoplasia; it provides definitive assessment of a possible concurrent

carcinoma and effectively treats premalignant lesions. Current surgical

options include abdominal, vaginal, and minimally invasive procedures.

Surgical option may also include total hysterectomy with or without bilateral

salpingo-oophorectomy in patients with a biopsy diagnosis of endometrial

intraepithelial neoplasia. Removal of the cervix together with the uterine

corpus permits staging of any incidentally discovered cancer and reduces the

risk of leaving behind residual disease.

Cancer of the Uterus

Cancer of the uterine corpus (uterine cancer) is observed in women over

50 years of age. More commonly the disease affects nulliparous women or

women of low parity with a delayed menarche or menopause. The incidence

of uterine cancer varies considerably in women of different nationalities.

More frequently the disease develops against the background of

hyperplastic processes of the endometrium (first pathogenetic variant) and is

combined with neuro-endocrine disturbances, diabetes mellitus, obesity, and

essential hypertension. Cancer may also develop in the presence of atrophic

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endometrium (second pathogenetic variant) in women without

neuroendocrine diseases.

Classification of Cancer of the Uterine Corpus

Stage 0: histological findings allowing to suspect malignancy of the

hyperplastic process of the endometrium.

Stage I: the tumor remains within the uterine body (Fig. 230).

Stage lA: the length of the uterine cavity does not exceed 8 cm.

Stage IB the uterine cavity is more than 8 cm.

The following histological groups are distinguished within stage I: G1 —

highly differentiated adenocarcinoma, G2 — differentiated adenocarcinoma

with zones of solid structure, G3 — undifferentiated carcinoma.

Stage II: the tumor has spread onto the corpus and cervix of the uterus

(Fig. 231).

Stage III: the tumor has spread outside the corpus but not outside the

true pelvis (Fig. 232).

Stage IV: the tumor has spread beyond the pelvis, has grown into the

bladder and rectum, or has given rise to distant metastases.

Clinical picture. The main symptom of endometrial cancer is abnormal

uterine bleeding in the reproductive or the premenopausal period, as well as

bleeding after the menopause (uterine cancer is found in every second

postmenopausal patient with uterine bleeding). Frequent findings are serous

leucorrhea with blood threads or leucorrhea of "meat slops" type, pain and

feeling of heaviness in the lower abdomen, which intensify and may be

convulsive in nature when there is accumulation of pus in the uterus

(pyometra).

Further progression of the process (stages III-IV) may be characterized

by marked symptomatology typical of impaired function of the adjacent

organs, and emaciation (cachexia).

Diagnosis. The diagnosis of uterine cancer is based on the history,

general physical and gynecological examination, as well as on additional

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methods of examination. Gynecological examination is directed at

determining the size and mobility of the uterus, the degree of possible

infiltration of parametrial and rectovaginal cellular tissue, and adnexal

enlargement.

Mandatory components also include cytological and histological

examination. Smears for the former are prepared from the material obtained

from the posterior vaginal fornix, cervical canal, and uterine cavity (in the

latter case the material is taken with the help of aspiration biopsy and by

washing off a sample with a Braun syringe). Histological examination of the

material is conducted after separate curettage of the mucous membrane of the

cervical canal and uterine mucosa. If following an insignificant dilatation of

the cervical canal, there is a discharge of crumby masses from the uterine

cavity; only scraping should be performed since diagnostic dilatation and

curettage in this case is unwarranted in view of possible perforation of the

altered uterine wall.

Fig. 230. Cancer of the uterus. Stage I

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Fig. 231. Cancer of the uterus, stage II Fig. 232. Cancer of the uterus,

stage III

In cases when an extended process is suspected (stages III-IV) separate

diagnostic dilatation and curettage may be substituted by radioisotope

examination.

Hysteroscopy (visual examination of the walls of the uterine cavity) has

been finding an increasingly wide application in recent years. Occasionally,

hysterosalpingography is performed for the diagnostic purpose.

Treatment given to patients with cancer of the uterine body should be

combined (surgical, X-ray, and hormonal).

The scope of surgical intervention (extirpation of the uterus along with

the adnexa, extirpation of the uterus with the adnexa plus lymphadenectomy,

expanded extirpation of the uterus with the adnexa by the type of surgery

described by Wertheim) depends on the stage of the disease as well as on the

patient's age and general status. In elderly patients with somatic diseases and

the neuroendocrine syndrome with marked obesity simple extirpation of the

uterus together with the adnexa is the most commonly employed procedure.

If there are no contraindications, the scope of surgery may be expanded since

removal of the lymph nodes of the true pelvis is also indicated in such

patients.

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In the second stage of multimodality treatment the patient is subjected

to distance radiation in a dose of 40 Gr.

Hormonal therapy consists of prolonged (up to 3-5 years) intramuscular

administration of 12. 5 per cent solution of hydroxyprogesterone caproate.

Within the first 2 months of the therapy the daily dose of the solution is 500

mg; later on, the dose is gradually decreased to 500 mg once a week.

Quite often one employs a multimodality treatment (surgical and X-ray)

and combined radiotherapy (combination of distance irradiation and

intracavitary gamma-therapy).

The prognosis is favourable in the initial stages of the disease

comprising 91. 5 per cent of five-year survival in stage I, 85. 5 per cent in stage

II and 57. 5 per cent in stage III.

Urgent care in endometrial cancer is necessary in patients with uterine

profuse bleeding or in those with a pyometra attended by manifestations of

acute inflammation in the true pelvis and systemic intoxication.

In the case of profuse uterine bleeding which cannot be arrested by

haemostatic therapy the method of choice is urgent surgical intervention

(hysterectomy).

To diagnose pyometra, one should perform bougienage and cervical

dilatation with Hegar's dilators, with the subsequent evacuation of pus.

Bougienage is carefully performed with a thin bulbous-end probe. In the case

of complication (uterine perforation) urgent surgical intervention is needed.

Uterine bougienage should be followed by a course of antibacterial and

disintoxication therapy after which separate diagnostic dilatation and

curettage become possible.

The diagnostics and management of precancerous diseases of

endometrium and endometrial cancer are summarized in table 20.

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Table 20.

Precancerous diseases of the endometrium m and endometrial

cancer management

Nomenclature Criteria Functional Category

Management

Benign endometrial hyperplasia (BEH)

1. Irregular glands with cysts 2. More glands than stroma 3. No cytologic change 4. Field-wide changes

Estrogen effect

Hormonal therapy

Endometrial intraepithelial neoplasia (EIN)

1. Cytologic change 2. Gland exceeds stromal area 3. Size >1 mm in single fragment 4. Exclusion of mimics 5. Exclusion of carcinoma

Precancer

Hormonal or surgical therapy

Adenocarcinoma

1. Myoinvasion 2. Solid epithelium 3. Maze-like glands 4. Cribriform architecture

Cancer

Surgical and/or radiotherapy

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Sarcoma of the Uterine Body

Sarcoma of the uterine body is a malignant tumour developing from

connective tissue of the myometrium or from muscle fibres. (Fig. 111). Not

uncommonly it develops inside uterine myoma. The rate of the disease is the

highest at the age of 45-50. Developing interstitially the tumour is

characterized by early and rapid metastatic spread. In many cases the main

symptom of uterine sarcoma is a rapid growth of a tumour. Other

characteristic features include prolonged and profuse menstruations, with

possible acyclic (breakthrough) uterine bleeding. However, histological

examination of the endometrium may reveal no sarcoma elements since the

uterine mucosa is rarely affected.

Treatment. The treatment usually involves extirpation of the uterus

together with the adnexa and subsequent radiotherapy. In view of very

unsatisfactory results of the treatment for uterine sarcoma and a rapid

propagation or recurrence of the tumour chemotherapy has been finding an

increasingly wide application. Such drugs as methotrexate, fluorouracil,

prospidine, adriamycin, etc. are recommended for this purpose.

Early surgical intervention in cases of a rapid growth of uterine myoma

may prevent the most prevalent forms of sarcoma of the uterine corpus.

Self test

1. Which of the following is not precancerous lesion of endometrium?

A. adenomatosis

B. cystic hyperplasia

C. adenomiosis

D. proliferation of the functional layer

2. Leucorrhea is a symptom of

A. cervical cancer

B. cancer of the uterus

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C. ovarian cancer

D. fallopian tube cancer

3. Hormonal therapy may be used in

A. cervical cancer

B. cancer of the uterine body

C. ovarian cancer

D. vaginal cancer

4 Does the treatment of uterine cancer depend on the age of patients?

A. Yes

B. No

5. Which of the following may be used for hormonal treatment of endomtrial

cancer?

A. hydroxyprogesterone caproate

B. progesterone

C. synestrol

D. legalon

6. Histologically the uterine cancer is not a

A. malignant adenoma

B. malignant acanthoma

C. adenocarcinoma (glandular neoplasm)

D. epidermoid carcinoma

7. What is the immediate cause of hyperplastic lesion of the endometrium?

A. inflammatory processes of the uterus

B. low estrogen level in the organism

C. high level of estrogens in the organism

D. just listed above

8. In patient of 30 years of age there is adenomatous hyperplasia of

endometrium. What is the treatment?

A. radiotherapy

B. chemotherapy

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C. treatment with estrogen drugs

D. treatment with gestogen drugs

9. Surgical treatment of endometrial cancer is indicated

A. in early stages of diasease (stage I)

B. in the late stage of disease

C. In every stage of disease

D. Is not indicated at all

10. In the case of profuse uterine bleeding which cannot be arrested by

hemostatic therapy? The method of choice is

A. urgent surgical intervention (hysterectomy)

B. curettage of the uterine cavity

C. urgent radiotherapy

D. urgent chemotherapy

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Chapter 18. CYSTS OF THE OVARY. OVARIAN

TUMORS

Cysts of the ovary

Retention cysts

Retention cysts belong to tumor-like formations of the female genital

organs. A cyst is a cavity filled with fluid and is secondary to either retention

or excessive secretion of fluid. Cysts enlarge as a result of fluid accumulation

and may be encountered in all parts of the female genital system: vulva,

vagina, cervix, ovary, and broad ligament of the uterus. Most commonly cysts

are localized in the ovary and supra-ovarian adnexa (paroophoritic cyst).

Cysts developing in the ovaries are divided into follicular cysts and lutein

cysts (Fig. 233).

Fig. 233. Retention cyst of the ovary

A follicular cyst develops from an atretic follicle, most frequently due to

an inflammatory process. A follicular cyst does not exceed 10-12 cm in

diameter; it has thin walls and its contents is transparent fluid of a straw or

orange color. The cyst is movable and softly elastic. On one of the cyst poles

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there may be unchanged ovarian tissue spread on the capsule. The internal

surface of the cyst is even, smooth, and lustrous.

Most often the wall of a follicular cyst consists of connective tissue and

has no internal epithelium or is lined with cubical single-layer epithelium.

A lutein cyst is less frequent than a follicular one. It is also caused by an

inflammation. In macro- and microscopic terms it is similar to a follicular

cyst.

A paroophortic cyst (cyst of the paroophoron) forms as a result of

secretion retained in the lumen of the tubules of the paroophoron situated

between the ovary and oviduct in the broad uterine ligament. A paroophoritic

cyst has two capsules because of its intraligamentous position: an inherent

one and one in the form of layers of the broad uterine ligament with a

crosswise vascular pattern (feature distinguishing it from other retention

formations) (Fig. 234). A cyst may measure up to 20 cm in diameter. It has

thin walls and is slightly mobile. Alongside a cyst one can usually palpate or

visualize by laparoscopy the unaltered ovary and oviduct flattened on the cyst

surface. The internal surface of the cyst is smooth, lustrous, and covered with

cylindrical or squamous epithelium.

Theca-lutein cysts are also classified as retention cysts of the ovaries

since they can spontaneously resolve as a result of the treatment of the

underlying disease (hydatidiform mole or uterine chorionepithelioma) with

which they are associated, being its manifestation.

Fig. 234. Paraoophoritic cyst

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Clinical picture. Retention cysts of the ovary are often asymptomatic

and only in the event of their complicated course related to torsion of the cyst

pedicle, or impaired nutrition or rupture of its capsule, clinical manifestations

of acute abdomen are encountered.

Diagnosis. The diagnosis of retention cysts is usually based on findings

of bimanual vaginal examination and is made when a formation measuring up

to 10-12 cm is palpated to the left or right side from the uterus. It is softly

elastic, mobile, and painless. Retention cysts are more frequently observed in

young age. The diagnosis of a retention cyst of the ovary in elderly women

should be made with considerable caution and only following the exclusion of

a true ovarian tumour.

Ovarian cysts should be differentiated from true ovarian tumours,

uterine myoma (subserous nodes), tubo-ovarian formations of the

inflammatory nature, and extragenital tumours.

To specify the diagnosis, one can resort to laparoscopy. In this case a

retention cyst is visualized as a thin-walled formation; one can see only an

unaltered portion of the ovary (most commonly in the area of its hilum) and

the uterine tube.

Treatment. Small retention cysts may resolve as a result of anti-

inflammatory therapy, which can be continued for no longer than 4-6 weeks.

If it is unsuccessful, surgical intervention is indicated (resection of the ovary

and even, when indicated, its removal). In the event of a paroophoritic cyst

surgery consists of its enucleation following resection of the layer of the broad

uterine ligament without removal of the ovary and fallopian tube.

Prevention of retention cysts is difficult and relies on the early and

adequate treatment of acute inflammatory processes of the internal genital

organs. In view of a possible relationship between retention cysts and

hormonal dysfunction of the ovaries, prevention of cysts should be aimed at

the study and correction of impaired hormonal relationships in the patient's

body.

600

Upon making the diagnosis of an ovarian cyst the patient should be

followed up. Modern methods of the diagnosis and treatment of retention

cysts may finally be considered as methods preventing ovarian cancer since in

every fourth patient with the diagnosis of "a retention cyst" a true ovarian

tumour is finally diagnosed.

Ovarian tumors

Ovarian neoplasms are diverse in their nature since the ovary contains

elements of all three germinal layers.

Histological classification of ovarian tumors

I. Epithelial tumors

A. Serous tumors

1. Benign:

cystadenoma and papillary cystadenoma;

superficial papilloma;

adenofibroma and cystadenofibroma

2. Borderline (of a potentially low degree of malignancy):

cystadenoma and papillary cystadenoma;

superficial papilloma;

adenofibroma and cystadenofibroma.

3. Malignant:

adenocarcinoma; papillary adenocarcinoma and papillary

cystadenocarcinoma; surface papillary carcinoma;

malignant adenofibroma and cystadenofibroma.

B. Mucinous tumors

1. Benign:

cystadenoma;

adenofibroma and cystadenofibroma

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2. Borderline (potentially of a low degree of malignancy):

cystadenoma;

adenofibroma and cystadenofibroma

3. Malignant:

adenocarcinoma and cystadenocarcinoma;

malignant adenofibroma and cystadenofibroma

C. Endometrioid tumors

1. Benign:

adenoma and cystadenoma;

adenofibroma and cystadenofibroma.

2. Borderline (potentially of a low degree of malignancy):

adenoma and cystadenoma;

adenofibroma and cystadenofibroma

3. Malignant:

carcinoma, adenocarcinoma, adenoacanthoma, malignant

adenofibroma and cystadenofibroma;

endometrioid stromal sarcoma;

mesodermal (Muller's) mixed tumors

D. Light cell (mesonephroid) tumors:

1. Benign: adenofibroma.

2. Borderline (potentially of a low degree of malignancy).

3. Malignant: carcinoma and adenocarcinoma.

E. Brenner's tumors:

1. Benign

2. Borderline

3. Malignant

F. Mixed epithelial tumors:

1. Benign

2. Borderline

3. Malignant

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G. Undifferentiated carcinoma.

H. Unclassified epithelial tumors.

II. Tumors of the genital cord stroma:

A. Granulosostromal cell tumors:

1. Granulosa-cell tumors (folliculomas).

2. Group of thecomas-fibromas:

thecoma;

fibroma;

unclassified.

B. Androblastomas: Sertoli and Leydig cell tumors:

1. Highly differentiated:

tubular androblastoma; Sertoli cell tumor;

tubular androblastoma with accumulation of lipids; Sertoli

cell tumor with accumulation of lipids (Lesen's lipid

folliculoma);

Sertoli and Leydig cell tumors;

Leydig cell tumor (hilum cell tumor).

1. Intermediate (transitional) differentiation

2. Poorly differentiated (sarcomatoid)

3. With heterologous elements

C. Gynandroblastoma

D. Unclassified tumours of the genital cord stroma

III. Lipid-cellular tumors.

IV. Germinal tumors:

A. Disgerminoma

B. Tumor of the endodermal sinus

C. Embryonic carcinoma

D. Polyembryoma

E. Chorionepithelioma

F. Teratomas:

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1. Immature;

2. Mature:

solid;

cystic (dermoid cyst, dermoid cyst with malignancy).

3. Monodermal (highly specialized):

ovarian struma;

carcinoid;

ovarian struma and carcinoid;

others.

G. Mixed germinal tumors

V. Gonadoblastoma:

A. Pure (without admixture of any other forms);

B. Mixed with disgerminoma and other forms of germinal

tumors;

VI. Soft tissue tumors, non-specific for the ovaries

VII. Unclassified tumors.

VIII. Secondary (metastatic) tumors.

The most frequent type of benign ovarian tumours is epithelial tumors

(cystomas).

Serous cystadenoma (simple serous cystoma) develops from the

mesodermal epithelium, most commonly in women aged from 40 to 50 years.

Cystadenomas usually measure up to 12 cm in diameter, but larger

tumours may also be encountered. Their content is liquid and transparent.

The capsule is denser than in retention cysts and is characterized by a marked

vascular pattern. Upon palpation the tumour feels as densely elastic.

In 5-10 per cent of all cases cystadenoma becomes malignant.

Serous papillary cystadenoma (cilioepithelial papillary cystoma) opens

the list as far as the potential possibility of a tumour to become malignant is

concerned (every other papillary cystadenoma turns cancerous). Up to 70 per

cent of cancerous tumours of the ovaries are papillary cystadenomas turning

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malignant. Most frequently this tumour occurs at the age of 50-60 years.

Most often it is bilateral, middle-sized, roundish or ovoid, densely elastic,

with smooth or tuberous surface and papillary internal growths (Fig. 235).

Fig. 235. Bilateral papillarycystoma of the ovaries.

Mucinous cystadenoma is the largest ovarian tumor, occasionally

occupying the entire abdominal cavity (tumors have been described which

weighed 50 kg and more), tuberous, multi-chamber with thick mucoid

contents, usually unilateral. Up to 5 per cent of such tumors turn malignant.

As for the degree of potential malignancy, granulosa-cell tumors

(folliculomas) come second after papillary cystadenomas and become

malignant in 25-30 per cent of all cases. Most granulosa-cell tumors are

unilateral. They may both be small and occupy the entire abdominal cavity.

Granulosa-cell tumors are most common in postmenopausal women and

possess (due to oestrogen secretion) feminizing hormonal activity.

Theca-cell ovarian tumors (thecomas) occur significantly less

commonly than granulosa-cell ones and also present a feminizing hormonally

active tumor. Structurally, it resembles the form of the ovary, is small, dense

to palpation, usually of solid structure on section, and yellow in color.

Microscopic findings include theca cells enclosed in the tumor. Thecomas are

605

more frequent in postmenopausal women. Tumors become malignant in 1-5

per cent of cases.

Ovarian fibroma actually presents as thecoma, i. e., a tumor made of

thecal cells that does not have hormonal activity. Malignancy is a rare

occurrence (1 per cent of cases). It follows the shape of the ovary, varies in

size (most often measuring up to 10-12 cm in diameter), and is very dense.

Sectional appearance is whitish in colour and fibrous in structure.

Androblastoma (arrhenoblastoma) belongs to masculinizing ovarian

tumors. It possesses androgenic activity, appears as smooth greyish-whitish

nodes, averaging 10-12 cm in diameter, and is usually unilateral. Tumor

consists of cells resembling those of the male sexual gland. Most commonly it

occurs in young age (25-35 years). Androblastomas have a benign course in

most cases. Yet, malignant forms are not infrequent.

Mature teratoma (dermoid cyst) is a neoplasm of variable consistency

(tight elastic with indurated sites) with the roundish or oval shape. It tends to

be localized anteriorly to the uterus, is unilateral, and averages 10-12 cm in

size. Section examination demonstrates fat, hair, cartilaginoid and bone

formations. A dermoid cyst occurs most commonly at the age of 20-40 years.

It accounts for 15 per cent of all ovarian tumors, with malignancy occurring in

1-1. 5 per cent of cases.

Disgerminoma is almost always malignant and usually occurs in

childhood. The tumour varies in size and is roundish or tuberous in shape.

The tumour is usually unilateral; its consistency is dense or tight elastic.

Clinical picture. Ovarian tumor may be asymptomatic. However, in

cases of large neoplasms, dysfunction of the adjacent organs (bladder and

rectum), torsion of the tumor pedicle, and impaired nutrition of the tumor

one can observe the corresponding symptomatology (low abdominal pain,

impaired micturition and defecation).

Almost all ovarian tumors possess some hormonal activity, which is not

uncommonly expressed in menstrual disorders. Tumors of the genital cord

606

stroma display the greatest hormonal activity. Thus, granulosa-cell and theca-

cell tumors can secrete elevated levels of estrogens and may cause

proliferative processes in the uterus, which leads to breakthrough (acyclic)

bleeding and to sanguineous discharge in postmenopausal women. Patients

feel a burst of vigor; "the second youth" appears to have come.

Arrhenoblastoma, having a masculinizing property, induces

amenorrhea, breast reduction, growth of hair on the face, and hoarse voice.

Ovarian fibroma is often accompanied by the development of ascitis and

hydrothorax.

The most common ovarian tumor in girls is mature teratoma. Yet, other

tumors, including malignant ones, may also be encountered. The clinical

picture of ovarian tumors in girls is distinguished by their ability to affect

sexual development. Thus, feminizing tumors are associated with precocious

puberty. On the other hand, disgerminomas are related to genital hypoplasia,

underdevelopment of secondary sex characters, and delayed menarche.

Arrhenoblastoma may also be reflected in delayed puberty.

Diagnosis. It is based on the history and general physical and

gynecological examinations. Of major significance are results of bimanual and

rectovaginal examinations. The diagnosis of an ovarian tumor is established

with consideration of the size, position, consistence, and mobility of a

formation palpated in the true pelvis laterally to the uterus.

The nature of a tumor may be determined only after laparotomy and its

removal, often only after histological examination.

Ovarian tumors should be distinguished from uterine and intestinal

tumors, retention cysts, inflammatory adnexal processes, and a dystopic

kidney. The diagnosis is specified with the help of sounding of the uterine

cavity, ultrasound scanning, laparoscopy, radiographic methods, and

examination of the gastro-intestinal tract and urinary system.

Treatment. The only available method of treatment is surgical. Only

true ovarian tumors call for mandatory surgical intervention. The scope of

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surgery depends on the nature of the tumor. Usually, the involved ovary

should be removed. The slightest suspicion of malignancy is an indication for

urgent histological examination to determine the scope of surgery. However,

exclusions are possible. For example, if a girl or a young woman has a

dermoid cyst, one can resort to ovarian resection. In cases of a papillary

ovarian cystadenoma (a high degree of potential malignancy) supravaginal

amputation of the uterus with the adnexa and resection of the omentum are

performed.

The main guarantee of reliable prophylaxis is regular (twice a year)

examinations. At present groups of patients at risk for the development of

tumors, including ovarian ones (since any true tumour of the ovary is

potentially malignant), have been identified. Such patients include those who

have been observed at a women's consulting centre for a long time for uterine

myoma and undifferentiated tumor-like formations of the small pelvis. Early

diagnosis and treatment of true tumors present reliable ovarian cancer

prophylaxis.

Ovarian Cancer

Ovarian cancer may be primary, secondary, and metastatic. Primary

cancer occurs in 4-5 per cent of cases, this tumor from the very beginning has

malignant nature. Secondary cancer – is one of the most frequent forms of

ovarian cancer, the incidence is about 80-85% in relation to all forms of

ovarian cancer. It may delevelop in papillary cystoma of the ovary; rarely in

pseudomucinous cystoma (other name is «cancer in cystoma»).

Metastatic tumors account for 20 per cent of all malignant neoplasms of

the ovaries. Most frequent findings are a metastatic tumor of the Krukenberg

type (metastases of cancer of the gastrointestinal tract) and metastases into

the ovaries in patients with breast cancer.

608

Symptomatology and choice of the method of treatment depend on

manifestations of the underlying disease. Of the greatest clinical interest is

secondary ovarian cancer developing from previous benign true tumors.

Four stages of ovarian cancer are distinguished.

Classification. (as described by the international federation of

Gynecology and Obstetrics (FIGO).

Stage I: Growth limited to the ovaries;

Stage IA: Growth limited to one ovary, no tumour on the external

surface, and capsule intact;

Stage IB: Growth limited to both ovaries; no tumour on the external

surface, and capsule intact.

Stage IC: IA or IB but with tumor on the surface of one or both ovaries,

with capsule rupture, or with ascites or peritoneal washings containing

malignant cells;

Stage II: Involving one or both ovaries with pelvic extension.

Stage IIA: Extension and/or metastases to the uterus and/or tubes.

Stage IIB: Extension to other pelvic tissues.

Stage IIC: Stage IA or IB but with tumour on the surface of one or both

ovaries, with capsule rupture, or with ascites or peritoneal washings,

containing malignant cells.

Stage III: Involving one or both ovaries with histologically confirmed

peritoneal implants outside the pelvis and/or positive retroperitoneal or

inguinal lymph nodes.

Stage IIIA: Grossly limited to the true pelvis with negative lymph nodes,

but with histologically confirmed microscopic tumour outside pelvis.

Stage IIIB: Involving one or both ovaries with histologically confirmed

implants on abdominal peritoneal surface 2 cm in diameter and with

negative lymph nodes.

Stage IIIC: Abdominal implants 2 cm in diameter and/or positive

retroperitoneal or inguinal lymph node

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Stage IV: involving one or both ovaries with distant metastases.

Clinical picture. In early stages the relevant symptoms are

unremarkable and only torsion of the tumor pedicle or rupture of the tumor

capsule may be associated with acute pain in the lower abdomen.

Dissemination of the process is attended by impairment of the general status

and functions of the pelvic organs. Other findings include weakness,

perspiration, loss of weight, rapid fatiguability, constant dull pain in the lower

abdomen, a feeling of abdominal bloating and abdominal enlargement due to

ascitis, dyspnea secondary to the presence of exudate in the pleural cavity,

and constipation. Acyclic uterine bleeding may occur.

Diagnosis. It is difficult in early stages of the disease because of

unremarkable symptomatology. Not uncommonly, a tumor is found during a

prophylactic examination. Ovarian cancer should be suspected if an indurate

ovarian tumor with a tuberous surface, which is somewhat mobile and is

combined with ascitis, is determined during gynecological examination.

Through the posterior fornix one can palpate dense "spikes" presenting

tumor-like masses.

In stages III-IV the disease is attended by ascitis and hydrothorax. In

the upper abdomen one can palpate a dense tuberous greater omentum, in

which metastases of the tumor are most often found. Metastatic masses may

affect virtually all portions of the abdominal cavity, including the hepatic area.

A group of risk for the development of ovarian cancer includes patients

with a prolonged recurrent inflammatory process of the uterine adnexa,

multiple uterine myoma, retention cysts, and vague tumor-like formations in

the true pelvis.

To establish the differential diagnosis, one can use such additional

methods as pelviography, laparoscopy, and ultrasound scanning. To specify

the stage of tumor dissemination, one should examine the gastrointestinal

tract (roentgenoscopy of the stomach, irrigoscopy) and the urinary tract

(excretory urography).

610

Treatment. The treatment should be combined (surgical intervention

and chemotherapy). Extirpation of the uterus and adnexa and resection of the

greater omentum are carried out. Yet, in the case of an extended process such

scope of surgical intervention is technically impossible. It is advisable to

remove major tumor-like masses in such cases.

Chemotherapy (thiotepa, cyclophosphamide, sarcolysine, fluorouracil,

etc.) is employed before and after surgery. Repeated courses of

polychemotherapy have found wide application.

Androgens are also employed in the combined treatment of ovarian

cancer.

Self test

1. Krukenberg’s tumor is

A. a primary tumor

B. a metastatic tumor

2. Which of the following is not a high risk for the development of ovarian

cancer?

A. a prolonged recurrent inflammatory process of the uterine adnexa

B. a multiple uterine myoma

C. the retention cysts

D. a chronic endocervicitis

3. The treatment of ovarian cancer should be

A. surgical

B. chemotherapeutical

C. combined (surgical intervention and chemotherapy)

D. only X-ray therapy

4. Which of the stages of ovarian cancer is characterized by dissemination of the

tumour outside the parietal pelvic peritoneum?

A. stageI

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B. stage II

C. stage III

D. stage IY

5. The treatment of mature teratoma should be

A. surgical

B. hormonal

C. physiotherapeutical

D. radiotherapeutical

6. Granulosa-cell tumors become malignant in

A. 25-30 per cent of all cases

B. 35-40 per cent of all cases

C. 45-50 per cent of all cases

D. 55-60 per cent of all cases

7. A paroophoritic cyst forms as a result of

A. secretion retained in the lumen of the tubules of the paroophoron

B. hydrogenous transformation of the paraoophoron

C. radiotherapy

D. congenital formation

8. Arrhenoblastoma, having a masculinizing property, induces all of the

following except

A. amenorrhea

B. breast reduction

C. growth of hair on the face

D. adiposogenital dystrophy

9. The risk of malignization of ovarian fibroma is in

A. 1 per cent of cases

B. 10 per cent of cases

C. 25-30 per cent of cases

D. 0. 1-0. 5 per cent of cases

612

10. Most frequently papillary cystadenomas occur at the age of

A. 10-20 years

B. 25-35 years

C. 35-48 years

D. 50-60 years

613

Chapter 19. CANCER OF THE FALLOPIAN TUBES

Cancer of the fallopian tubes is the rarest gynecologic malignancy.

Overall, tubal cancer accounts for 0. 1 to 0,5 percent of all gynecologic

cancers.

Primary cancer of the uterine tube is rarely encountered. More

frequently it is secondary to propagation of the malignant process from the

uterus or ovary onto the oviduct.

The average age of the patients with this cancer is 50 to 60 years. Risk

factors are not well defined, however, chronic inflammatory disease, such as

salpingitis, tuberculosis is a possible etiologic factor. Patients sometimes have

a remote history of infertility.

Because of the rarity, information regarding etiology, epidemiology and

treatment is limited.

More than 95% of fallopian tube cancers are papillary serous

adenocarcinomas, arising from the epithelium of the fallopian tubes. A few

are sarcomas (Fig. 236).

The spread pattern is similar to that of ovarian cancer. Fallopian tube

cancer is spread by direct extension, by peritoneal seeding, or through the

lymphatics.

Classification depends on stages.

Staging is similar to that for ovarian cancer:

Stage 0: carcinoma in situ (limited to tubal mucosa).

Stage I: limited to the fallopian tubes

Stage IA: limited to one tube,

Stage IB: limited to both tubes,

Stage IC: stage 1А or 1В + ascites containing malignant cells

Stage II: involving one or both fallopian tubes with pelvic extension

Stage IIA: extension and/or metastasis to the uterus or ovaries,

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Stage IIB: extension to other pelvic tissues,

Stage IIC: stage 2А or 2В + ascites containing malignant cells

Stage III: involving one or both fallopian tubes with peritoneal implants

outside the pelvis or positive retroperitoneal or inguinal lymph nodes.

Stage IV: involving one or both fallopian tubes with distant metastasis.

Fig. 236. Cancer of a Fallopian tube

Clinical picture. The signs and symptoms of fallopian tube cancer are

often vague, with the patient giving a history of lower abdominal and pelvic

pain that has been mild but chronic in nature. Most patients present with an

adnexal mass or vague abdominal or pelvic complaints such as abdominal

discomfort, bloating or pain. As the disease progresses, intraperitoneal

metastases lead to other gastrointestinal symptoms and, with progression,

abdominal distension and ascites. Some patients have vaginal bleeding, and

many report an amber-yellow discharge prior to diagnosis. Less than 1/3 of

patients present with hydrops tube profluens – a triad of pelvic pain, copious

watery discharge, and adnexal mass. Some authors have suggested that

abdominal pain relieved by the rapid release of a “tea-coloured” vaginal

discharge (hydrops tubae profluens) is pathognomonic for fallopian tube

cancer.

Diagnosis. The diagnosis is difficult. Cytological examination of an

aspirated sample from the uterine cavity or cervical canal may reveal atypical

615

cells, whereas examination of samples obtained by curettage of the

endometrium ascertains benign alterations. The diagnosis may be specified

by laparoscopy.

Treatment. The treatment is combined, including removal of the uterus

with the adnexa, omentectomy, pelvic and para-aortic lymph node dissection,

and subsequent radio- and chemotherapy.

Regular medical examination is the best type of prevention of any

genital tumours, and tubal tumours particularly.

Self test

1. Cancer of the fallopian tubes is the most rare gynecologic malignancy.

A. yes

B. no

2. The average age of the patients with the cancer of fallopian tubes is

A. 50 to 60 years

B. 20-30 years

C. 40-50 years

D. 12-16 years

3. “Tea-colored” vaginal discharge is

A. typical for tubal cancer

B. uncharacteristic for tubal cancer

C. more characteristic for vaginal cancer

D. characteristic for ovarian cancer

4. All of the following is a characteristic of tubal carcinomas except

A. adenomatous cell type

B. papillary excrescences

C. bilaterality

D. watery vaginal discharge

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5. Which of the following is the most important prognostic factor for patients with

advanced tubal carcinoma?

A. grade of tumour

B. bulk of residual tumour left behind after initial surgery

C. stage of initial presentation

D. duration of symptoms preoperatively

6. Hystologically fallopian tube cancers usually are

A. papillary serous adenocarcinomas

B. neurosarcomas

C. fibroadenomas

D. adenomyosis

7. A malignant tumor from epithelial tissue is

A. adenoma

B. carcinoma

C. fibroadenoma

D. sarcoma

8. What is the main method of tubal malignancy diagnostics?

A. histological examination of samples obtained by curettage of the

endometrium

B. chief complaints and anamnesis data

C. US

D. laparoscopy

9. What operation is indicated in case of tubal malignancy?

A. amputation of failured tube

B. amputation of both tubes

C. extirpation of the uterus with adnexa

D. Wertheim’s operation with subsequent radio- and chemotherapy

10. Tubal cancer is

A. the rarest malignant disease

B. the most freguent malignant disease

617

Chapter 20. TROPHOBLASTIC DISEASES

Trophoblastic Disease (HydatiformMole)

Gestational trophoblastic disease is a term for a group of neoplasms,

derived from the human placenta. Trophoblastic diseases can follow a

spontaneous abortion, an actopic pregnancy, or a full-term pregnancy.

Histologically, the forms of trophoblastic disease include hydatidiform

mole (complete and partial), invasive mole (choriocarcinoma destruen),

choriocarcinoma.

Hydatiform Mole

Hydatidiform mole is a disease of the ovum, which is characterized by

excessive growth of the epithelium of chorionic villi. The villi have become

hydropic and trophoblastic elements have proliferated. Hydatidiform mole is

localized in the uterus. The placental tissue in hydatidiform mole presents a

mass of vesicles of various sizes, which are filled with fluid. Two distinct types

of hydatidiform mole have been described: partial and complete (total)

hydatidiform moles. Partial hydatidiform mole is pregnancy characterized by

replacement of a portion of the placenta by hydropic villi. With complete

moles the fetus and membranes are absent and generalized hydropic changes

are present, resulting in the characteristic gross appearance of a mass of

grape-like tissue replacing the placenta. Variable amounts of trophoblastic

proliferation are present, and fetal vessels are not identified microscopically.

Partial moles are characterized by focal hydrops of placental changes that

may not be identified and are more frequently associated with a fetus or

amniotic membranes. Hystologically, there is focal trophoblastic proliferation

and evidence of fetal vessels in placental villi.

618

Some hydatidiform moles erode the wall of the uterus, burrow into

myometrium and may even burst through the uterus into either the peritoneal

cavity or the broad ligament giving rise to internal hemorrhage. This is known

as invasive (destructive hydatidiform) mole. (Fig. 133)

Hydatidiform mole without atypia and proliferation should be

considered a benign disease while destructive hydatidiform mole presents a

malignant tumour since it destroys tissues and metastasizes into various

organs.

Hydatidiform mole may transform into choriocarcinoma.

Choriocarcinoma is an invasive, usually widely metastatic tumour

composed of malignant trophoblastic cells without hydropic villi. Incidence of

transformation of hydatidiform mole into choriocarcinoma ranges from 1 to

18 per cent.

Placental site trophoblastic tumour, consisting of intermediate

trophoblastic cells that persist after a term of pregnancy, is rare.

Clinical features.

A hydatidiform mole is more common after pregnancies in very young

(less than 17 years) or older (late 30s and 40s) patients. A hydatidiform mole

often manifests within 10-16 weeks after conception by a rapidly enlarging

uterus, which is often larger than expected for estimated gestational age.

Patients often present with vaginal hemorrhage and spontaneous

abortion of atypical hydropic vesicles. Benign ovarian cysts (theca-lutein

cysts) are caused by ovarian stimulation of human chorionic gonadotropin

(hCG) and are detected in approximately 20 percent of patients with complete

moles. Hydatidiform mole usually leads to abortions, although the mole may

be retained in the uterus.

The most frequent symptoms are:

-Vaginal bleeding. It occurs as irregular, small hemorrhage combined

with watery discharge. The hemorrhage usually starts during the 2nd month

619

of pregnancy and recurs irregularly until the time of abortion when severe

bleeding may develop.

-Symptoms of toxemia are very significant and often in patients with

hydatidiform mole. Excessive vomiting is not uncommon, blood pressure may

be raised. Feet may become edematous. Albuminuria may be found.

-Uterus is usually longer than would be expected in this term of

gestation and has a peculiar doughy consistence.

-A fetus is frequently identified in partial mole.

In complete form of hydatidiform mole there is no fetus in the uterus,

only changed chorion. There is no fetal heart sounds, fetus is not detected on

ultrasound examination, X-ray.

Diagnosis. It is based on the clinical picture, which, apart from signs

of pregnancy and occasional symptoms of gestosis, is characterized by an

extremely rapid growth of the uterus, inconsistent with the gestational age,

non-uniform uterine consistency, and ovarian enlargement. The clinical

diagnosis of molar gestation is supported also by characteristic

ultrasonography findings consisting of a “snow storm” pattern of mixed

echogenic foci, reflecting the edematous hydropic villi and intrauterine

hemorrhagе.

Thecal cysts may develop in the ovaries. Urine levels of HCG are

dramatically elevated. Reliable signs of pregnancy (foetal movements and

heartbeat) are absent in patients with complete form of hydatidiform mole.

Hydatidiform mole should be differentiated from threatened abortion,

hydramnion, multiple pregnancy, placenta abruptio, and uterine myoma.

The diagnosis can be specified by ultrasound scanning and amnioscopy.

Pregnancy tests will be positive in high dilution due to increased

output of urinary gonadotropin.

Serum HCG levels are markedly elevated in paients with hydatidiform

mole. HCG is produced by the proliferated trophoblastic tissue, and high

serum levels of the subunit of HCG aid in the diagnosis of a gestational

620

trophoblasic disease. Passage of grape-life molar suggests the diagnosis,

and histological examination confirms it.

Treatment.

In half the cases the abortion is spontaneous, but there is always a

tendency for the abortion to be accompanied by a severe uterine bleeding.

Another danger of the mole is that a malignant tumour (choriocarcinoma)

sometimes develops.

The hydatidiform mole should be removed from the uterus after the

determination of the diagnosis. Simultaneous removal (dilatation and

curettage of the uterine cavity, vacuum aspiration) of the hydatidiform

mole with the mandatory histological examination of the material obtained

is obligatory. Curettage of the uterine cavity may be done in early stages of

gestation – prior to 12 weeks of pregnancy. In terms more than 12 weeks

delivery of the hydatidiform mole should be stimulated medically. To

accelerate separation and expulsion of the mole, the woman is given

oxytocin, prostaglandine and other drugs stimulating uterine contractions.

In cases of profuse bleeding and opened cervical canal, one or two fingers

introduced into the uterine cavity should extract the mole. In cases of

profuse bleeding and the cervical canal closed for the finger, the mole

should be removed with curettage of the uterus. The curettage should be

done very accurately due to high danger of uterine perforation because of

thinning of the walls.

After the removing of the mole the special care of the patient must be

done to prevent the development of choriocarcinoma.

In the benign form of hydatidiform mole the recommended treatment

is 2-3 courses of methotrexate therapy, in destructive hydatidiform mole

three courses of polychemotherapy (methotrexate, rubomycin,

adriamycin).

With the purpose of choriocarcinoma prevention patients with a

history of hydatidiform mole are subjected to a 2-6 year follow-up. Apart

621

from ordinary clinical examination, urinary HCG levels are measured twice

weekly for two months and monthly thereafter; lung roentgenography is

performed once every three months. If the course is favourable, the HCG

titre becomes negative three weeks after removal of the hydatidiform mole.

Choriocarcinoma.

Choriocarcinoma (chorionepithelioma) (Fig. 134) is a malignant uterine

tumour developing in half of all cases from the hydatidiform mole; less

commonly it develops after deliveries and abortions. The tumour develops

from trophoblast elements. Choriocarcinoma in the form of a nodular

crimson tumour may be positioned under the mucous membrane or in the

midst of the muscular layer (interstitially), gradually growing through all

layers of the uterus; it easily disintegrates, which is often accompanied by

profuse bleeding. Choriocarcinoma in the form of friable dark blue nodes

often metastasizes into the vagina, less frequently into the ovaries and uterine

tubes.

Clinical picture.

It is characterized by acyclic prolonged, occasionally profuse uterine

bleeding (absent in intramuscular position of nodes), serous sanguineous

leucorrhea, often with a putrefactive odour, and mild low abdominal pain.

Prolonged bleeding may lead to secondary anemia, while attendant infection

may be a cause of the inflammatory process of the female genital organs.

Choriocarcinoma is characterized by early metastatic spread via blood to the

vagina, liver, brain, and, more commonly, to the lungs. In the latter case the

disease is attended by cough and blood-tinted sputum. The disease progresses

rapidly and may lead to the lethal outcome.

Diagnosis. It is based on the thorough study of the history (a history

of a hydatidiform mole, delivery, abortions). Of great significance is

determination of HCG titres in the urine and separate diagnostic dilatation

and curettage (in most cases tumour elements may be determined

622

histologically). Thecal cysts developing in choriocarcinoma in 40-50 per

cent of cases have a definite diagnostic significance since they are able to

undergo inverse development in the time course of the disease.

Treatment. The treatment may be conservative (chemotherapy) and

surgical.

Chemotherapy is based on the use of methotrexate, mercaptopurine,

and rubomycin.

Systemic measurement of HCG levels in the urine serves as a criterion

of treatment efficacy.

Surgical treatment is indicated in profuse uterine bleeding, tendency

of the tumour to grow into the surrounding tissues and threat of uterine

perforation, a large size of the tumour (the uterus is larger than the 10-week

gravid uterus), and the absence of response to chemotherapy. Extirpation

of the uterus is performed; in young women the adnexa are left intact where

it is possible.

Following conservative treatment, the patient may conceive and have

a normal delivery.

Prevention of choriocarcinoma consists in the early and correct

treatment of hydatidiform mole. Since choriocarcinoma may also develop

after normal pregnancy, to prevent the disease it is necessary to inspect

thoroughly the afterbirth (to determine its integrity) and to perform

correctly all manipulations related to pregnancy termination.

Self test

1. Which of the following is consistent with hydatidiform mole?

A. a uterus that is large for dates

B. a presence of a fetus

C. theca-lutein cysts

D. a uterus firm and irregular in shape

623

2. A 25-year-old woman presents with a molar gestation at 12 weeks from her last

menstrual period. Which of the following is the most appropriate management for

this patient?

A. removing of the hydatidiform mole and the chemotherapy

B. obtaining of a quantitative HCG titer

C. hysterotomy

D. observation of the patient and prolongation of the pregnancy

3. Which of the following factors are poor prognosis indicators for metastatic

gestational trophoblastic neoplasma?

A. a patient of 35

B. diagnosis of disease at 6 weeks postpartum

C. presence of a fetus

D. hysterectomy as treatment

4. Choriocarcinoma more often develops from the

A. hydatidiform mole

B. hysterectomy

C. pelvic inflammation

D. adenomyosis

5. Which of the folllowing is not an indication for surgical treatment of

choriocarcinoma?

A. profuse uterine bleeding

B. tendency of the tumour to grow into the surrounding tissues

C. hreat of uterine perforation

D. effective chemotherapy

6. Hydatidiform mole usually results from

A. abortion, hemorrhage

B. fetal malformations

C. postmaturity

D. cephalo-pelvic siaproportion due to a big fetus

624

7. Incidence of transformation of hydatidiform mole into choriocarcinoma ranges

A. from 1 to 18 per cent

B. from 20 to 30 per cent

C. from 40 to 50 per cent

D. more than 50 per cent

8. Choriocarcinoma is a real malignant uterine tumour.

A. yes

B. no

9. The most appropriate method of evacuation of complete hydatidiform mole is

A. a hysterectomy

B. an induction of abortion

C. a curettage of the uterine cavity

D. a suction curettage

10. Staging of trophoblastic malignancy usually utilizes all of the following except

A. quantified HCG

B. chest X-ray

C. cheast/head/abdominal CT scan

D. angiography

625

Chapter 21. GYNECOLOGICAL DISEASES IN

CHILDHOOD AND ADOLESCENCE

The development of pediatric gynecology as a separate trend of science

has considerably extended the notion of specific features of genital diseases in

girls. At present, the principles of prevention and treatment of gynecological

diseases of childhood and adolescence have been elaborated, which call for:

(1) health education of girls, their parents and teachers at kindergartens and

schools; (2) organization of regional gynecological centers for children and

adolescents; (3) establishment of specialized gynecological clinics and

consultation centers. Despite the advances made in rendering the

gynecological care to children and adolescents, situations often arise that

require emergency aid.

Tumours

Tumours in children and adolescents are a relatively rare finding. The

data on the character and clinical course of tumours are controversial and

depend on the groups of patients hospitalized. Genital tumours of girls are

reported to be potentially malignant in 50 per cent of cases.

Genital tumours of various structures can develop in childhood and

adolescence. Germinal tumours are frequently observed before puberty. Other

tumours can develop at the onset of the pubertal period, which indirectly

indicates the role of hormonal effects in their occurrence. Morphologically,

tumours typical for the young age are divided into innocent (mature

teratomas, dermoid cysts) and malignant (teratoblastomas). These

newgrowths are referred to as germinal tumours. Dysgerminomas are worth

mentioning among the tumours of the genital cord stroma.

Various pieces of information on the incidence and clinical course of

different tumours, which are often based on individual observations, provide

626

no precise idea of the problem. We consider it necessary to briefly describe

the genital tumours in children and adolescents basing primarily on our own

observations in this age group of 150 patients. According to the data obtained,

genital tumours are not an extremely rare finding in this age group: about 4

per cent of patients under 18 that were treated at the gynecological

department of our clinic had tumours and tumour-like formations of the

genitalia.

Diseases of childhood and adolescence, which are surgically treated,

differ considerably from those of adults. The majority of girls underwent

surgery for tumours and tumour-like formations revealed in the adnexa,

whereas women are most frequently operated on for tumours of the uterus,

particularly myoma.

Tumours and tumour-like formations most often develop in the adnexa.

According to our data, innocent tumours revealed in the pubertal period are

more common. It should be emphasized that due to the specific character of

hospitalization the number of girls with malignant tumours of the ovaries is

greater among patients admitted to the oncological hospitals than to the

gynecological ones. The physician should always remember about the

possibility of a malignant tumour developing in a girl.

Innocent tumours are characterized by rapid growth. Tumours and

tumour-like formations of the adnexa are not uncommonly combined with

appendicitis.

In the absence of complications (twisted tumour pedicle, suppuration)

benign tumours of the ovaries in girls follow a milder course than in adults.

Pain commonly develops only when the ovarian formation becomes large in

size. In girls, the adhesive process in the small pelvis is encountered

extremely rarely.

The ovarian cysts in infants and girls are a less common finding than in

adults. Small follicular cysts may remain undiagnosed.

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Torsion of ovarian tumour is most often associated with a dermoid cyst

owing to the specific anatomy (long pedicle). This tumour has teratoid origin

and can be found at any age (cases have been described of twisted tumour

pedicle in girls aged 4 and 5, the tumours reaching considerable size); the

symptoms of the acute abdomen develop therewith.

Malignant newgrowths of the ovaries (teratoblasto-mas,

dysgerminomas) can also cause conditions requiring emergency care. Like in

adults, the need for emergency surgery in girls with ovarian tumours arises

when the surgical intervention has not been performed in time. The principle

that must be observed while treating the women with ovarian tumours

(immediate operation) applies in full measure to girls.

Hormone-producing tumours are a rare finding; granulosa-cell tumours

and, less commonly, thecomas develop in this age group.

Feminizing ovarian tumours in girls are usually characterized by vivid

clinical manifestations due to the large amount of estrogenic hormones

produced by the tumour. Signs of precocious puberty are witnessed by the

engorged breasts, secondary sex characters (growth of hair on the pubis,

enlarged clitoris and labia pudenda), and uterine bleedings that precede the

menstrual-like discharge.

In children and adolescents, masculinizing ovarian tumours are found

exceptionally rarely. If the symptoms of virilization are manifested, the

masculinizing tumour of the ovary can be suspected. Delayed sexual

development may be observed as a symptom of masculinizing tumour though

this happens extremely rarely. In these cases the differential diagnosis is

difficult. The patients should be followed-up at a specialized in-patient

setting.

A well-timed operation can help to prevent the development of obesity

and severe essential hypertension. Besides, early surgery for a malignant

tumour may bring favourable long-term results.

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Tumours of the external genitalia, vagina, and uterus are rarely

observed among children and adolescents (8 per cent of all the tumours and

tumour-like formations of the adnexa). These newgrowths are malignant as a

rule (sarcoma of the vagina, cervix or corpus uteri).

When malignant tumour develops, the blood-tinted reeking vaginal

discharge, which is the leading symptom of the disease, appears. Later, pain

of various intensity concurs. Parents promptly consult the physician in the

event of blood-tinted vaginal discharge occurring in little girls. The older girls

(after the menarche has set in) do not visit the doctor for a long time as a

result of which in most cases the disease is diagnosed in the advanced stage.

The physician should bear in mind that the formation arising from the

ovary is most likely the tumour but not the cyst. A malignant newgrowth

should be suspected in cases where the tumour originates in the external

genitalia, vagina, or corpus uteri. The diagnosis of tumours and tumour-like

formations of the uterus and adnexa may present considerable difficulties,

which is to a large extent explained by the lack of information.

The diagnosis may not be established in time because the possibility of

occurrence of tumour in infants or girls is neglected. When a girl complains of

pain in the lower abdomen and her behavior changes, the pediatrician should

refer her to the gynecologist. Commonly, the tumour is easily palpated

through the peritoneal coat. The diagnosis is confirmed during the rectal

examination. In girls the uterus and adnexa are placed rather high and

descend into the true pelvis only by the end of pubertal period to occupy the

adult position.

Limited dimensions of the true pelvis do not allow the tumours to be

located in the pelvic cavity even when the ovarian formations are

comparatively small. These specific anatomical features determine the

absence of symptoms of compressed urinary bladder and rectum. When

indicated, the rectum can be examined under anesthesia. The short-term

anesthesia ensures adequate relaxation of the anterior abdominal muscles

629

and makes palpation of the internal genitalia easier. Ultrasound or X-ray

examination of the true pelvis is indicated under the conditions of

pneumoperitoneum, when the diagnosis is uncertain.

As our experience shows, ovarian tumour may be mistaken for

pregnancy, and a serious psychic trauma may be inflicted to a girl through the

physician's fault.

Before the diagnosis of pregnancy is established, it should be thoroughly

verified (gynecologist’s consultation, ultrasound study, determination of

human chorionic gonadotropine).

Tumours and tumour-like formations of the adnexa in girls have to be

differentiated primarily from appendicitis, particularly when the pedicle of

the tumour is twisted. Rectal examination helps to specify the diagnosis.

Ovarian tumour combined with appendicitis was observed in every fifth of our

patients operated on.

The dystopic kidney or its tumour, as well as overfilled urinary bladder,

can simulate a newgrowth of the ovary. To avoid diagnostic errors, it is

necessary to inspect the rectum when the urinary bladder has been emptied.

Intravenous pyelography is indicated in suspected renal pathology.

Auxiliary methods of examination, such as vagino-scopy, endoscopy,

radiography of the true pelvic organs under the condition of

pneumoperitoneum, and ultrasound study are recommended to verify the

diagnosis of genital tumours and tumour-like formations.

Surgery for genital tumours in children and adolescents should be

maximally sparing (partial resection of the ovary or enucleation of the

tumour). When the cyst is paroophoritic, only enucleation is performed. The

adnexa have to be completely removed in torsion of the tumour pedicle, when

the ovarian tissue has undergone pathological changes to the extent that calls

for its elimination.

Urgent histological study of the removed specimen is of particular

importance since the range of surgical intervention largely depends on its

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results. In the climacteric or postmenopausal women, visual inspection of the

affected organ can be decisive with respect to the volume of surgery, whereas

in girls the need for radical surgery should be grounded on the histologically

confirmed malignancy of the newgrowth. It is necessary to refer infants and

girls to the specialized in-patient settings, where the highly skilled specialists

can perform auxiliary examinations.

Like women, girls should be subjected to emergency surgery in torsion

of the tumour pedicle, rupture and suppuration of the capsule.

Intraoperative examination of the appendix is essential, since in a large

number of girls appendectomy has to be simultaneously resorted too owing to

its chronic inflammation. Inspection of the adnexa during appendectomy is

equally important, because there were cases of the appendix removal where

the ovarian formation with the twisted pedicle remained. We had to re-

operate on such patients.

Inflammatory Diseases of the Genitalia

Conditions, which induce adnexitis in girls, fall far short of those in

women. Septic infection and gonorrhea provoke inflammatory diseases

extremely rarely. Adnexitis of tuberculous etiology may be encountered

among little girls. Severe inflammation is observed in suppuration of the

hematosalpinx originating as a result of a developmental defect of the internal

genitalia. The disease runs with the typical clinical picture of the acute

abdomen.

The diseases of the large intestine, particularly appendicitis, are the

most frequent causes of adnexitis in girls. This is explained by the close

anatomical relationships between the appendix and adnexa. Inflammation of

the appendix often involves the adnexa.

Appendectomy may be followed by adnexal inflammation a few months

later, which is probably explained by the latent inflammatory process that

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manifests itself as a result of a provoking effect (cooling, extragenital

infection, etc.).

The clinical picture is characterized by sudden pain in the lower

abdomen attended with nausea and vomiting, frequent urination, and high

body temperature. A 'tumour' is diagnosed after the acute abdominal

symptoms disappear. The diagnosis is often late since it does not occur to

physicians to relate this condition to adnexal inflammation. The examination

demonstrates tender formations in the adnexal area. When these patients are

examined through the rectum, tenderness of the uterus is revealed on its

displacement. A tender formation of varying form and size is palpated

posterior to the uterus, mostly to the right. Its consistence is uneven, varying

from dense to tight elastic, and the surface is irregular; absence of mobility of

these tumour-like formations is characteristic.

Purulent tubo-ovarian formations of the adnexa that occasionally

adhere to the appendix are most often found during the operation. We

observed a patient in whom the gangrenous appendix, which was intimately

fused with purulent tubo-ovarian formation, was self-amputated. It should be

pointed out that surgical treatment is commonly associated with considerable

difficulties when purulent tubo-ovarian formations are combined with

inflammatory changes in the appendix.

Important practical conclusions result from the above. When

appendicitis is diagnosed in girls, the gynaecologist's consultation is a must to

find out the condition of the adnexa. To reveal inflammatory changes in time,

the adnexa should necessarily be inspected during surgery for appendicitis,

and while operating on inflammatory changes in the adnexa, the appendix

should be examined; appendectomy is performed when the abnormality is

visualized.

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Developmental Defects of the Vagina and Uterus

The attention of many researchers has been drawn to studying the

genesis of congenital anomalies of the urogenital system. This is connected

with the fact that these defects not only make the woman suffer badly but also

cause disturbances of the reproductive function. Some authors voice the

opinion on the possible role of the environmental factors during

embryogenesis (intoxication, temperature effects, etc.).

Hereditary factors in the form of chromosomal and gene mutations can

also induce developmental defects. According to our data, the aggravated

heredity was evident in 40 per cent of women (spontaneous abortions,

idiopathic infant mortality, impaired menstrual function, childless couples,

developmental defects in the family). Parents are often over 35-40 years of

age.

Mothers of many patients have experienced stress situations associated

with war, prolonged starving, and injury. Parents of some of the patients were

alcoholics or were exposed to the occupational (chemical or radioactive)

hazards.

Congenital anomalies of the vagina and uterus are among the frequent

causes of an urgent surgical intervention. Developmental defects attended

with completely or partially delayed outflow of the menstrual blood are

clinically manifested during puberty.

The developmental defect of the vagina is characterized by completely

impaired menstrual outflow, the uterus functioning normally. In these

patients the uterus occupies normal median position; its lower pole can be

reached during the recto-abdominal examination. This abnormality manifests

itself at the menarche age and often requires emergency surgical aid.

Diagnostic errors are made in many cases: ovarian tumour, appendicitis, etc.

are diagnosed. Young girls with acute pain in the lower abdomen are

erroneously subjected to the ungrounded, occasionally repeated laparotomies.

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The uterus is extirpated in cases where only the septum of the vagina should

be dissected.

While making the diagnosis, it is necessary to pay attention to the size of

the missing portion of the vagina, the time and intensity of pain, and also to

the dimensions of the tumour-like formation in the true pelvis. The case in

point may be atresia of the hymen, aplasia of the lower third of the vagina,

aplasia of lower two thirds of the vagina, absence of the upper third of the

vagina, and finally, complete absence of the vagina with the functioning

uterus.

The diagnosis and treatment of atresia of the hymen are most simple. In

these patients a cyanotic swelling, which is well seen on inspecting the

external genitalia, bulges out in the area of the vaginal orifice. Treatment

consists in dissecting the hymen.

It is more difficult to make the diagnosis if from one to two thirds of the

vagina are missing. The tumour-like formation, which may have the form of a

sand glass, is determined in the centre of the true pelvis during the recto-

abdominal examination. In the event of the distended cervix, the common

receptacle for the menstrual blood is formed (distended uterus, cervix, and

vagina). Surgical correction consists in the restoration of the patency of the

vaginal tube by incising the septum, lowering the edges of the distended

vagina, and suturing them in the area of the vaginal orifice.

The absence of the upper vaginal third is nearly always related to the

underdeveloped cervix. Pain develops early. The rounded formation, which is

tender to palpation, is found in the centre of the pelvis during the recto-

abdominal inspection. The uterus is emptied during surgery, but since the

cervical canal is absent this will eventually lead to the cicatrization at this site,

which interferes with the menstrual outflow. The repeated bougienage and

dissection of the cicatrices in the vaginal cupola usually prove ineffective and,

therefore, extirpation of the uterus has to be resorted to in many cases. When

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the vagina is completely absent and the uterus is functioning, artificial vagina

is created in rare cases where the cervix is present.

If emptying of the hematometra through the cervical canal and suturing

the cervix to the vaginal cupola are managed, this operation is normally a

success. When the hematometra is emptied through an orifice artificially

created in the uterus, and this site is sutured to the vaginal cupola, the orifice

soon becomes obliterated, and the hematometra recurs.

In the event of a completely delayed menstrual outflow and the late

performance of surgery (which often happens), the hematocolpos (in the

presence of a vaginal portion), hematometra, and hematosalpinx occur. The

days of menstrual bleeding are characterized by severe pain. When infection

concurs, the contents of the uterus and fallopian tubes suppurate. The body

temperature is elevated, and the pain sharply intensifies; the peritoneal

manifestations develop. The sharply tender tumour-like formations are

palpated in the true pelvis. Emergency surgery is needed in these cases. The

diagnosis is based on the history, results of examination of the external

genitalia and rectum.

The success of surgery largely depends on what vaginal portion is

missing. In atretic hymen its cross-like dissection and emptying of the

hematocolpos are warranted. When the lower third of the vagina is absent,

the tissues are separated and incised reaching the vaginal tube after which the

edges of the vagina are sutured to the area of the vaginal orifice. When the

middle third of the vagina is absent, the tissues are incised between the lower

and upper thirds of the vagina, which is followed by suturing of their mucosa.

As a rule, such procedure is effective in this abnormality. Absence of the

upper third or the entire vagina are most unfavourable and characterized by

the absence of the vaginal fornices; the cervix is normally underdeveloped or

absent. As was noted above, surgical correction is of little effect and

technically complicated.

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Partially impaired menstrual outflow develops in functioning of the

rudimentary closed horn of the uterus. The sharply pronounced pain, which

appears early, is typical for the clinical picture.

The diagnosis presents difficulty (we observed patients in whom acute

appendicitis or other intra-abdominal abnormality was diagnosed). Excretory

urography, which is one of the efficacious auxiliary methods of investigation,

demonstrates absence of the kidney on the side of the rudimentary horn.

Besides, the adnexa are absent in half the patients. Laparotomy with removal

of the rudimentary uterus is necessary in such cases.

The pathological condition described is very difficult to diagnose.

Persistent primary algomenorrhea, blood-tinged or purulent vaginal

discharge, and also a tumour-like formation in the true pelvis allow a

congenital anomaly to be suspected. When the condition is diagnosed,

surgical treatment presents no difficulty. The site of the rudimentary closed

vagina is dissected sufficiently widely, thereby creating conditions for the

outflow of the menstrual blood.

It should be pointed out that the diagnostic errors are common in

genital developmental defects and ungrounded surgical interventions are

often performed.

This is explained by the lack of information on the given pathology,

whereas the monthly recurring pain in the lower abdomen and the tumour-

like formation in the true pelvis in girls of the pubertal age should always

suggest congenital anomalies of the reproductive system.

Pain is typical for all types of genital developmental defects; however,

the intensity and character of pain have specific features that are determined

by the form of the anomaly. A periodically recurring and intensifying,

gnawing pain is most typical for atresia of the hymen, aplasia of the vaginal

portion, and duplex vagina and uterus with partial aplasia of one of the

vaginas. A primary colicky pain that rapidly becomes permanent and grows in

intensity is more characteristic of girls with aplasia of the entire vagina and

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the functioning uterus and of patients with rudimentary, closed and

functioning horn of the uterus. The disease runs the most severe clinical

course in the latter cases.

Occasionally, the disease can be diagnosed only after the auxiliary

methods of investigation have been employed: ultrasound study, radiography

of the small pelvis under the conditions of pneumoperitoneum, excretory

urography, and laparoscopy.

The duplex vagina and uterus with partial aplasia of one of the vaginas

combined with the rudimentary, closed and functioning horn of the uterus

present the greatest difficulties for the diagnosis.

As it was already emphasized, excretory urography must be indicated

for all the patients in whom a congenital anomaly of the genitalia is suspected

not only because the developmental defects of the uterus and vagina are

frequently combined with anomaly of the urinary system, but also due to the

fact that absence of the kidney revealed by the excretory urography in

algomenorrhoea patients almost reliably indicates partially aplastic vagina in

case it is duplicated. Presence of the closed horn of the uterus can also be

suspected on the side of the absent kidney.

Although the condition of young girls with impaired menstrual outflow

due to a developmental genital defect not infrequently requires emergency

surgery, they should be transported to a specialized hospital to specify the

diagnosis and to undergo surgery, which presents considerable technical

difficulties.

Bleedings

Dysfunction of the ovaries, genital tumours, diseases of the blood, and

injury in childhood and adolescence can induce vaginal hemorrhage. Internal

hemorrhage is commonly associated with apoplexy of the ovary usually

encountered among girls with established menstrual function, though the

condition can also develop at an early age. The cases are reported of apoplexy

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of the ovary with heavy blood loss in girls of 8 and 10 years of age. Juvenile

bleedings are typical for the pubertal age.

Juvenile bleeding is a dysfunctional uterine hemorrhage, which is

manifested during the period of sexual maturity. It is caused by altered

secretion of sex hormones due to disturbed neuro-endocrine regulation of the

menstrual cycle during puberty. Chronic and acute infections and somatic

diseases, hypovitaminoses, stressful situations, and unfavourable course of

the antenatal development facilitate the occurrence of juvenile bleedings

affecting the functioning of the hypothalamic-pituitary-ovarian system.

In adolescence, the immaturity of morphological structures of the

hypothalamus and other links of the system that ensure the normal menstrual

cycle can give rise to particularly severe bleedings. Hypoplasia of the uterus

increases the duration of bleeding. Bleedings are mostly anovulatory in nature

and develop against the background of atretic follicles rapidly leading to

anemia. The heavy blood loss can induce the secondary changes in the blood

coagulation and anticoagulation systems. Deviations in somatic development

(infantile body build or morphotype exceeding the norm) are often noted in

young girls suffering from juvenile bleedings.

Disturbances of the menstrual cycle are typical for patients with juvenile

bleedings: suppressed menses precede abundant bleeding. Pathological

bleeding often develops during the first menstruation.

When the diagnosis of the 'juvenile bleeding' is being made, diseases of

the blood and organic lesions of the genitalia (feminizing tumours of the

ovary, tumours of the uterus or vagina, etc.) should first of all be excluded.

When bleeding arises during the first menstruation or resembles

menorrhagia, a blood disease should be suspected; similar bleedings are

observed in the Werlgof disease, hypoproconvertinaemia, and various

thrombocytopenic conditions.

Nasal and gingival bleedings, easily occurring subcutaneous

extravasates, and the cyclic character of uterine bleedings suggests disease of

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the blood, the study of which helps to confirm the diagnosis. The Werlgof

disease is accompanied by reduction of the thrombocyte level;

hypoproconvertinaemia is characterized by low prothrombin level (50-30 per

cent). When a blood disease is suspected, it is necessary to consult the

hematologist because these diseases, which are occasionally manifested only

during the first menstruation, should be diagnosed and treated by a specialist.

Estrogen-producing tumours of the ovary, as well as tumours of the

uterus or vagina, can induce uterine bleedings. In these cases rectal and

auxiliary examinations (ultrasound, vaginoscopy, radiography of the small

pelvic organs under conditions of pneumoperitoneum) help to confirm the

diagnosis.

Treatment of juvenile bleedings should include invigorating therapy, the

use of agents contracting the uterus and hemostatics (Ergot, Ergotal,

Ergotamine), hormone therapy, and diagnostic dilatation and curettage as an

extreme measure. Occasionally, bleeding can be spontaneously arrested

following invigorating therapy and elimination of factors that cause emotional

stress.

When bleeding is profuse, urgent measures should be taken to arrest it

for which purpose the estrogen hemostasis is employed. The point is that the

dysfunctional bleeding always occurs in response to a fall in the hormone

level, which is eliminated by the administration of estrogens (these

preparations are preferable during puberty). Proliferation of the

endometrium recurs in the mucosa of the uterine corpus, and the bleeding

stops. Elimination of the fall in the hormone-level, in its turn, normalizes the

ratio between the-follicle-stimulating hormone (FSH) and luteinizing

hormone (LH).

The estrogen hemostasis is accomplished by administering 1 ml of 0. 1

per cent of dihydrostilboestrol solution intramuscularly every 2-4 hours, or

folliculin by 10 000-20 000 MU every 2-3 hours.

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As a rule, bleeding stops a day after the administration of hormones was

begun. The hormone therapy should not be discontinued immediately after

the arrest of bleeding, since in response to a fall of the hormone level bleeding

recurs. Administration of estrogens should be continued in gradually reduced

doses, and then followed by treatment with progesterone (1 ml of 1 per cent

solution intramuscularly for 5-6 days). The menstrual-like reaction ensues

after the progesterone has been discontinued.

Invigorating and antianemic therapy should not be neglected during the

hormonal hemostasis. These patients should be followed-up by a specialist for

a long time after the emergency aid has been rendered. There are other

schemes for the hormonal hemostasis to be carried out (with the help of

synthetic progestins). In girls, the diagnostic dilatation and curettage is

performed only for vital indications, when all the methods of therapy that

have been used prove ineffective. During the curettage the necrotized

hyperplastic mucosa of the uterus is removed which arrests the bleeding. In

the majority of patients histological study of the obtained sample reveals

hyperplastic processes in the endometrium including the development of

atypical hyperplasia and adenomatous polyps.

Patients with juvenile bleedings should be systematically followed-up

and treated by the pediatric gynecologist.

Injuries to the Genitalia. Foreign Bodies in the Vagina

Genital organs can be injured as a result of falling on acute objects, in

street traumas, etc. Traumas can be extremely severe and accompanied by

ruptures of the adjacent organs, particularly in little girls.

Injury to the genitalia is usually attended with abundant bleeding,

especially when the clitoris is damaged. Emergency care includes the arrest of

hemorrhage by ligating the bleeding vessels and restoring the intactness of

the injured tissues. The anesthesia should be given to examine the girls with a

genital trauma and to suture the ruptures. When anemia is marked,

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transfusion of blood and its substitutes is warranted. In addition, the

antitetanus serum should be administered. The principles of treatment of

hematomas do not differ from those in adults.

Penetration of foreign bodies into the vagina is mostly observed among

girls under 8 years of age. A foreign body causes inflammatory changes in the

vaginal mucosa. The puriform discharge, sometimes mixed with blood,

appears. It is not always easy to detect the foreign body. A carefully performed

rectal examination and particularly vaginoscopy allow the diagnosis to be

verified.

When a foreign body provokes inflammatory changes in the

surrounding tissues and adhesions, it should be removed under anesthesia,

because the procedure is extremely painful. Besides, the child's restless

behaviour does not allow the foreign body to be carefully removed without

injuring the adjacent organs. In the event the foreign body is mobile the

physician manages to remove it by pushing to the vaginal orifice manipulating

by the finger introduced into the rectum.

Self test

1. Which from the following infectious processes are frequent in girls

A. septic infection

B. gonorrhea

C. adnexitis of tuberculous etiology

D. colibacillus infection

2. Prescribe the medicine, which leads to uterine contraction.

A. Folliculin

B. norephedrine

C. methylergometrine

D. partusisten

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3. Treatment of juvenile bleeding should include all of the following except

A. antianemic therapy

B. hormonal therapy

C. heparin

D. hemostatric drugs

4. Genital tumours of girls are reported to be potentially malignant in

A. 50 per cent of cases

B. 25 per cent of cases

C. 75 per cent of cases

D. 15 per cent of cases

5. What is the most freguent type of tumour in girls?

A. hormone-producing tumours

B. germinal tumours

C. hysteromyoma

D. choriocarcinoma

6. Treatment of juvenile bleedings should be started with

A. agents contracting the uterus and hemostatics, hormone therapy

B. diagnostic dilatation and curettage

C. antianemic drugs

D. vitamins and antianemic drugs

7. Hymenal anomalies are usually associated with

A. renal anomalies

B. uterine anomalies

C. no other anomalies

D. patent ductus arteriosus

8. In children vaginitis due to poor hygiene is frequently because of

A. chlamidia

B. fungus

C. coliform bacteria

D. anaerobic bacteria

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9. Injury to the genitalia is usually attended with

A. abundant bleeding

B. red colour of affected area

C. genital itch

D. anemia

10. The diagnosis of atresia of the hymen is based on findings of

A. cyanotic swelling, bulges out in the area of the vaginal orifice

B. encreased amount of menstrual flow

C. Decreased amount of menstrual flow

D. Retension of urine

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Chapter 22. FEMALE DISPENSARY-

PROPHILACTIC MDICAL EXAMINATION OF

GYNECOLOGICAL PATIENTS

Female dispensary is an ambulatory clinic for women. There are two

types of female dispensary:

- The first is female dispensary only for pregnant

- The second is female dispensary only for gynecological patients.

Sometimes may be mixed dispensary both for obstetrical and

gynecological patients. The main mission of this ambulatory is prophylactic

medical examination of women. The prophylactic medical examination of

patients is an active determination of gynecological diseases of women at

early stages of processes, dynamic and complex treatment. On the other hand

it should be prophylaxis of gynecological diseases, and prophylaxis of disease

spreading.

Patients with cervicitis and endocervicitis, condilomas, cervical erosion,

endometritis, parametritis, pyosalpinx need prophylactic medical care.

Noninflammatory diseases, such as leukoplakia, kraurosis, disturbances of

menstrual cycle, infertility, neuroendocrine syndromes, benign tumours of

female genitalia, endometriosis are indications for prophylactic medical care.

The duration of dispensary prophylactic observation of those patients is

different. For example, patients with acute and subacute inflammations of

female genitalia should be observed about 3 months after special treatment in

a hospital.

Patients with precancerous diseases (kraurosis, leukoplakia, and others)

must be observed continually: patients before 40–2 times a year, patients

after 40–3 times a year, even after surgical treatment.

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Patients with uterine myoma must be observed with special gynecologic

examination continually, once in 3 months, and even more depending on

their health.

If a patient does not come to ambulatory clinic for planned

examination, she must be invited to the ambulatory by phone, post, or nurse

may be send for inviting a patient for the examination and observing her

living conditions.

Moreover, every woman must be prophylactically observed once a year.

Prophylactic examination may be arranged at factories, plants, colleges, and

schools. During those prophylactic examinations one can pay attention to the

character of menstrual cycle, reproductive function, any pains. External

genitalia, perineum, the region of anus would be inspected. For virgins rectal

examination is used depending on indications. Other patients must undergo

speculum vaginal examination, and microscopic and bacteriological

examination of smears must be done as well. For women in premenopausal

age, and after menopause cytologic examination of smears is necessary. If any

gynecological disease is found, the patient is recommended a special care and

observation. If it is indicated, patients must be hospitalized for special

treatment.

In Ukraine there are regular medical check-ups aimed at the prevention

of malignant tumours, including cancer of the female genital organs. The key

place belongs to mass prophylactic examinations (at least twice annually) of

women aged 30 years and over. Prophylactic examinations are conducted in

women's consulting centers, industrial enterprises, and special gynecological

rooms in polyclinics. A high quality of prophylactic examinations is ensured

by mandatory use of colposcopy and cytological examination of cervical

smears. Women with gastric and breast cancer should be examined by a

gynaecologist to detect metastatic ovarian cancer at early stages.

The most important components in the prevention of cancer of the

ovaries and other female genital organs are recognition of precancerous

645

diseases, their early and appropriate treatment, and active follow-up of these

patients. With this purpose it is helpful to identify groups of risk for the

development of genital tumours and to ensure a follow-up and treatment of

such patients.

Five groups of high risk for cancer of the female genitalia are identified.

Group I: women at risk for the development of cancer of the external

genitalia (patients with vulval kraurosis and vulval and vaginal leucoplakia).

Group II: women at risk for the development of cervical cancer (patients

with ectopia, erosion-affected ectropion, recurrent polyps, leucoplakia and

dysplasia of the cervix).

Group III: women at risk for the development of uterine cancer

(patients with aggravated oncological heredity, neuroendocrine and metabolic

disturbances, ovulatory disorders, hyperplastic processes in the

endometrium, hormone-active ovarian tumours, and uterine myoma).

Group IV: women at risk for the development of ovarian cancer

(patients with aggravated oncological heredity, with a history of ovarian

surgery, ovarian cysts, chronic adnexitis, multiple uterine myoma, ovarian

dysfunction, and benign ovarian tumours).

Group V: women at risk for the development of tubal cancer (patients

with chronic recurrent adnexitis).

Health education in the form of talks and lectures plays a large role in

the prevention of genital cancer in women.

Rational management of parturition reduces the incidence of cervical

injuries and diminishes the risk of the development of cervical ectropion.

Women with an identified or suspected precancerous process or a

genital tumour should be referred to specialized hospitals for the appropriate

examination and treatment.

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Medical examination of working capacity. In Ukraine special medical

committees assess working capacity of patients, following the appropriate

treatment and follow-up.

Self test

1. dispensary prophylactic system of gynecological patients means

A. treatment of patients in a hospital

B. treatment of patients in an ambulatory clinic

C. prophylactic and dynamic medical examination and complex

treatment of patients

in female dispensary

D. public health education

2. Patients with precancerous diseases of female genitalia must be observed

A. 2-3 times a year

B. once a year

C. about 3 months after special treatment in hospital

D. every month

3. A patient with uterine myoma must be observed

A. once in 3 months

B. once in 6 months

C. depending on her complaints

4. Patients with acute inflammations of female genitalia should be observed

A. about 3 months after special treatment in hospital

B. once a year

C. once in 6 months

D. no special after treatment observation

5. The main mission of female ambulatory clinic is

A. a prophylactic medical observation of women

B. a treatment of the out-patients

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6. Every woman must be observed for prophylaxis once

A. a year

B. in 6 months

C. in 3 months

D. in 3 years

7. For women in premenopausal age, and after menopause cytologic examination

of smears is

A. necessary

B. is not necessary

8. If a patient does not come to ambulatory clinic for planned examination

A. gynecologist should wait for her in his office

B. gynecologist may break off dispensary prophylactic observation of

this patient

C. nurse should be send for inviting a patient for the examination and

observing her

living conditions

D. patient should be hospitalized under compulsion

9. Erosion-affected ectropion means

A. I group of risk for cervical cancer

B. II group of risk for cervical cancer

C. III group of risk for cervical cancer

D. IV group of risk for cervical cancer

10. Group IV means

A. women at risk for the development of ovarian cancer

B. women at risk for the development of tubal cancer

C. women at risk for the development of cervical cancer

D. women at risk for the development of intestinal cancer

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Chapter 23. HYGIENIC REGIMEN IN FEMALE

Hygiene of Girls

Proper hygiene is necessary from the first day of a girl's life. Apart from

the general care for the newborn, special care of the genitalia is required. It is

recommended that the external genitalia be regularly washed with a spray of

warm water with a small amount of potassium permanganate solution or with

children's soap (a spray of water should be directed from the genital organs to

the anus) with the subsequent drying and treatment of the area of the external

genitalia, inguinal and intergluteal folds, with a wool cotton tampon soaked in

sterile vegetable oil or children's cream.

A nurse should teach the mother the rules of caring for the newborn.

Thorough observance of all hygienic rules of caring for the newborn girl will

reliably prevent the development of genital infections.

The child should have a separate bed and bathtub. Her clothes and linen

should be laundered separately.

In the neutral period of genital development girls should take hygienic

showers, wash daily the genitalia (with water and children's soap), and

change the underwear regularly. In case of irritation of the external genital

organs, chamomile and bur marigold teas are used for washing the genitalia.

Genital hygiene should be particularly thorough in girls suffering from

exudative diathesis, obesity, diabetes, and systemic infectious diseases since

they are at a high risk for developing vulvovaginitis.

In the prepubertal period girls display significant changes in the

external and internal genitalia and the appearance of secondary sex

characters. Walks in the fresh air, exercise, active physical games, and regular

and adequate meals facilitate the proper physical development. Physical loads

should correspond to the possibilities of the growing body. Hard physical

work is unacceptable at this age.

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In the course of lectures and talks with parents and girls it is necessary

to let them know the physiological peculiarities of the pubertal period and

rules of the proper genital hygiene.

In the pubertal period girls should be explained the necessity to observe

the proper hygienic rules during menstruations (washing of the genitalia

twice-thrice per day and frequent change of sanitary pads).

Lectures and talks carried out by physicians and nurses are also

important from the viewpoint of moral upbringing of future females and

mothers. Older girls should be explained that the appearance of

menstruations does not mean that they have become sexually mature since

the process of sexual maturation is completed only at about 18 years of age.

Smoking and drinking of alcoholic beverages exert a particularly harmful

effect on the body at this age. A premature onset of sexual activity, pregnancy,

abortions, and deliveries in the period of physiological immaturity are

detrimental for a growing body.

Hygiene of Women

General Hygienic Regimen

A hygienic regimen is the correct alternation of work and leisure.

Women in the Ukraine have an opportunity to work in any branch of the

national economy they choose. But wherever they work they are always

covered by measures aimed at ensuring healthy working conditions for

women. Much attention is also paid to physical development of women and

involvement of them into exercise. Groups of health are set up on the basis of

stadiums, swimming pools, and voluntary sports societies where people swim,

jog, do aerobic exercises, etc. Students are encouraged to join sports circles or

clubs. At working places special breaks are envisaged for doing occupational

gymnastic exercises, which help to combat fatigue and improve respiration

and blood circulation.

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Skin hygiene should be adequate (regular hygienic showers, hygienic

baths). Women are recommended to do morning exercises, to sponge down

with cold water (to improve general resistance to colds), and to take hygienic

showers in the evening. In summer time it is useful to bathe in open pools,

take air and, if not contraindicated, sun baths.

Rational diet plays an important role in the proper hygienic regimen.

Food should be diverse, while its energy value (calory intake) should

correspond to physical expenditures. Meals should be taken regularly. Apart

from the main nutrients, food should contain sufficient amount of vitamins

(vegetables and fruits). Women with a tendency to obesity are recommended

to restrict the intake of carbohydrates (sugars, flour products, sweets).

In the course of health education activities (talks and lectures) it is

necessary to convey to the audience the knowledge about the harmful effect of

smoking and drinking. The use of alcoholic beverages may greatly affect the

female body at any age. Hence, the task of health workers is to constantly and

everywhere conduct a campaign against alcohol.

A woman should take necessary measures to prevent any deviations in

her urinary and bowel habits.

Clothes should be chosen with due regard to the hygienic norms and

current weather. Cotton or wool underwear is preferable.

Hygiene During the Menstrual Period

Menstruation is a manifestation of a specific function of the female

body; it denotes the onset of sexual maturity and influences all the bodily

functions. Menstrual blood should be allowed to have a free outflow. For this

purpose absorbable sanitary pads (from cotton wool) or tampons (to be

changed several times per day) are employed.

During the menstrual flow the external genitalia should be washed with

warm water and soap several times a day. During menstruation the woman is

not allowed to take a bath, go to the bathhouse, bathe in a swimming pool or

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any other water reservoir but should take a warm hygienic shower. Any sports

activities are forbidden during the menstruation. The woman is also

recommended to shun overcooling and poignant food and spices. The woman

should have regular bowel movements.

Intercourse is strictly forbidden during the menstruation since it may

cause infection or intensify the menstrual bleeding. Vaginal irrigation and

other therapeutic vaginal procedures are not permitted during menstruation

either.

Sexual Hygiene

The legitimate age for marriage in the Ukraine is 18 years when the

pubertal period is over and the woman becomes sexually mature. It should be

explained to the woman that the observance of sexual hygiene is essential for

her health and that sexual promiscuity poses a high risk of contracting

sexually transmitted diseases.

The first coitus is attended by hymenal rupture and the formation of

lacerations on the mucosa of the vaginal vestibule. To prevent possible

infection, it is necessary to institute a particularly thorough care for the

genital organs, including their careful washing with warm water and

abstinence from coitus for a few days.

Some deviations from normal sexual life suggest genital diseases and

may lead to neurosis and reactive depression.

One of the most common sexual disorders is frigidity. It may be

expressed as either the absence of sexual satisfaction or decreased or even

absent sexual excitability. Frigidity is more common in women and may be a

sequela of pathological states or caused by such non-physiological factors as

improper upbringing, the absence of love for the spouse, and/or conditions,

which interfere with the creation of an intimate set-up.

Diseases that may be attended by frigidity include ovarian dysfunction,

central nervous system and metabolic diseases, chronic intoxication with

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nicotine and alcohol. Frigidity may also be associated with genital

malformations in both females and males. Of definite importance may be

poor personal hygiene, in particular genital hygiene, of one of the partners.

The decision, whether the given deviation from the norm is physiological or

pathological, is made by a sexopathologist following the examination of both

partners. The proper option for medical personnel in such cases is to

promptly refer such patients to a sexopathologist.

In the wake of the first coitus attended by sharp pain the woman may

develop vaginismus (reflex spastic contraction of muscles of the vaginal

vestibule and pelvic floor hampering intercourse). This is most often due to

functional disturbances of the nervous system, and such patients should be

referred to a neuropathologist. There is a close correlation between the

unsatisfactory sex life, sexual disorders, and neuroses. Any abnormalities of

the sexual life may finally result in neurosis. A neuropathologist and a

sexopathologist working as a team should treat sexually related neuroses.

It is impossible to establish any common denominator with regard to

the normal frequency of intercourse since the latter depends on the age,

temperament and health of both partners. The major yardstick in this respect

is how the partners feel after coitus. If it is followed by drastic fatigue,

weakness, and malaise, the partners are recommended to cut down on the

frequency of intercourses they have. Coitus is forbidden during

menstruations, in the period of treatment from sexually transmitted diseases,

during the first and last two months of pregnancy, and during four weeks

after abortion and six weeks postpartum.

Before getting married, it is advisable for both partners to consult a

doctor about her or his health status, which may help to reveal possible

asymptomatic diseases that could adversely affect their progeny. Special

genetic consultative centres deal with the questions pertaining to

transmission of hereditary diseases. People with a family history of hereditary

diseases about to get married and spouses who have already given birth to

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children with hereditary disorders or malformations should be referred to

these genetic centres.

Self test

1. Choose the solution, which may be used for washing of external genitalia in

girls.

A. chamomile tea

B. oxygen peroxide

C. 0. 9% solution of natrium chloridum

D. tincture of iodine

2. During menstrual flow tampons should be changed

A. several times per day

B. once a day

C. owing to volume of bleeding

D. should not be changed during a day

3. During the menstrual flow the external genitalia should be washed with warm

water and soap for

A. several times a day

B. six times a day

C. two times a day

D. four times a week

4. Diseases that may be attended by poor hygiene are the following except

A. ovarian dysfunction

B. central nervous system diseases

C. inflammatory diseases

D. disturbances of a sexual function

5. The first coitus may lead to inflammations of the mucosa of the vaginal vestibule

due to

A. lacerations

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B. changing of a hormonal status

C. alteration of a vaginal mycroflora

D. psychologic stress

6. The warm bath is

A. indicated during menstrual flow for women

B. contraindicated during menstrual flow for women

7. What is better for women during menstrual flow?

A. to have a bath for personal hygiene

B. to have a shower-bath (douche)

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Chapter 24. URINARY TRACT DISEASES IN

FEMALE

Urinary Tract Infections in Women

Urinary tract infections (UTIs) in women are among the most common

problems encountered by the gynecologist. Twenty percent to 40% of women

will have a UTI sometimes in their lifetime. Women are 30 times more likely

than men to suffer a UTI, and of those women affected, 20% have more than

three UTIs per year. It is not surprising, then, that complaints related to the

urinary tract account for 7 million annual outpatient visits, 1 million

hospitalizations.

UTIs comprise a collection of diseases that can be classified based on

both the anatomy and the complexity of the disease. Anatomically, upper

UTIs involve the kidney, resulting in pyelonephritis. Pyelonephritis may be

chronic, subclinical, or acute, with this chapter focusing on management of

the latter. Lower UTIs involve the urethra and bladder, resulting in acute

urethritis and acute cystitis, respectively.

UTIs can be further classified as complicated or uncomplicated. A

complicated UTI is associated with a condition that increases risk for

acquiring infection, failing therapy, or suffering increased morbidity. These

associated conditions may be structural (obstruction, catheterization, renal

calculi), metabolic (diabetes, pregnancy, chronic renal failure), or functional

(impaired host [AIDS, neutropenia] or unusual pathogen).

Complicated UTIs can range in severity from simple cystitis to urosepsis

with shock; thus, it is the associated conditions, not severity of disease, that

make a UTI complicated. Some authors argue that true uncomplicated UTIs

only occur in nonpregnant, healthy adult women with no neurologic or

structural dysfunction. Eighty percent of UTIs fall into this group.

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The urinary tract is normally an enclosed, protected, and sterile

mucosal surface. Washout of bacteria by urine flow is the primary host

defence against infection. This process is nearly continuous in the upper tract

but only intermittent in the lower. Uropathogens are generally not virulent,

but instead are highly adapted to ascend, colonize, and grow in the urinary

tract, subsequently causing cell damage and infection. The colon is the

primary reservoir for most uropathogens. Over 95% of infections result from

enteric bacteria ascending the urinary tract. Although the exact process of

ascent is unknown, enteric bacteria colonize the vagina and periurethral area,

ascend the urethra into the bladder, multiply in the urine, reflux into the

ureters, and ultimately colonize and invade the renal parenchyma. Factors

that alter urine washout, change the characteristics of the urine, or facilitate

entry of bacteria into the urinary tract increase risk for development of a UTI.

The primary risk factors in young healthy women for development of an

uncomplicated UTI are sexual intercourse and diaphragm use with

spermicide. Less than 5% of UTIs result from hematogenous spread during

septicemia. These organisms tend to be more virulent, causing severe

pyelonephritis or even microabscesses within the kidney.

The most common uropathogens responsible for development of a UTI

are enteric gram-negative bacilli of the class Enterobacteriaceae. Escherichia

coli is responsible for over 80% of UTIs in reproductive-aged females.

Staphylococcus saprophyticus causes 5% to 20% of UTIs in this group, with

other enterics such as Klebsiella, Enterobacter, Enterococcus, Proteus,

Pseudomonas, and Group B Streptococcus causing the balance of infections.

Hospitalized, catheterized, and immunosuppressed patients tending to suffer

UTIs from more virulent bacteria as well as Candida, colibacillus infections

are much less common in this group, causing less than 40% of infections.

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Clinical Presentation

Asymptomatic Bacteriuria

Asymptomatic bacteriuria is simply the presence of bacteriuria in a

patient with no symptoms of cystitis or pyelonephritis. This condition is most

common in elderly and pregnant women. The incidence of asymptomatic

bacteriuria increases with the age to as high as 40% in women over 60. Thirty

percent of individuals become symptomatic within 1 year. Identification of

asymptomatic bacteriuria in elderly women is of questionable benefit, as no

association with excess morbidity and mortality has been demonstrated. In

contrast, it is critical that the gynecologist identify asymptomatic bacteriuria

in a pregnant woman. While only 4% to 7% of pregnant women will have

asymptomatic bacteriuria, 30% of these will subsequently develop

pyelonephritis if untreated. Asymptomatic bacteriuria has also been

implicated in stillbirth and preterm labour, but this remains controversial.

Acute Cystitis

Acute cystitis is most commonly seen in reproductive-aged women. The

most typical symptoms include dysuria, frequency, urgency, and suprapubic

or abdominal discomfort. Hematuria occurs in up to 40% of women with

acute cystitis. More general complaints may also be described, such as fatigue,

malaise, irritability, and diaphoresis, dysuria. Fever (greater than 38°C) and

severe abdominal pain are rare, and should make the emergency physician

consider upper tract disease or alternative diagnoses. Microscopic urinalysis

reveals pyuria, bacteriuria, and, frequently, hematuria.

Acute Recurrent Cystitis

Acute recurrent cystitis is defined as three or more episodes of acute

cystitis within a year. It occurs in 20% of individuals with acute cystitis,

usually as the result of separate episodic uncomplicated infections.

Individuals with recurrent cystitis should be identified for consideration of

UTI prophylaxis.

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Acute Urethritis

Acute urethritis presents with symptoms nearly identical to those of

cystitis. There may be a coexistent cervicitis and vaginal discharge. Pyuria

without evidence of bacteriuria is common on urinalysis, with subsequent

cultures growing minimal uropathogens. Chlamydia trachomatis, Neisseria

gonorrhoeae, and the herpes simplex virus are the usual causative organisms.

Acute Pyelonephritis

Acute pyelonephritis can present with variable severity, from a mild

cystitis-like illness with flank pain to a more severe illness with fever, chills,

nausea, vomiting, sweats, and flank and/or abdominal pain. Absence of

cystitis symptoms is not uncommon. Costovertebral angle tenderness is a

common physical finding. Urinalysis reveals pyuria, bacteriuria, hematuria,

and white blood cell casts; the latter are highly specific for acute

pyelonephritis.

Urosepsis

Urosepsis is most likely to manifest in women with indwelling catheters,

immunosuppressive disorders, urinary obstruction, complicated UTIs, or

serious underlying medical problems. Elderly women from extended care

facilities are at greatest risk. Typically, such patients present with nonspecific

signs and symptoms, including fever, confusion, weakness, tachycardia,

tachypnea, and dehydration. Family members or nursing home staff may

provide valuable history, as the patient often cannot provide one herself. If

alert, the patient may complain of incontinence, abdominal pain, thirst,

dyspnea, or even cough. Fever is often present, but hypothermia is not

unusual. Examination will usually reveal dehydration or compensated shock,

but delayed presentation may result in severe hypotension and septic shock.

Symptomatic catheterized patients

Urinary catheterization is responsible for the vast majority of

nosocomial UTIs. Incidence of infection for indwelling catheters is 5% per

catheter-day. Such UTIs are, by definition, complicated, with manifestations

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ranging from mild suprapubic pain, bladder spasms, and incontinence

around the catheter to fulminant sepsis. All symptomatic catheterized

patients should be treated with broad-spectrum antibiotic therapy.

Differential Diagnosis

The gynecologist should be aware that female patients differ from those

of other outpatient settings. Patients presenting with urinary symptoms are

more likely to have gynecologic disease (vaginitis, pelvic inflammatory

disease, and sexually transmitted disease), upper tract disease, and social

circumstances that complicate access to care and follow-up when compared

with other outpatient settings.

The differential diagnosis of acute dysuria includes the following:

acute urethritis, acute cystitis, and vaginitis. Generally, urethritis is

characterized by a more gradual onset and occurs in patients who have

concomitant vaginal symptoms. Urgency, frequency, and urinary

incontinence commonly accompany the dysuria of acute cystitis. The

bladder, when infected or inflamed, contracts spasmodically to create these

symptoms. Vaginitis is common and presents with external dysuria and

vaginal discharge. Frequency and urgency are lacking because the bladder

is not involved.

Flank pain typical of pyelonephritis is common in other diseases as

well. Patients with unilateral costovertebral angle tenderness may have

renal calculi, perinephric abscesses, renal infarcts, and neoplastic or

traumatic processes.

The gynecologist must base the differential diagnosis on the

presenting complaint, and then narrow it with additional history, physical

examination, and laboratory examination.

History

Historical information of importance includes the nature of the

dysuria (external or internal), the duration of symptoms, and

accompanying symptoms of urgency, frequency, incontinence, abnormal

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vaginal discharge, external genital lesions, fever, back pain, hematuria, or

foul-smelling urine. A detailed sexual history, including the possibility of

pregnancy, the number of partners, and the type of birth control method

used, is also prudent. The medical history should be explored in an effort to

identify any factors that would make an otherwise uncomplicated UTI

complicated.

Physical Examination

The examination begins with an assessment of vital signs and

hydration status. Examination of the genitourinary tract includes

assessment of costovertebral angle tenderness, suprapubic mass, or

tenderness, and examination of the external genitalia and urethra. A pelvic

examination should be performed in women in whom the diagnosis is

unclear and in women whose history suggests a diagnosis of either

urethritis or vaginitis. It is important to note the presence or absence of

indwelling catheters, as they place the patient at risk for a complicated UTI.

When combined with a good history, a careful physical examination

should enable the physician to identify patients with urosepsis, acute

cystitis, and acute pyelonephritis, and should allow the physician to predict

whether the patient has a complicated or uncomplicated infection.

Urinalysis Collection

A urine specimen should be collected by the method most appropriate

for the patient's clinical status and capacity to cooperate with cleansing

guidelines. In the presence of obesity, menstrual blood, copious vaginal

discharge, or an anatomic abnormality, the preferred method for obtaining

a urine specimen is an in-and-out urethral catheterization of the bladder.

The main risk is induction of UTI, but this occurs less than 1% of the time

in a normal host. For non-menstruating, thin patients lacking vaginal

discharge, a clean-catch urinalysis can be utilized. The sample should be a

midstream specimen obtained after perineal cleansing with gauze

moistened by either saline or tap water. No benefit has been proven from

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soap cleansers. Some experts suggest that urine from a freshly wet diaper

can be collected for accurate analysis. Regardless of the means by which the

urine is obtained, the specimen should be processed promptly after

collection, as stagnation increases colony counts.

Dipstick Chemical Tests/Urine Microscopy

The nitrite test depends on bacterial reduction of nitrate to nitrite.

The test is more likely to be positive with gram-negative bacteria. It may be

falsely negative in the presence of low-count UTIs, dilution, antimicrobial

therapy, and infections caused by non– nitrate-reducing bacteria such as S.

saprophyticus, Acinetobacter, and enterococcus. While the negative

predictive value of a nitrite test ranges from 0. 27 to 0. 70, the positive

predictive value is 0. 96. Thus, a positive nitrite test strongly suggests the

presence of bacteriuria, while a negative test does not exclude it. The

leukocyte esterase test detects the presence of neutrophil granules and

connotes pyuria greater than or equal to 8 to 10 white blood cells per high-

power field. The sensitivity for the leukocyte esterase test ranges from 0. 75

to 0. 90, while the specificity is more precisely defined as being 0. 95. False-

positive results have been reported with Trichomonas, and false-negative

results have been seen in urinalysis with dipsticks positive for glucose and

ketones.

The ease of use and availability of these tests can assist the emergency

physician in identifying UTIs. Generally, a completely negative dipstick

analysis corresponds to a negative microscopy evaluation, although 5% of

UAs with negative dipstick results are found to have abnormal urine

microscopy. Urinary microscopy has been shown to change patient

management in only 5% of patients, and, therefore, consideration must be

paid to both the turn-around time and the cost of each test. For cases in

which the diagnosis is clear, a dipstick should suffice. Full microscopic

evaluation may be of assistance in the more complicated cases and in cases

in which false-negative or false-positive results are expected.

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Understanding the limitations of the nitrite and leukocyte esterase tests

better enables the clinician to decide when to employ microscopic analysis.

Urine Culture

Isolation and quantification of uropathogens in culture may help

differentiate the various UTIs.

The vast majority of young, otherwise healthy women with probable

UTI do not need cultures or sensitivity tests. Urine cultures should be

obtained in any woman with potential for a complicated UTI; acute

bacterial pyelonephritis; fever without focus; relapsing UTI; recently

treated, documented UTI; fever and neutropenia; indwelling bladder

catheterization; or sepsis.

Other Laboratory Studies

Patients with urosepsis, acute bacterial pyelonephritis, or complicated

UTI should have creatinine assessed, as renal dysfunction may occur with

upper tract infections. Similarly, several studies have shown little to no

discrepancy between the organism cultured from the urine and that

cultured from the blood. Because blood cultures are costly and often do not

add to the clinical evaluation, careful thought should be given as to whether

they are necessary. In the adult patient with a UTI, blood cultures are

recommended when the diagnosis is unclear, when urine culture cannot be

obtained (catheterization impossible), or when bacteremic seeding of the

kidneys is possible (endocarditis). They need not be performed for routine

pyelonephritis. Vaginal cultures can be helpful when vaginitis and

urethritis are likely, though their results are not available for initial

management decisions. A pregnancy test is indicated if pregnancy is

possible.

Imaging Studies

Radiologic imaging of the woman with uncomplicated UTI is seldom

indicated. Routine imaging of women with pyelonephritis is also not

recommended, as 75% of adults with pyelonephritis have normal anatomy.

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Indications for emergent or urgent imaging are not clearly defined, but in

general, patients who are severely ill, patients who fail to respond to

appropriate antimicrobial therapy, and patients with recurrence within 3

days of finishing treatment may deserve radiographic evaluation in the

form of either ultrasonography or computed tomography.

Treatment

Urosepsis

Prehospital management and immediate resuscitative efforts are

necessary for women with urosepsis. Airway management and the

provision of supplemental oxygen, intravenous crystalloids, and antibiotics

are the mainstays of care. Administration of appropriate antimicrobial

agents should begin in the ED as soon as possible. Although urine and

blood cultures should ideally be obtained prior to the administration of

antibiotics, culture acquisition should not delay the administration of

appropriate therapy. Examples of suitable antibiotic choices include a

third-generation cephalosporin, imipenem–cilastatin, ticarcillin–

clavulanate, or ampicillin in combination with an aminoglycoside.

Uncomplicated Cystitis

Patients with cystitis can be treated with oral antimicrobial agents as

outpatients. Due to growing concerns about antimicrobial resistance,

increasing attention has been placed on the choice of antimicrobial therapy

and its duration. In vitro studies have found increasing resistance of

common urinary pathogens to commonly used agents. As with all

antimicrobial therapy, the choice of agent must be tailored to regional

susceptibility patterns. Despite the increasing resistance of many urinary

pathogens to trimethoprim–sulfamethoxazole (TMP/SMX), this agent

remains an extremely well tolerated and effective agent in most of the

cases. Furthermore, there are increasing data to suggest that overuse of

fluoroquinolones is leading to increasing uropathogen resistance. Overall,

TMP/SMX remains an excellent first-line agent for most cases of

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uncomplicated UTIs. For patients with a contraindication to TMP/SMX or

those in an area where resistance is a significant concern, fluoroquinolones

or nitrofurantoin remain viable alternatives. Several experts feel that if

treating with nitrofurantoin, a 7-day regimen is more effective than a 3-day

one. Beta-lactam antibiotics cannot be advocated as first-line agents in

patients without contraindications to the aforementioned agents due to the

high incidence of resistance to these drugs. Three-day regimens of

treatment seem to confer an advantage over single-dose therapy in terms of

the incidence of symptom recurrence. This is thought to be due to the

inability of the single-dose regimens to eradicate uropathogens from the

vagina, urethra, and rectum. For patients with severe dysuria, a 1- to 2-day

course of a urinary analgesic, such as phenazopyridine 200 mg three times

per day, is also advisable.

Uncomplicated Pyelonephritis

Patients with pyelonephritis who are febrile and vomiting should be

treated with antipyretics, antiemetics, and intravenous fluids.

Antimicrobial therapy is similar to that for patients with uncomplicated

cystitis. Many authors advocate the use of single-dose parenteral therapy

followed by oral therapy for duration of 10 to 14 days. Acceptable

parenteral agents include gentamicin or third-generation cephalosporins.

Because some patients develop worsening symptoms within 24 to 36 hours

of hospital discharge, early follow-up is recommended.

Complicated Urinary Tract Infections

In general, agents used for the treatment of complicated UTIs are

similar to those used for uncomplicated infections, with the specific agent

chosen on the basis of known or presumed susceptibilities of the infecting

organism. Due to the structural abnormalities inherently associated with

complicated infections, a longer course of therapy is warranted to

effectively sterilize the urinary tract. In addition, close follow-up is

mandatory to ascertain effective cure.

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Urinary Tract Infections Complicating Pregnancy

Antibiotics commonly used to treat UTIs are contraindicated in

pregnancy. TMP/SMX is relatively contraindicated in the first trimester

due to its inhibition of folate metabolism, and is contraindicated in the

third trimester due to its potential to cause kernicterus in the newborn.

Fluoroquinolones may damage growing cartilage and epiphyses of long

bones, their use in pregnancy is contraindicated. Other viable alternatives

for treating the parturient with cystitis include nitrofurantoin,

sulfisoxazole, and cephalexin. Due to the high incidence of complications

affecting both the mother and the fetus, pyelonephritis in pregnancy has

historically been an infection treated as an inpatient. Recent studies,

however, have shown that patients may be managed as outpatients with

close follow-up. If outpatient management is elected, 10 to 14 days'

treatment is recommended, as is consultation with the patient's

obstetrician to assure close follow-up.

Asymptomatic Bacteriuria

Treatment of asymptomatic bacteriuria is not advocated except

during pregnancy. Pregnant women with bacteriuria have a markedly

increased risk of acute pyelonephritis and the accompanying risks of

prematurity and low-birth-weight infants. Treatment is again directed at

the etiologic organism. Recommended regimens include 3-day courses of

amoxicillin, an oral cephalosporin, or nitrofurantoin.

Recurrent Cystitis

Women with more than three UTIs within 1 year may benefit from

longer term prophylactic therapy. Postcoital prophylaxis with one-half of a

TMP/SMX tablet (40/200 mg) may benefit those whose recurrences have

clearly been related to intercourse. Continuous daily prophylaxis for 6

months with TMP/SMX, nitrofurantoin, norfloxacin, cephalexin, or

trimethoprim has also been shown to decrease the morbidity of recurrent

UTIs. Unfortunately, approximately 40% to 60% of these women will

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reestablish their pattern of frequency of infections within 6 months of

discontinuing prophylactic therapy.

Disposition

Role of the Consultant

Consultants are seldom required for uncomplicated UTI in women.

Patients with cystitis do not require follow-up unless symptoms worsen or

recur. Uncomplicated acute pyelonephritis may be referred to primary care

physicians for subsequent management. As noted, pregnant women with

pyelonephritis require close follow-up, and consultation with their

obstetricians is advised. Some women with complicated UTI may require

urologic and medical consultation.

Indications for Admission

Patients with urosepsis and serious underlying medical problems may

require critical care admission if they are hemodynamically unstable, require

mechanical ventilation, or have complicating medical conditions. Patients

with complicated pyelonephritis or uncomplicated pyelonephritis associated

with toxicity are candidates for hospital admission (serious medical

conditions, dehydration with inability to maintain a normovolemic state, and

inability to take oral medication). The young, nonparous, otherwise healthy

woman with acute, uncomplicated, and nontoxic pyelonephritis may respond

within hours of initiating appropriate therapy and may be subsequently

managed as an outpatient.

Wetness /Urinary Incontinence

Urinary incontinence, the involuntary loss of urine, is a symptom or

sign of urinary tract dysfunction; it is not a disease. The presence of even

minor degrees of urinary incontinence may be a devastating problem for

patients, preventing them from leaving home or enjoying normal activities.

The clinician must determine (a) whether it is urine that is leaking, (b) the

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source of the urinary loss, (c) the underlying pathophysiologic mechanism,

and (d) the appropriate therapy.

I. Nonurinary Wetness

As a first step, the type of fluid actually leaking should be identified.

Nonurinary perineal wetness may easily be confused with incontinence. Urine

may be identified by measuring the creatinine level of the fluid, which will be

markedly elevated in urine. Agents that colour the urine, such as indigo

carmine or phenazopyridine, can also be used. If the perineal fluid does not

obviously stain with these agents, it is not urine. A perineal pad is helpful in

collecting the perineal fluid, and it can be weighed to quantify the leakage.

Nonurinary perineal wetness can occur from various sources.

A. Gastrointestinal tract: diarrhea, fistula, or leakage from a colostomy

or ileostomy

B. Vagina: vaginal discharge, exudate, or transudate

C. Serous or purulent drainage from perineal infection or hidradenitis

D. Perspiration

E. Subjective wetness: a complaint of wetness when no wetness is

demonstrated

II. Nonurethral Wetness

A. Fistula.

Wetness caused by fistulae may follow hysterectomy, radiation to the

pelvis, or birth trauma. The most common type of fistula is vesicovaginal. A

fistula may develop years after radiation therapy has been completed. The

patient typically will complain of constant urinary wetness. Urinary fistulae

are generally easy to diagnose on physical examination or cystoscopy. If the

fistula is not obvious but is suspected on clinical grounds, the patient may be

given a urinary coloring agent and instructed to wear a vaginal tampon and

perineal pad. In the case of a urinary fistula to the vagina, the tampon will be

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stained but the perineal pad will not. Vesicovaginal and urethrovaginal

fistulae may be repaired by a transvaginal or transvesical approach,

depending on the location of the fistula and the experience and preference of

the surgeon. Ureterovaginal fistulae require an abdominal approach because

reimplantation of the ureter into the bladder is usually necessary.

B. Ureteral ectopia, in which the ureter congenitally inserts into a

location other than the normal bladder trigone, may cause incontinence in

female patients if the insertion is distal to the external urethral sphincter.

Although ureteral ectopia is usually associated with a duplex renal collecting

system in female patients, single ectopic ureters are encountered on rare

occasions. The ectopic orifice usually drains the upper pole of a duplex system

and may insert in the urethra, vagina, or perineum. Male patients with

ureteral ectopia are generally not incontinent because ureteral insertion will

always be proximal to the external sphincter; however, they may present with

epididymitis. Ectopic ureter is almost always discovered in childhood. The

patient or parents may note continuous urinary incontinence despite a

normal voiding pattern. In the case of a duplicated system with a poorly

functioning upper pole segment, treatment may consist of excision of the

upper pole and a varying length of its draining ureter. In the case of a single

collecting system or a duplex system with good function of the upper pole

moiety, treatment is reimplantation of the ureter into the bladder.

C. Vaginal reflux of urine during voiding may result in postvoiding

wetness. This condition may occur with vaginal stenosis or atrophy,

congenital urethral “female hypospadias,” or repositioning of the urethra

intravaginally following incontinence surgery.

III. Urethral Incontinence

Pathophysiology of continence.

Urinary continence requires that the bladder store an adequate volume

of urine at low pressure, efficient urethral sphincteric function, and integrity

669

of the neurologic control mechanisms to coordinate voiding and continence.

The bladder neck must remain closed at all times, except during voiding, and

must be able to withstand momentary increases in intraabdominal pressure.

The prostatic and membranous portions of the male urethra act as the

primary continence mechanism; the entire female urethra performs this

function. In both sexes, the urethra prevents leakage by several important

mechanisms.

1. Smooth-muscle tone is the single most important factor in

maintaining minute-to-minute continence.

2. Striated muscle fibers are found within the urethral wall and in the

periurethral area. The striated muscle constitutes the second line of defence

against incontinence. The striated muscle within the urethral wall consists of

“slow-twitch” fibers specialized to maintain constant tone. The periurethral

fibers consist of “fast-twitch” fibers that can be rapidly activated to provide

auxiliary compression, such as might be required during coughing. The

periurethral striated muscle, innervated by the pudendal nerve, is much

stronger in males than in females.

3. Coaptation of the mucosa acts as a seal and reduces the urethral

muscular tone required to prevent leakage. Female estrogens cause the

urethral mucosa to proliferate and mature. It has been suggested that this

factor may partially explain the increased incidence of stress incontinence in

postmenopausal women. Urethral scarring, such as after multiple incisions

for recurrent urethral strictures, may affect the ability of the urethra to coapt

effectively.

The classification of incontinence is traditionally based on clinical

symptoms rather than the pathophysiology.

1. Stress incontinence is defined as the involuntary loss of urine during

physical effort that is not caused by a bladder contraction. Terms such as

genuine stress incontinence and urethral incompetence are sometimes used

as synonyms. As a symptom or sign, stress incontinence does not indicate any

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particular disease. It may be seen in both male and female patients but is

much more common in women. Most commonly, this type of incontinence

occurs in the upright position. Maneuvers that commonly elicit stress

incontinence include coughing, lifting, straining, and laughing. The amount of

urine lost is usually small, unless a bladder contraction is precipitated at the

same time. Minimal or occasional stress incontinence probably occurs in all

women at some point in their lives; however, significant stress incontinence

(defined as occurring two or more times a month) affects 5% to 10% of

women between the ages of 35 and 64. Stress incontinence is unusual in

nulliparous women and becomes more prevalent as parity increases. In

women, most instances of stress incontinence result from a defect in the

pelvic support of the bladder neck (type I stress incontinence) or both the

bladder neck and urethra (type II). In both of these types, increased

intraabdominal pressure causes hypermobility of the bladder neck or urethra.

In type III stress incontinence, there is no urethral hypermobility, but an

intrinsic urethral defect is the cause of incontinence. Type III incontinence

(sphincteric insufficiency) may be caused by trauma, denervation, multiple

surgical procedures, radiation therapy, or postmenopausal atrophy.

2. Urge incontinence is loss of urine associated with marked urinary

urgency. Other storage symptoms are typically also present, such as

frequency, urgency without incontinence, nocturia, and enuresis. By

definition, involuntary bladder contractions that are idiopathic are referred to

as detrusor instability, whereas those that occur in conjunction with a known

neurologic disease (e. g., stroke, multiple sclerosis, spinal cord injury) are

known as detrusor hyperreflexia. Typically, the patient reports the loss of

considerable amounts of urine under specific circumstances, such as during

cold weather, hand washing, or emotional upsets. In about one-third of

patients with detrusor instability, there is a history of enuresis in childhood.

In contrast to genuine stress incontinence, urge incontinence becomes

increasingly likely as the bladder fills to capacity. Coughing or other stressful

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episodes may provoke bladder contractions (stress hyperreflexia of the

bladder), making this type of incontinence difficult to differentiate from

genuine stress incontinence.

3. Overflow incontinence is sometimes called paradoxical incontinence

because it results from chronic urinary retention. The patient leaks urine

episodically and never voids normally. Leakage may be worsened by any

increase in intraabdominal pressure. This type of incontinence may be caused

by neurogenic impairment of bladder contractility or by outflow obstruction.

4. Total incontinence refers to constant diurnal and nocturnal

incontinence without normal voiding. The symptoms may be similar to those

of overflow incontinence, but total incontinence may be differentiated from

overflow incontinence in that little or no urine is obtained on catheterization

of the bladder. This type of incontinence may be seen in neuropathic bladder

dysfunction (especially peripheral neuropathy), after obstetric or surgical

injury to the female urethra.

5. In functional incontinence, the urinary organs are normal but the

patient voids without regard to the social norms of time and place. This may

be seen in patients with organic dementia, psychiatric disease, or physical

problems of mobility or dexterity.

6. Mixed incontinence is frequently encountered in clinical practice. For

example, an elderly male diabetic may have impaired detrusor contractility

leading to increased postvoid residual as well as detrusor hyperreflexia

resulting from small cerebral lacunar infarcts.

7. Postvoid dribbling may be caused by collection of urine in the

urethral bulb or in a urethral diverticulum.

The major mechanisms of incontinence are classified below.

1. Detrusor abnormalities may cause incontinence by interfering with

the ability of the bladder to store urine.

a. Loss of compliance. A bladder that cannot maintain a low intra-

vesical pressure during filling is said to have low compliance. Once the

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intravesical pressure exceeds that of the urethra, incontinence occurs even

without a bladder contraction. This sequence of events can be seen in cases of

myelodysplasia or other forms of neurogenic bladder dysfunction, and after

bladder operations or pelvic irradiation.

b. Overactivity. This term denotes an involuntary detrusor contraction

(pressure >15 cm H2O) that occurs during filling, either spontaneously or

with provocative maneuvers such as standing upright. As mentioned before,

when a specific neurologic cause, such as cerebrovascular disease exists, the

term detrusor hyperreflexia is used. Detrusor instability in men is most often

associated with outflow obstruction. In women, the cause of detrusor

instability is most often idiopathic. Detrusor instability can be demonstrated

in approximately one-third of all women presenting with incontinence. If

severe urgency is present, inflammatory or malignant conditions of the

bladder (such as carcinoma in situ) should be ruled out with cystoscopy and

urinary cytology.

2. Urethral sphincter incompetence may result from various causes.

a. Loss of anatomic support is by far the most common and most

important cause of urethral incompetence in female patients (see Table 11-3).

Anatomic support of the female bladder neck and urethra results from the

combined action of the pubourethral and urethropelvic ligaments and the

supportive elements of the pelvic diaphragm. Loss of pelvic support may

result from age-related loss of elasticity or multiparity. Of patients with

urethral incompetence, about 50% have an associated cystocele or

cystourethrocele and 25% have a rectocele. These manifestations of pelvic

floor prolapse should be corrected at the time of surgery for stress urinary

incontinence. With lesser degrees of pelvic floor laxity, there may be no

obvious prolapse of pelvic organs, but abdominal straining may displace the

urethra and bladder neck downward into the vagina "hypermobility of the

urethra". Why displacement of the urethra is associated with stress

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incontinence is not clearly understood, but several hypotheses have been put

forward:

- Unequal transmission of pressure occurs as the urethra is displaced

from an intraabdominal position. During episodes of increased

intraabdominal pressure (stress), more pressure is transmitted to the bladder

than to the urethra, and urine is forced out.

- Mechanical disadvantage to the periurethral muscles results when the

urethra is excessively mobile. These muscles cannot efficiently occlude the

urethra during stress, became their anatomic relation to the urethra, which is

no longer normal.

- Slow sphincter contraction in women with stress incontinence has

been documented. In some women with stress incontinence, the ability of the

urethra to compress rapidly enough to prevent leakage during episodes of

stress is decreased. The relation of this finding to urethral hypermobility is

not understood.

b. Estrogen deficiency leading to loss of urethral mucosal coaptation has

been suggested as a factor in urethral incompetence.

c. Denervation of the urethra may occur in conjunction with peripheral

neuropathy, such as that found in diabetes mellitus.

d. Urethral scarring may result from interference with the urethral

blood supply. Multiple surgical operations or trauma may result in a urethra

that is noncompliant and unable to coapt, frequently producing total

incontinence.

Diagnosis of incontinence

Initial evaluation of the incontinent patient:

- The history is very helpful in determining the nature, duration, and

severity of incontinence.

- Physical examination in female patients should include a speculum

examination, bimanual pelvic and rectal examination, and occasionally

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cystoscopy (particularly if prior incontinence surgery has been performed).

The presence of cystocele and rectocele on straining should be noted and

graded. In most cases, the diagnosis can be made reliably on the basis of

history, physical examination, and a few specialized tests.

1. Pad tests may be used to quantify the amount of urine lost during a

24-hour period. The wet pads are weighed and the weight of the dry pads

subtracted, leaving the weight of urine lost.

2. Postvoid residual urine should be determined after the patient has

voided. A low voided volume may reflect diminished bladder capacity. If

there is little postvoid residual urine, overflow incontinence can be ruled

out. The postvoid residual can be determined by catheterization.

Alternatively, the use of small, portable ultrasound (US) postvoid bladder

scanners can obviate the need for catheterization.

3. The Marshall-Bonney test is performed during the pelvic

examination by asking the patient to bear down or cough with a full

bladder. If incontinence is observed, the test is repeated, after the urethra is

gently elevated (but not obstructed) by two fingers, placed inside the

vagina. If incontinence is corrected by this maneuver, it indicates that a

urethropexy or colposuspension should be successful. Although many

authorities place little credence in this aspect of the Marshall-Bonney test,

the objective demonstration of stress incontinence is valuable.

4. The Q-tip test is used to diagnose urethral hypermobility. After a

sterile Q-tip is placed within the urethra, the patient is asked to cough or

bear down. The normal urethra allows little movement of the shaft of the Q-

tip during this maneuver. With urethral hypermobility, there is obvious

movement.

Urodynamic tests are designed to measure pressure or flow during

bladder filling or voiding.

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1. Cystometrogram. The intravesical pressure is measured during

bladder filling and during contraction to assess bladder function. The most

common abnormality found is detrusor instability. Because detrusor

instability and urinary incontinence may coexist, the presence of detrusor

instability is not a contraindication to surgical therapy of incontinence;

however, the patient should be forewarned that irritative symptoms might

persist even after successful surgery. Conversely, the finding of detrusor

areflexia, especially if associated with diminished bladder sensation,

indicates the possibility of neuropathic incontinence. In patients with

detrusor areflexia, there is a high likelihood that intermittent

catheterization will be required after surgery for incontinence.

2. Long-term ambulatory monitoring of bladder pressure is

performed with solid-state transducers and portable data storage devices.

This technique monitors bladder pressure over an extended period (24 to

72 hours) and is much more sensitive than conventional cystometry in

detecting detrusor instability.

3. Abdominal leak point pressure is measured during a conventional

cystometrogram and is useful in both men and women with incontinence.

The bladder is gradually filled with contrast and monitored

fluoroscopically. After a volume of at least 200 mL is reached, the patient is

placed in a sitting or upright position and asked to perform the Valsalva

maneuver gradually. The lowest total bladder pressure at which leakage is

detected is the abdominal leak point pressure. If no leakage occurs with the

Valsalva maneuver, the patient is asked to cough several times, with

repeated fluoroscopic observation for the presence of leakage. The

abdominal leak point pressure of female patients with type I stress

incontinence typically is above 120 cm H2O; among those with type II

incontinence, it is usually between 60 and 120 cm H2O; and among those

with type III incontinence, it is usually below 60 cm H2O.

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4. Urethral pressure profile. This test, which measures pressures

generated along the length of the urethra, is occasionally useful in the

evaluation of incontinence. Although patients with urethral incompetence

tend to have lower values than healthy persons, there is so much overlap

that static measurement of the urethral pressure profile is of little

diagnostic use. The stress urethral pressure profile is more useful; it

requires simultaneous measurement of intravesical and urethral pressure.

In women with urethral incompetence, urethral pressure falls below

bladder pressure during coughing or stress and allows leakage of urine.

This abnormality is corrected by successful surgery.

5. Uroflow measurements in patients with incontinence are used to

detect outflow obstruction. In female patients, this is an extremely rare

cause of incontinence. It is much more common in male patients and may

be the cause of detrusor instability. The uroflow pattern in detrusor

instability is one of rapid attainment of high peak flow rates, whereas

obstructed voiding is characterized by a low maximal flow rate and

prolonged duration of voiding.

6. Voiding cystourethrography is often a useful test in the diagnosis of

incontinence and may be combined with simultaneous urodynamic studies.

Voiding cystourethrography is performed by filling the bladder with

radiographic contrast and it allows voiding to occur. Fluoroscopic

visualization of the bladder and urethra may give valuable information

about vesicoureteral reflux, trabeculation of the bladder, sphincteric

function, and outflow obstruction. In the upright position, contrast should

not leak below the bladder neck. Intrinsic urethral dysfunction (caused by

neuropathy or trauma) is possible if an open bladder neck exists at rest.

With urethral incompetence, increased intraabdominal pressure will cause

the bladder base and urethra to move inferiorly and the urethra to fill with

contrast.

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7. The pressure-flow video study is the urodynamic study combined

with simultaneous voiding cystourethrography. It is useful when it is

difficult to determine whether or not a bladder neck opening is a result of

detrusor contraction. This technique permits accurate diagnosis of detrusor

instability, detrusor-sphincter dyssynergia, and intrinsic urethral

dysfunction. It is indicated in patients with neurogenic incontinence, those

who have failed surgery, or patients with combined incontinence and

obstruction.

8. Sphincter electromyography is occasionally useful in the diagnosis

of incontinence. Proper innervation and function of the striated muscle

(external) sphincter is important for coordinated micturition.

Electromyography can therefore be used to demonstrate neuropathic

involvement of the striated perineal muscles in peripheral neuropathies

associated with diabetes mellitus, alcoholism, multiple sclerosis, and

myelodysplasia. Electromyography is often performed simultaneously with

a cystometrogram.

Endoscopy may be useful in either sex to rule out bladder

trabeculation, stones, tumour, or diverticulum. In men with

postprostatectomy incontinence, endoscopy may be used to assess the

presence of strictures or bladder neck contractures.

Pharmacologic treatment

An authoritative drug reference should be consulted before any

medications are prescribed. The following sections contain guidelines only

and describe many, but not all of the drugs used in treating incontinence.

a). Detrusor instability may be treated effectively in many instances

with anticholinergic agents or related compounds. Most of the drugs in this

class produce dry mouth, blurred vision, mild tachycardia, drowsiness, and

constipation. Dryness of the mouth is so common with most anticholinergic

agents that it can be used to monitor for adequacy of drug effect. In general,

if no effect on the bladder is noted, the dosage can be increased, until

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significant dryness of the mouth is reported by the patient. Dryness of the

mouth tends to become less prominent after several weeks of therapy. This

class of agents is contraindicated in patients with narrow-angle glaucoma

because mydriasis may cause acute intraocular hypertension. In addition,

all the medications listed below have prominent anticholinergic effects and

should therefore be used with caution in the elderly and in all patients with

autonomic neuropathies, hepatic or renal disease, hyperthyroidism,

coronary artery disease, congestive heart failure, cardiac tachyarrhythmias,

hypertension, or hiatal hernia associated with reflux esophagitis. In

patients with detrusor instability resulting from outlet obstruction, the use

of these medications may lead to urinary retention.

1. Oxybutynin chloride is widely prescribed for detrusor overactivity.

It has anticholinergic, antispasmodic, and local anesthetic actions. The

recommended dose is 5 mg orally two to four times daily. It is available in

liquid form for children. A slow-release form (Ditropan XL) is now

available.

2. Tolterodine tartrate is a new anticholinergic agent with a

significantly lower profile of side effects. In particular, dry mouth is less

prominent, so that patient compliance is improved. It is given in doses of 2

mg twice daily.

3. Flavoxate hydrochloride is similar to dicyclomine in its

pharmacologic properties. The recommended dose is 100 to 200 mg orally

three or four times daily.

4. Imipramine hydrochloride is a tricyclic antidepressant that blocks

uptake of norepinephrine by peripheral adrenergic nerves. Clinically, it

suppresses bladder contractions and increases urethral pressure, but the

mechanisms involved are unclear. The usual adult dose is 25 to 50 mg

orally four times daily, reduced in elderly patients. Caution should be used

when treating any patient with underlying cardiac disease. The drug can be

combined with an anticholinergic agent such as oxybutynin, which permits

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a lower dose of these agents to be effective. The side effects of imipramine

and the precautions regarding its use are similar to those for the other

drugs listed above, but when it is combined with anticholinergic agents, its

anticholinergic side effects may be additive. Other important side effects

include obstructive jaundice, abnormal liver function, skin rash, and

agranulocytosis. Central nervous system effects include parkinsonism,

sedation, irritability, and fine tremor. A baseline electrocardiogram should

be obtained in elderly patients or in those with underlying cardiac disease.

b). Urethral incompetence. Drug therapy should be considered for

patients who have intrinsic urethral incompetence without hypermobility,

those who refuse or are not well enough for surgery, and those for whom

surgical procedures have failed.

1. Pseudoephedrine hydrochloride is a sympathomimetic agent that is

available alone or as a component in cold and allergy preparations. The

usual dose is 30 to 60 mg orally up to four times daily. All

sympathomimetic agents should be used with caution in the elderly and in

patients with hypertension, diabetes mellitus, ischemic heart disease,

hyperthyroidism, increased intraocular pressure, and bladder outlet

obstruction from prostatic hyperplasia.

2. Phenylpropanolamine hydrochloride is an adrenergic agonist used

in doses of 50 mg orally three times daily. Like pseudoephedrine, this drugs

work by increasing the muscular tone at the bladder neck and in the

urethra. If detrusor instability is present, an anticholinergic agent may be

used concurrently. Phenylpropanolamine is contraindicated in patients

receiving monoamine oxidase inhibitors.

3. Estrogens have been reported to produce subjective improvement

in postmenopausal women with stress incontinence, apparently by

enhancing the mucosal quality (and therefore coaptation potential) of the

urethra. Various preparations have been used, including 0. 3- to 1. 25-mg

Premarin tablets daily, one applicator full of Premarin vaginal cream daily,

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and 1 mg of estradiol orally three times daily. Because estrogens have been

reported to increase the risk for endometrial carcinoma and

thromboembolic events, patients should receive the lowest effective dose

and should be monitored every 3 to 6 months during therapy for vaginal

bleeding.

VI. Surgical treatment

A. Fistulae. Small vesicovaginal fistulae sometimes respond to

endoscopic fulguration of the fistula tract. Most, however, require some

type of surgical procedure. Repair may be either by the transvaginal or

transabdominal route, depending on the preference and experience of the

surgeon. Basic principles of fistula repair include (a) complete separation of

the involved organs around the area of the fistulous tract; (b) watertight

closure of each organ, preferably with nonoverlapping suture lines; (c)

interposition of another tissue, if possible, such as omentum or

peritoneum. Approximately 80% of traumatic fistulae are closed

successfully with one operation, although in patients who have had

radiation therapy, the success rate is only 50%.

B. Ureteral ectopia. Usually, the ectopic ureter is draining the upper

pole of a duplicated renal unit.

C. Sphincteric incompetence

1. Intraurethral and bladder neck injections should be considered in

female patients with a well-supported urethra and urinary incontinence.

a. Cross-linked bovine collagen elicits a minimal foreign-body

reaction and has not been associated with particle migration. It has recently

gained popularity for use as a urethral bulking agent in both male and

female patients with incontinence. It is injected through a special needle

into the submucosal space of the urethra near the bladder neck. This can be

done either transurethrally or periurethrally. The material begins to

degrade in 3 months and is completely resorbed within 1 year. The

procedure may need to be repeated but has a reasonable success rate (25%

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to 50%) and very low morbidity in well-selected patients. In men with

incontinence after transurethral prostatic resection (post-TURP

incontinence), moderate success rates have been reported. In patients who

have had radical prostatectomy or pelvic irradiation, success rates are

significantly lower because of tissue fibrosis.

2. Retropubic suspension procedures

a. Marshall-Marchetti-Krantz procedure. The retropubic space is

developed, allowing placement of absorbable sutures adjacent to the

urethra and at the bladder neck. The sutures are tied to the periosteum of

the pubis, so that the urethra and bladder neck are elevated toward the

pubis. The operation has a success rate of about 85% and rarely causes

outflow obstruction. Its major disadvantage is that it cannot repair

coexistent cystocele or urethrocele. The major complication is osteitis pubis

(3%).

b. Burch colposuspension. Nonabsorbable sutures are placed in the

anterior wall lateral to the urethra and bladder neck and are tied to the

iliopectineal (Cooper's) ligaments. The success rate is reported to be more

than 80%. The procedure can be used to correct coexistent mild-to-

moderate cystoceles. Complications include detrusor instability, bladder

trauma, postoperative retention, and osteitis pubis.

c. Sling procedures are usually reserved for patients with type III

incontinence or in whom a previous operation has failed. The urethra is

dissected out to permit placement of various materials, such as rectus

fascia, Marlex, Mersilene, or Silastic, around it. The tension of the sling is

adjusted to allow elevation of the bladder neck. Voiding difficulties are

common, and most patients must use intermittent self-catheterization for

an average of 30 days. Success rates vary from 75% to 95%. The major

complications are operative injury to the urethra or bladder and delayed

erosion of the sling into the urethra.

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3. Vaginal procedures

a. Anterior colporrhaphy is commonly used to repair mild stress

incontinence, especially when associated with cystocele or rectocele.

Through a vaginal incision, the bladder neck and urethra are exposed. The

pubocervical fascia is sutured in the midline to provide support for the

bladder neck. Although the success rate of anterior colporrhaphy (65%) is

not as high as that of suprapubic procedures, anterior colporrhaphy can

correct coexistent prolapse, is very well tolerated, and has a low morbidity

rate.

b. The Stamey procedure is a vaginal sling procedure performed both

vaginally and through a small suprapubic incision. A nylon bolster suture is

used bilaterally to suspend the urethra. Endoscopy is performed to make

sure no injury to the urethra or bladder has occurred. The procedure is

simple to perform and has a success rate of approximately 90%. The

complications include infection of the suture material, which requires its

removal.

c. The Raz procedure is similar to the Stamey procedure except that

the sutures are not placed near the urethra but are situated well laterally

into the anterior vaginal wall. It is thus a colposuspension from below.

Success rates are similar to those for the Stamey procedure.

d. Pubovaginal sling procedures, as stated above, are usually reserved

for patients with type III incontinence or in whom a previous operation has

failed. The urethra is dissected vaginally to permit placement of a sling,

usually a strip of rectus fascia. The sling is then brought out through a

suprapubic incision and tied loosely. Voiding difficulties are common, and

most patients must use intermittent self-catheterization for an average of

30 days but occasionally longer. Success rates are reported to be above

90%. The major complications are operative injury to the bladder, erosion

of the sling, wound infection, and prolonged retention.

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4. Artificial urinary sphincter. This device consists of a periurethral

cuff, a pressure-regulating balloon inflated in the prevesical space, and a

control valve implanted into the labia (or scrotum if used in men) (Fig. 11-

1). When the control valve is activated (with a gentle squeeze), the

periurethral cuff pressure lowers for several minutes to allow voiding, then

automatically repressurizes. To prevent erosion into the urethra, the device

is activated 6 weeks after implantation, when healing has progressed. The

device should be used only in complicated instances of incontinence in

which the standard procedures previously described have failed. Like all

prosthetics, these devices may be complicated by mechanical failure or

infection. In male patients, the cuff can be placed around the urethra or

around the bladder neck. The control valve is then implanted into the

scrotum. Patients with good manual dexterity who are highly motivated are

candidates for this procedure. Detrusor instability or poor bladder

compliance are relative contraindications. Approximately one-third of

patients require revision of the device at some point. Nevertheless, the

overall success rate is reported to be as high as 95% (including

reoperations).

D. Diminished bladder capacity leading to incontinence may be

managed by augmenting the native bladder with a detubularized segment

of bowel. The goal of this surgery is to produce a compliant, low-pressure

reservoir without contractions that cannot be inhibited.

1. Augmentation cystoplasty may be accomplished by a variety of

techniques with an isolated segment of bowel, such as ileum, cecum,

stomach, or ileocecal segment, to improve the bladder capacity and lower

the intravesical pressure.

2. Urinary diversion. Supravesical diversion is generally applied as a

last resort in incontinent patients. The simplest method is an ileal conduit,

in which the ureters are implanted into an isolated segment of small bowel.

A cutaneous ostomy is then created, and the urine collected in a bag.

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Continent supravesical diversions have also been designed, in which

detubularized bowel is used to fashion a urinary reservoir. The patient then

empties this “substitute bladder” several times a day by catheterizing a

small stoma brought up to the skin. Because the stoma is continent, no

external appliance is needed. Supravesical diversion is indicated when

incontinence is unmanageable by other means or when serious upper

urinary tract deterioration is caused by high intravesical pressure or

vesicoureteral reflux.

The vaginal pessary is in some ways the female counterpart of the

Cunningham clamp. Available in various sizes, a vaginal pessary is a hard,

rubber, doughnut-shaped device placed in the vagina to compress the

urethra. It is generally fitted by a gynecologist.

E. Absorbent aids are usually made of disposable material with a

waterproof backing.

1. Pads are commonly used by both women and men for mild-to-

moderate incontinence. It has been estimated that 10% to 20% of sanitary

napkins sold in the United States are purchased for incontinence rather

than menstruation. The pads can be worn under the patient's usual

underwear or under absorbent underwear.

Injuries During Operations

The injury may involve the bladder or one of the ureters. Bladder

injuries are easily repaired, and usually heal and give no further trouble. On

the other hand, ureteral injuries are difficult to repair satisfactorily and are

very likely to interfere with kidney function later.

Bladder injury.

There are certain precautions, which should be taken before doing any

operative work in the region of bladder. First, the bladder should always be

emptied by catheterization shortly before the operation. If by oversight this

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has not been done before the patient comes to the operating room, time will

be saved in the end if the operation is delayed long enough for the patient to

be catheterized.

There are numerous dangers involved when the incision is made with

the bladder distended. First, there is a danger of opening the bladder in

incising the peritoneum. This danger is also present when the bladder is

pulled high up on the surface of the tumour. To avoid this danger the first

incision through the peritoneum is always made at the upper end of the

incision. It must be taken in enlarging the incision downward to be sure of the

location of the upper edge of the bladder, so as to avoid cutting into it.

After the peritoneum is opened, if the bladder has not previously been

emptied, it presents as a large cystic mass constantly pushing into the field,

interfering with the accuracy of the work and prolonging materially the time

of the operation.

In doing hysterectomies and removing abdominal tumours, the bladder

should be located and separated from the anterior wall of the uterus or from

the tumour early in the operation, so as to avoid cutting or clamping it.

In complete hysterectomy care should be taken to identify the bladder-

roll and the ureteral-roll on each side and to push them well out of danger.

If in spite of precautions mentioned, the bladder is injuried, it is to be

repaired. Sometimes the injury consists simply of a stripping off of a small

portion of the muscular wall. This is repaired by putting in a few sutures,

which reinforce the thin area with the thicker portion of the wall.

More serious injuries are to be observed when the bladder cavity is

opened. If the opening is small and the condition such that the remaining

separation of the bladder can be carried out without further injury, it is

advisable to close the opening as soon as made. If, on the other hand, the

bladder wall is so adherent as to be likely to be further turn, it is well to

complete the removal of the tumour and then make all bladder repair at one

time. Whether the opening is large or small, the principles of its closure are

686

the same. The first row of sutures should be of fine silk, threaded in a small

full-curved round-pointed needle. These sutures are preferably interrupted

and, taking firm hold of the bladder wall, extend close to the mucosa but not

into it. The reinforcing sutures, which bury the first row, may be of catgut and

continuous.

Ureteral injury.

Ureter ligated. – If it is discovered during the course of an operation

that a ureter has been tied, an attempt is made to loosen the ligature, which

blocks it. This can usually be done, any vessels that start bleeding are being

caught again. Exceptionally, the patient may be in such a poor condition and

the suspected ligature in such a critical position in regard to possible

hemorrhage, that it may be thought best to leave the ligature and depend on

postoperative nephrostomy and drainage of the kidney until the ligature is

absorbed and the ureter reopenes.

Ureter clamped. - The decision as to what to do is determined by the

extent of the injury. If the ureter has been severely crushed, probably to the

point of disorganization of the wall and mucosa and consequent obliteration

of the lumen, division of the ureter and uretero-ureteral anastomosis of

healthy end are advisable if the patient is in condition to stand the additional

work.

If the patient condition is poor, it is best to depend on postoperative

attempt to open the ureter by cystoscopic ureteral catheterization with resort

to nephrostomy for kidney drainage, if the ureter cannot be opened.

Ureter cut. – Uretero-ureteral anastomosis is preferable to

ureterovesical anastomosis because it preserves the function of the normal

ureterovesical junction.

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Self test

1. The incidence of UTIs in women is about

A. 10-20 %

B. 20-40 %

C. 40-50%

D. 1-2%

2. The most common uropathogens responsible for development of a UTI are

A. enterobacteriaceae

B. escherichia coli

C. staphylococcus saprophyticus

D. klebsiella;,enterobacter

3. Acute recurrent cystitis is defined as

A. two episodes of acute cystitis within a year

B. three or more episodes of acute cystitis within a year

C. two episode of acute cystitis within 2 years

D. three episodea of acute cystiris within 2 years

4. Urine cultures should be obtained in women with all of the following conditions

except

A. potential for a complicated UTI

B. acute bacterial pyelonephritis

C. fever without focus

D. asymptomatic bacteriuria

5. Type I stress incontinence in women means

A. defect in the pelvic support of the bladder neck

B. both the bladder neck and urethra

C. internal urethral defect

D. nothing from listed above

6. Type II stress incontinence in women means

A. defect in the pelvic support of the bladder neck and urethra

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B. defect in the pelvic support of the bladder

C. internal urethral defect

D. nothing from listed above

7. In postmenopausal women with stress incontinence estrogens may be used

A. yes

B. no

8. If the bladder is wounded during the operation , it should be closed

A. as soon as made

B. after the main operation is complete

C. in a few days after the first operation

D. in a few weeks after the first operation

9. Cateterization of bladder before abdominal operation is necessary for prevention

of its injury.

A. yes

B. no

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Chapter 25. APPENDICES

Appendix 1. Tests

Task 1.

A 52-year - old woman suffering from obesity complains of bloody

discharges from genital tract during 4 days. Last normal menses were 2 years

ago. Histological investigation of biopsy of the endometrium has revealed

adenomatous hyperplasia. Which reasons from listed below promoted the

development of disease?

1. Hypersecretion of estrogens by ovaries

2. Excessive transformation of preandrogens from fatty tissues

3. Poor aromatization of preandrogens owing to hypothyroidism

4. The increased contents of FSH

5. Supersecretion of androgens by the cortex of adrenal glands

Task 2.

The data of a separate diagnostic curettage of the uterus made up in

connection with bleeding in a postmenopausal period reveals no pathology in

the scraping of the mucous of the cervical canal but a highly differentiated

adenocarcinoma is found at endometrium. Metastases are not found. Which

method of treatment is the most correct?

1. Surgical treatment + chemotherapy

2. Surgical treatment and radiotherapy

3. Radiotherapy

4. Surgical treatment and hormonal treatment (hormonal therapy)

5. Surgical treatment and hormonal therapy

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Task 3.

A 27-year-old woman complains of the disorders of menstrual function

for 3 months, irregular pains in the abdomen. On bimanual examination,

there is an elastic globulous formation, painless, 7cm in diameter in the right

appendages. A fluid formation, unicameral, smooth, 4 cm in diameter in a

right ovary is observed on ultrasound.

What method of treatment is the most preferable?

1. Administration of an estrogen–gestogen complexes within 3 months with

the new survey

2. Operative treatment

3. Prophylactic medical examination on an outpatient basis

4. Anti-inflammatory therapy

5. Chemotherapy.

Task 4.

A 40-year-old patient complains of colic pains in the lower abdomen

and abundant bloody discharge from reproductive tract. Last 2 years she had

menses for 15-16 days, abundant, with clots, painful. In anamnesis there are 2

medical abortions. On bimanual examination myomatous node, protruding

into the cervix, 3 cm in diameter, is revealed. Discharges are bloody,

moderate. Choose a correct procedure to perform

1. Operation: untwisting of the nodes protruding into the cervix

2. Hormonal hemostasis

3. Vitamin therapy

4. Supravaginal amputation of the uterus without appendages

5. Hysterectomy without appendages

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Task 5.

A 40-year-old patient complains of yellow colour discharges from the

vagina. Bimanual examination shows no pathological alteration Smear test

reports trichomonas vaginalis and mixed (compound) flora. Colposcopy

reveals two hazy fields on the front (anterior) labium of the cervix with a

negative iodine probing.

Your next possible step to do.

1. Diathermocoagulation of the uterus cervix

2. Specific treatment of trichomoniasis

3. Amputation of the cerix

4. Treatment of specific vaginitis with the subsequent biopsy

5. Cryotherapy of uterus cervix

Task 6.

A32-year-old woman consulted a gynecologist concerning abundant

long menses within 3 months. On bimanual examination the body of the

uterus is enlarged according to about 12 weeks of pregnancy, distorted,

tuberous, of dense consistence. Appendages are not palpated. Histologyical

investigation of mucosa of the body of the uterus reveals cystic and

adenomatous hyperplasia of endometrium.

Optimum medical procedure to be done

1. Surgical treatment

2. Hormonal therapy

3. Phytotherapy

4. Radiation therapy

5. Vitamin therapy

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Task 7

A 24- year-old woman having normal menstrual function has got

irregular cycles, according to the tests of functional diagnostics anovulatory.

The content of prolactin in blood is increased. Choose the most suitable

investigation method (examination).

1. Determination of level of gonadotrophic hormones

2. Computer tomography of the head

3. Ultrasound of a pelvic cavity

4. Progesteron assay

5. Determination of the contents of testosterone-depot in blood serum

Task 8.

A 29- year -old patient has had a surgical treatment concerning the

benign serous epithelial tumor of the ovary. The postoperative period has

passed without complications. What is necessary to prescribe in the

rehabilitation period?

1. Hormonal therapy and proteolytic enzymes

2. Antibacterial therapy and adaptogens

3. Laser therapy and enzyme therapy?

4. Magnetotherapy and vitamin therapy

5. No further observation is necessary

Task 9.

A 26-year-old woman complains of sudden pains in the lower abdomen,

irradiating to the anus, nausea, giddiness, dark bloody discharge from genital

tract within one week, the delay of menses for 4 weeks. Signs of irritation of

the peritoneum are positive. On bimanual examination borders of the body of

the uterus and its appendages are not determined because of sharp pain. The

693

fornixes of the vagina on the back and right sides of the vagina are painful and

protruded. What is the most probable diagnosis?

1. Interrupted tubal pregnancy

2. Apoplexy of the ovary

3. Acute right-hand adnexitis

4. Torsion of the leg of the tumour of the ovary

5. Acute appendicitis

Task 10.

At the gynecology department there is a 32-year-old patient with the

diagnosis: "the acute bartholinitis". The body temperature is 38,2C,

leucocytes = 10,4 x109, the ESR = 24 mm / hour. In the area of big gland of

the vestibulum there is a hematoma, the sign of the fluctuation is positive,

sharp pain.

What treatment is the most correct one? (What method of treatment is

the most preferable)?

1. Antibiotics, Sulfanilamides

2. Surgical dissection, drainage of an abscess of the gland, antibiotics

3. Surgical dissection, drainage of the abscess of the gland

4. Antibiotic therapy

5. Antibiotics, detoxication and bio-stimulating drugs

Task 11.

A 33-year-old woman has got a perforation of a uterine wall in the area

of fundus during curettage of the uterus cavity concerning incomplete

infected abortion.

What is the most appropriate procedure to perform?

1. Suturing of a perforated foramen (aperture) after excision of the edges

694

(borders) of the wound

2. Suturing of a perforated aperture

3. Hysterectomy

4. Antibiotic agents, observation

5. Absolute bed rest, observation.

Task 12.

In case of bleeding appearance caused by infiltrating cancer of the

uterus cervix, it's necessary to conduct

1. A tight tamponade of vagina

2. An amputation of uterus cervix

3. Clamping of lateral parametriums

4. Laparotomy, ligation of internal iliac artery

5. Laparotomy, expanded extirpation of the uterus (Wertheim's

hysterectomy)

Task 13.

For treatment of vaginitis caused by Candida's fungus it is better to use

1. "Polyjnuks"

2. Progestogel

3. "Clotremazol"

4. Vagilac

5. The above given answers are wrong

Task 14.

These are characteristic signs of gonococcus.

1. The intracellular diplococci

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2. The positive Gram’s-stain

3. Rounded shape

4. Tropism for the laminated flat epithelium

5. Everything enumerated above

Task 15.

In case of tuberculosis of genital organs a primary focus is located most

often in

1. Lungs

2. Bones

3. Urinary excretory system

4. Lymph nodes

5. At the peritoneum

Task 16.

All of the listed below are methods of provocation of gonorrheal process,

except

1. Intake of a spice and salted food

2. Smearing of the cervical canal with combined Lugol's iodine solution and

glycerin

3. Intramuscular injection of a sinestrol 2% solution

4. Diathermy of a lumbosacral area

5. Regional injection of a gonovaccine

Task 17.

What disorders of menstrual function are the most characteristic of the

uterus myoma?

696

1. Oligomenorrhea

2. Hyperpolymenorrhea

3. Algomenorrhea

4. Amenorrhea

5. Metrorrhagia

Task 18.

Which of the methods of examination is the most informative in the

diagnostics of tube infertility?

1. Tubal insufflation

2. Hysterosalpingography

3. Transvaginal echography

4. Laparoscopy with chromosalpingoscopy

5. Contrast pelviography

Task 19.

Making the diagnosis of cervical cancer with the detection of initial

stage is possible at

1. the expanded colposcopy

2. Histological investigation of the biopsy material

3. Cytological investigation of the smears

4. Hysterocervicoscopy

5. Ultrasound of the pelvic organs

Task 20.

The majority of benign ovarian tumors are transformed into

1. Fibroma

697

2. Serous cystadenoma

3. Mucinous cystadenoma

4. Thecoma

5. Teratoma

Task 21.

Everything enumerated below is attributed to the retention cysts of the

ovaries, except

1. Follicular cyst

2. Dermoid cyst

3. Yellow body's cyst

4. Paraovarian cyst

5. "Chocolate cyst

Task 22.

A 35 –year-old patient having the right ovarian cyst after a quick

bending felt sharp pain in abdomen on the right. At the moment of admission

to the hospital the condition is satisfactory, the pulse is 86 b/min, AP –

115/80 mm Hg, to – 37,2ºC. Abdomen is soft, painful at the right

illiohypogastric area where muscle tension is noted. A menstrual function is

normal. On vaginal examination the vagina is bulky, fornices are free and

painless. The uterus has normal size. It is dense and mobile. The left adnexa

are without any peculiarities. In the area of the right adnexa a tumor-like

mass of 12x8x8 cm is palpated, its consistency is elastic, painful. There were

noted increasing pains during examination. What kind of complication was in

that case?

1. Rupture of cyst

2. Infection of cyst

698

3. Torsion of cyst

4. Malignant degeneration

5. Bleeding into cyst

Task 23.

A 75-year-old patient complains of appearing a tumor-like mass from

vagina at small physical exertion and suppression of urine. In a recumbent

position the above-mentioned tumor can be easily set into the vagina after

which the urination renews. On examination pudental fissure gapes at the

time of exertion, the whole uterus and vagina walls with a urinary bladder and

a rectum come out, mucosa of the uterus is dry, atrophic. The patient has

severe somatic pathology an ischemic heart disease, cardiosclerosis, in

anamnesis, double myocardial infarction. Surgical treatment is offered.

Which volume of surgical intervention is the most rational for that patient?

1. Frontal and back colporrhaphy

2. Ventrosuspension

3. Vaginal hysterectomy

4. Median colporrhaphy

5. Manchester operation

Task 24.

A 26-year-old patient is 7 months after last labor (childbirth). She is

breast-feeding now and she has not had menstrual flow for all this time. But 2

weeks ago the patient complained of nausea, vomiting in the morning.

What is the probable diagnosis?

1. Gastrointestinal disorder.

2. Disturbances of menstrual cycle.

3. Early pregnancy. What likely diagnosis should be made?

699

1. Colposcopy.

2. Ultrasound examination.

Task 25.

A 16-year-old patient with developed secondary genital signs complains

of extended pains in the lower abdomen, irradiating to rectum, discomfort in

her monthly menstrual cycle for 1-2 days, absence of menstrual flows.

Somatically she is healthy. On examination non -perforated hymen of tumor-

like consistency in posterior vaginal area is felt on the tip of which the uterus

can be palpated, appendages cannot be felt.

What disease can be diagnosed?

1. Tumor of genital organs.

2. Tumor of intestine.

3. Atresia of vagina.

4. Algodismenorrhea.

5. Primary false amenorrhea, hematocolpos. What does this symptom cause?

1. Hypofunction of ovaries.

2. Congenital anomaly of hymen.

3. Chronic vulvovaginitis.

Task 26.

A 48-year-old patient has no menstrual bleeding for 2 months and after

this a severe loss of blood from the uterus started. 2 years ago menstrual cycle

was disturbed with intervals of 2-3 months between cycles. On speculum

examination there are no abnormalities except of the blood loss from the

uterus.

What disease can you think of?

1. Shreder hemorrhagic metropathy

700

2. Cancer of the uterus

3. Incomplete abortion

4. Myoma of the uterus

5. Climacteric disturbance of menstrual cycle What additional method of

investigation can be used in this case?

1. Fractional diagnostic curettage of mucosal membrane from uterine cavity,

with the following histological examination

2. Colposcopia

3. X-ray of pelvic area

Task 27.

A 25-year-old patient is infertile for 3 years. She complains of painful

and prolonged menstruations, accompanied by spasmodic pains. On

bimanual examination uterus is increased in size and looks like 8 weeks of

pregnancy; appendages cannot be palpated. Using probe and diagnostic

curettage of the uterine cavity its deformation is found. Specimen of the

curettage is normal in volume.

What is the probable diagnosis?

1. Cancer of the body of the uterus

2. Submucosal myoma of the uterus

3. Internal endometritis

4. Menorrhagia, algodismenorrhea

Task 28.

A 20-year-old woman in a few days after unexpected sexual act had a lot

of discharge from the cervix with a bad odor, pain in lower abdomen and

cutting pain while micturition.

701

On examination uterus was in normal size, adnexa were enlarged, while

palpating pain was felt.

Which pathologic condition can be thought of?

1. Acute adnexitis due to gonorrhea

2. Chronic bilateral adnexitis in the stage of attack

3. Chronic tuberculosis of appendages

Task 29.

A 57-year-old patient has reddish discharge after 10 years of

menopause. On bimanual examination blood discharge from genital tract is

found. Size of the uterus is normal. Adnexa are not found.

What pathology can it be?

1. Submucous myoma of the uterus

2. Poliposis of the uterus

3. Cancer of the corpus of the uterus

4. Internal endometriosis

Task 30.

A 32-year-old woman presents with a 4-year history of infertility. Diagnostic

evaluation reveals no abnormalities other than mild endometriosis on laparoscopy.

Treatment expecting to enhance fertility includes

1. Danazol

2. Medroxyprogesterone

3. GnRH

4. All of the above

5. None of the above

702

1 - 2

2 - 5

3 - 1

4 - 1

5 - 5

6 - 1

7 - 2

8 - 1

9 - 1

10 - 2

11 - 1

12 - 1

13 - 3

14 - 1

15 – 1

16 – 3

17 – 2

18 – 4

19 – 2

20 – 2

21 – 2

22 – 3

23 – 4

24 - 3

25 - 5, 2

26 - 5, 1

27 - 2

28 - 1

29 - 3

30 - 5

703

704

Учебное издание

Rybalka A. N., Zabolotnov V. A., Kamilova I. K. at al.

OBSTETRICS AND GYNECOLOGY

Textbook in 2 volumes

(на английском языке)

Edited by Professor A. N. Rybalka

Под редакцией профессора А. Н. Рыбалка

г. Симферополь, ул. К. Маркса, 60

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