Practical Gynecology 221002 234708
Practical Gynecology 221002 234708
Practical Gynecology 221002 234708
CLN
Mzhda Sahib Ja'far
1st Edition
Table of Contents
What are the conditions that gynecology deals with? .............................................................1
History Taking in Gynecology ........................................................................................................1
Demographic Data...........................................................................................................................1
Chief complaint .................................................................................................................................1
History of present illness .................................................................................................................1
Gynecological History .....................................................................................................................1
1. Menstrual History ...................................................................................................................1
2. Contraception .........................................................................................................................2
3. History of Infertility ................................................................................................................2
4. Vaginal discharge..................................................................................................................2
5. Incontinence .............................................................................................................................3
6. History of pap smear فحصى شووشە............................................................................3
7. Any prolapse ..........................................................................................................................3
8. Sexual History ........................................................................................................................3
Past obstetrical history ....................................................................................................................3
Social History ....................................................................................................................................3
Family History ...................................................................................................................................3
Drug, Allergy & Blood Transfusion ................................................................................................3
Medical history .................................................................................................................................3
Surgical history .................................................................................................................................3
Examination.........................................................................................................................................3
Inspection ...........................................................................................................................................3
Internal Inspection .........................................................................................................................3
Palpation............................................................................................................................................4
Normal Menstrual Cycle ...................................................................................................................4
Physiology..........................................................................................................................................4
Fertility & Infertility ..........................................................................................................................4
For Fertilization We Need ..........................................................................................................4
Types of infertility.........................................................................................................................4
How we can know that a ♀ is fertile from history? ................................................................5
How to investigate a woman when she is a suspected case of infertility? .........................5
Disorders of the Menstrual Cycle ...................................................................................................6
Heavy or Irregular Cycle ................................................................................................................6
Causes .............................................................................................................................................6
Amenorrhea .......................................................................................................................................6
Primary Amenorrhea ....................................................................................................................6
Secondary Amenorrhea ...............................................................................................................7
Post-Menopausal Bleeding .............................................................................................................7
Causes .............................................................................................................................................7
How to Approach? ........................................................................................................................8
Notes ...............................................................................................................................................8
Heavy Menstrual Bleeding (Menorrhagia) ..................................................................................8
Causes .............................................................................................................................................8
How to Approach..........................................................................................................................8
Management..................................................................................................................................8
Fertility Control (Contraception) .....................................................................................................9
Types ..................................................................................................................................................9
1. Microgynon .................................................................................................................................9
2. HD ................................................................................................................................................9
3. Yasmin .........................................................................................................................................9
4. LD .............................................................................................................................................. 10
Indications.................................................................................................................................... 10
5. Diane 35 .................................................................................................................................. 10
6. Depo – provera ...................................................................................................................... 10
7. (Androgen Effect) (Male Side) ............................................................................................. 10
8. Provera..................................................................................................................................... 10
9. Lenestrnol ................................................................................................................................. 10
10. I-pill........................................................................................................................................ 11
11. Condom ................................................................................................................................. 11
12. HRT......................................................................................................................................... 11
13. IUCD ...................................................................................................................................... 11
Contraindication ......................................................................................................................... 11
Complications.............................................................................................................................. 11
Notes ............................................................................................................................................ 11
Failure Rate................................................................................................................................. 11
Mechanism ................................................................................................................................... 11
Notes on Intrauterine Device (IUD) (Copper T) ..................................................................... 11
14. Merena (Hormonal IUD). .................................................................................................... 12
Its Action ...................................................................................................................................... 12
Indications.................................................................................................................................... 12
Note on contraceptive pills generally ....................................................................................... 12
Abortion ............................................................................................................................................. 12
Types ............................................................................................................................................... 12
1. Threatened Abortion .......................................................................................................... 12
2. Incomplete Abortion............................................................................................................ 12
3. Induced Abortion ................................................................................................................. 13
4. Missed abortion (Miscarriage).......................................................................................... 13
5. Complete Abortion.............................................................................................................. 13
Types of Abortion & Their Characteristics ................................................................................ 13
Causes ............................................................................................................................................. 14
Management .................................................................................................................................. 14
Missed – Miscarriage ................................................................................................................ 14
Threatened abortion ................................................................................................................. 15
Incomplete miscarriage ............................................................................................................. 15
Legal ............................................................................................................................................ 15
Illegal ........................................................................................................................................... 15
Illegal subsequent ...................................................................................................................... 15
Septic miscarriage ..................................................................................................................... 15
Religious Abortion ...................................................................................................................... 15
Management of a Woman With Miscarriage...................................................................... 15
Misoprostol ..................................................................................................................................... 16
(< 𝟏𝟐 𝒘𝒆𝒆𝒌𝒔) ........................................................................................................................... 16
(> 𝟏𝟐 𝒘𝒆𝒆𝒌𝒔) ........................................................................................................................... 16
Side effects of misoprostol ....................................................................................................... 16
Requirements for Curettage ........................................................................................................ 16
What Are The Steps For Doing Curettage? ............................................................................. 17
D & C (Dilatation & Curettage) ..................................................................................................... 17
Ergometrin....................................................................................................................................... 18
Contraindications of Ergometrin .............................................................................................. 18
What are the complications of curettage? ............................................................................... 18
Immediate.................................................................................................................................... 18
Late............................................................................................................................................... 18
Some Notes .................................................................................................................................... 18
Trophoblastic Diseases .................................................................................................................. 19
Types: .............................................................................................................................................. 19
Presentation:- ................................................................................................................................. 19
Diagnosis ......................................................................................................................................... 19
Causes ............................................................................................................................................. 19
Treatment ........................................................................................................................................ 19
Follow Up ........................................................................................................................................ 20
8 days course. ............................................................................................................................ 20
Notes................................................................................................................................................ 20
Radiology in Gynecology ............................................................................................................. 20
For Examining Tubal Patency We Can Use.............................................................................. 20
Hysterosalpingogram (Fluroscopy)............................................................................................. 21
Indications.................................................................................................................................... 21
We Must ...................................................................................................................................... 21
If There is No Opacification There May Be: ......................................................................... 21
Complications of Hysterosalpingogram ................................................................................. 21
Abortion .......................................................................................................................................... 21
Why we prefer vaginal U/S over abdominal U/S? .............................................................. 21
Early Pregnancy Bleeding ............................................................................................................. 21
Causes ............................................................................................................................................. 21
Outpatient Gynecological drugs.................................................................................................. 22
IUCD................................................................................................................................................. 22
Bleeding .......................................................................................................................................... 22
1st/ Non- Hormonal ................................................................................................................... 22
2nd/ Hormonal ............................................................................................................................ 22
Hyperprolactinemia (Pituitary) ................................................................................................... 22
We use......................................................................................................................................... 22
Depo-provera (Medrpxy-progestrone-acetate) ..................................................................... 23
Zoladez (LHRH analogue)............................................................................................................ 23
Climen – contain estrogen – ciproterone (anti – androgenic effect) ................................... 23
Uses .............................................................................................................................................. 23
Side effects ................................................................................................................................. 23
Danazol/ - Androgenic Effect..................................................................................................... 23
So Anti – Estrogenic effect: ...................................................................................................... 23
Side effects: ................................................................................................................................ 23
Progyluton....................................................................................................................................... 23
Contraindication ......................................................................................................................... 23
Side effects ................................................................................................................................. 24
Ectopic Pregnancy ........................................................................................................................... 24
Management .................................................................................................................................. 24
Ovarian Cyst .................................................................................................................................... 24
Functional Cyst ............................................................................................................................... 25
Functional Cyst/ Symptoms ...................................................................................................... 25
Criteria U/S ................................................................................................................................ 25
Management............................................................................................................................... 25
Follicular Cyst/ ↑ FSH. .................................................................................................................. 25
Corpus Luteal Cyst/ ...................................................................................................................... 25
Pelvic Organ Prolapse (Prolapse) ............................................................................................... 26
Prolapse/ Causes .......................................................................................................................... 26
What Are The Causes For Weak Ligament? ............................................................................ 26
Uterine Prolapse ............................................................................................................................ 26
Degree of Severity .................................................................................................................... 26
Vaginal Wall Prolapse ................................................................................................................ 26
Degree of Protrusion ................................................................................................................. 26
Symptoms .................................................................................................................................... 27
Diagnosis ..................................................................................................................................... 27
Management For Both Uterine & Vaginal Wall Prolapse ..................................................... 27
Vaginal Wall Prolapse ............................................................................................................. 27
Uterine Prolapse ........................................................................................................................ 27
Endometriosis ................................................................................................................................... 27
Causes ............................................................................................................................................. 27
Incidence ......................................................................................................................................... 28
Presentation .................................................................................................................................... 28
In myometrium (Adenomyosis).................................................................................................. 28
Lung (rare) ................................................................................................................................... 28
Urinary bladder ......................................................................................................................... 28
Peritoneum................................................................................................................................... 28
Rectum .......................................................................................................................................... 28
On fallopian tubes..................................................................................................................... 28
On ovaries................................................................................................................................... 28
Cervix........................................................................................................................................... 28
Generally in reproductive organs .......................................................................................... 28
Diagnosis ......................................................................................................................................... 28
Grading .......................................................................................................................................... 29
Treatment ........................................................................................................................................ 29
Medical ........................................................................................................................................ 29
Surgery ........................................................................................................................................ 29
Notes .................................................................................................................................................. 29
Ovarian Cyst .................................................................................................................................. 29
Dysmenorrhea ................................................................................................................................ 29
Vaginal Discharge......................................................................................................................... 30
Physiological: .............................................................................................................................. 30
Pathological: ............................................................................................................................... 30
Pap Smear ...................................................................................................................................... 30
Miscellaneous ................................................................................................................................. 30
Semen Analysis ........................................................................................................................... 31
Useful Images .................................................................................................................................. 31
Mzhda Sahib Ja'far | Practical Gynecology
What are the conditions that gynecology deals with?
1. Menstrual cycle problems (common)
Amount. Regularity. Pain.
2. Infection (PID, ……)
3. Infertility.
4. First ∆ of pregnancy (<20 weeks) or early pregnancy.
Ectopic. Abortion. H. mole.
5. Endometriosis.
6. Tumors.
Ovaries. Uterus. Cervix.
7. Contraception and family planning.
Abortion
Abortion < 20 weeks Some said 24 weeks
I.U.F.D > 20 weeks
Types
1. Threatened Abortion
- Fetus is viable. - 50% may continue.
- Cervix is closed.
- Slight pain & slight discharge (blood).
2. Incomplete Abortion
- Part of the fetus & placenta - Profuse vaginal bleeding.
remain. - Dilated cervix (open os).
- Severe lower abdominal pain.
Trophoblastic Diseases
Types:
- Molar (hydatiform mole). - Chroriocarcinoma.
- Persistent.
Presentation:-
- Asymptomatic - Big for date.
- Bilateral big ovarian cyst (HCG) ovarian stimulator.
- Profuse vaginal bleeding.
- Exaggerated sign & symptom of pregnancy.
Trophoblastic disease Partial.
Complete (↑ risk of choriocarcinoma).
Diagnosis
- U/S → snow storm العاصفە الثلجیە
- When we see it is like هێشوەترێ العنقود العنب
Causes
- Is genetic, abnormal fertilization. - Normal ovum & 2 sperm/ complete.
- Abnormal (empty) & 2 sperm/ partial.
So double paternal chromosomal material.
There is a risk to have another trophoblastic disease in subsequent pregnancies.
Treatment
- Previously → hysterectomy
Radiology in Gynecology
Plain X-ray for ovarian cyst + if it is dermoid there is teeth or a piece of bone.
- We can use iodine as (Contrast). - IVU → Intravenous urography.
For Examining Tubal Patency We Can Use
- Hystereosalpingogram.
- Laparoscope under GA by using methylene blue dye it is superior to
Hysterosalpingogram in that:-
To define peritoneal causes of infertility like (endometriosis)
- Polycystic ovary.
Ectopic Pregnancy
Is the implantation of a fertilized egg outside to the uterine cavity or endometrium of
uterus.
- At (8-10 weeks) of gestation, if a lady with pain & bleeding, we think of ectopic
mostly.
- But if the ectopic is in the rudimentary horn, it may continue to 16 weeks, and then the
horn will rupture and she comes with shock, bloated abdomen, …………. .
- Normally 𝛽 HCG is > 𝟏𝟓𝟎𝟎 at 5th week.
- If we have for example 1400 → we do U/S.
- After that another HCG → If HCG doubled so normal pregnancy.
→ If HCG not increased so ectopic or abnormal (miscarriage).
- And then laparoscopy.
- So the most useful modalities for ectopic are:
U/S. HCG level. Laparoscopy.
Management
1. Conservative:
If the fetus not viable. Tube not ruptured.
< 3𝑐𝑚. No hemoperitonium.
We give her methotrexate (single or multiple) doses.
Follow up important by vaginal U/S and 𝜷 HCG.
2. Laparoscopy
- Salpingotomy. - Salpingectomy.
Areas outer uterus for ectopic
90% in tubes.
10%
ovaries. Abdominal cavity.
Cervix.
Up to 10% may have recurrent ectopic.
If the other tube is patent she has chance to be pregnant but less chance.
Ovarian Cyst
Polycystic ovarian syndrome is different from ovarian cysts:
- It is a group of features (syndrome).
- Small cyst on ovary (they are not actual cyst).
Endometriosis
It is implantation of endometrium outside the uterine cavity.
Causes
We don’t know the definitive cause but:-
1- Retrograde menstruation. 2- Hematological spread.
Notes
Polycystic ovarian syndrome → hormonal.
Ovarian Cyst
Functional or Physiological
Follicular cyst. Corpus luteal cyst.
Pathological (dermoid,……..)
Ovarian Cyst
Benign - Dermoid → Very rarely → Malignant (terato sarcoma)
Enlarges with age. Congenitally in the ovary.
Contain germ cells.
Malignant.
Dysmenorrhea
1. Primary (physiological) → pain during the first 24 hours of menstruation and decrease
↓ after that it is like an ischemic pain because the basic of menstruation is ischemia
(vascular spasm) of uterus.
Useful Images
(a) Cusco’s speculum; (b) Cusco’s speculum in position. The speculum should be inserted at about 45° to the vertical and
rotated to the vertical as it is introduced. Once it is fully inserted, the blades should be opened up to visualize the
cervix.
(a) Sim’s speculum; (b) Sim’s speculum inserted with the patient in the left lateral position. The speculum is being used to
hold back the posterior vaginal walls to allow inspection of the anterior wall and vault. The speculum can be rotated
180° or withdrawn slowly to visualize the posterior wall.
(a) Bimanual examination of the pelvis assessing the uterine position and size; (b) bimanual examination of the lateral
fornix.
Tanner staging.
Hysteroscope.
Combined oral contraceptive pill preparations. Monitoring blood pressure in a woman taking the
combined oral contraceptive pill.
Depo-Provera.
Implanon. Implanon.
Diaphragms.
Varieties of prolapse.
Treatment of prolapse.