Gynaecology
Gynaecology
-ve Feedback
GABA
Neuropeptide Y
Ovary → E2, P
LH
CHOLESTEROL
3 BHSD Pregnenolone FSH
Progesterone
17 OHP AROMATASE
ANDROSTENEDIONE ESTRONE
17 βHSD
Testosterone ESTRADIOL
FSH dependent
-ve feedback
Granulosa cell
Estradiol Inhibin B
LH surge
LUTEAL PHASE
ENDOMETRIAL CHANGES
‐ Post ovulation- Endometrium thickens + fluid in pouch of Douglas
ANOVULATORY CYCLES
PGE2
Withdrawal of progesterone → Prostaglandins
PGF2
Painful Menstruation
1° spasmodic dysmenorrhea
RELATIONS
LAYERS
BLOOD SUPPLY
• Lymphatic drainage;
- The obturator and the internal & external iliac nodes
NERVE SUPPLY
Cervix 05:07
LYMPHATIC DRAINAGE
• Internal iliac LN
• Hypogastric iliac LN
• Obturator LN
• Paracervical / parametrial LN
• Exterior iliac LN
Fallopian Tube 07:58
ADENEXA
• Interstitium - Narrowest
• Isthmus - 2.5 cm
• Site of tubectomy
• Ampulla - 5 cm
• Site fertilization
• Infundibulum - 2.5 cm
• Pick up ovum
• Blood supply
- Medial 2/3rd by uterine artery
- Lateral 1/3rd by ovarian artery
• The canal is directed upward and backward, forming an angle of 45⁰ with the
horizontal in erect posture
• Looks 'H' shaped on transverse section
• L of anterior wall - 7cm
• L of posterior wall - 9cm
RELATIONS
• Maturation index: P/ I / S
- Before ovulation: 0 / 30 / 90
- After ovulation: 0 / 60 / 40
• Vaginal pH
- Maintained by Döderlein’s bacillus
- Glycogen → Lactic acid
- pH: 4.5 to 5.5 → Reproductive
- Menopause/Before Puberty - alkaline = 6-8
- At puberty - Shifts from alkaline to acidic
- Pregnancy: 3.4 to 4.5 – Most acidic
- Menstruation > 7
BLOOD SUPPLY
• From 3 arteries;
1. Descending vaginal artery - branch of Uterine Artery / Internal Iliac Artery
2. Internal pudendal artery
3. Middle rectal artery
Ovary 14:48
• Blood supply - ovarian artery
• Nerve supply - T10
• Lymphatic drainage - Paraaortic LN
• Venous drainage ;
- Left side → Left renal vein
- Right side → Inferior vena cava
N PARAMETERS OF MC:
Normal 4.5-8.0
Light < 20
AUB
• Acute causes
- That which is insufficient in volume as to, in the opinion of the treating
clinician, require urgent or emergent intervention
• Chronic causes
- AUB present for most of the previous 6 months
ETIOLOGY
• P - Polyps
• A - Adenomyosis
• L - Leiomyoma
• M - Malignancy & hyperplasia
• C - Coagulopathy
• O - Ovulatory dysfunction
• E - Endometrial
• I - Iatrogenic
• N - Not defined
• PALM – Structural abnormalities
• COIE – Functional abnormalities
Diagnosis and Evaluation
SIS If intracavitary
lesion is suspected
and hysteroscopy is
not available (Grade
A ; Level 1)
• Risk factors
- Diabetics
- Hypertension
- Obesity
- Hormone replacement therapy
- Tamoxifen therapy
• Endometrial polyp
- Echogenic/White in color
- Projects in endometrial lumen
- Stalk may be identified by saline infusion sonography
- Feeding vessel sign
• Fibroid
- Hypoechoic/Black
- Distends the uterine cavity
- Broad based
- Peripheral vessels
Adenomyoma 06:42
• On examination
- Uterus will be uniform globular enlarged
- Max - 14-16 weeks sign
FIBROID – UTERUS
AUB-C 09:38
Puberty Menorrhagia
• In refractory cases von – Willebrand disease with uncontrolled uterine bleeding with
above medical management, specific factor replacement where possible or
desmopressin to be given in consultation with haematologist
• When surgical interventions are indicated for appropriate pre-intra and post-
operative management of bleeding – Factor replacement/desmopressin
AUB-O 10:20
ETIOLOGY
• PCOS
• Hypothyroidism
• Hyperprolactinemia
• Stress
• Obesity
• Excess weight loss
• 1st line - combined oral contraceptive pills
- Uterus will be uniform globular enlarged
- Max - 14-16 weeks sign
AUB-E 10:20
AUB-I 11:26
• Iatrogenic
• Breakthrough bleeding
• Estrogen breakthrough
- Threshold of estrogen low
- Suprathreshold bleeding
• Progesterone break through bleeding
- High progesterone results in atrophy and altered endometrium
- Bleeding occurs from unsupported endometrial vessel
AUB-N 12:12
Not specified
Treatment Algorithm: AUB-N
Embryology 01:50
1) GONADS
if present if absent
Males
Testis
Seminal Vesicle
Epididymis
Ejaculatory duct
Ductus deferens
Females
No SRY Gene
Remnants Of
Parovarian Cyst)
Wolfian Duct – Gartner’s Duct
(Gartner’s Cyst)
Gartner’s Duct Vs Cystocele
• Irreducible • Reducible
• Tense & Shiny
• Vaginal • Vaginal rugosities
Rugosities Lost Present
• No Cough • Increase On
Impulse Coughing
Disolution : Initially When The Two Mullerian Ducts Fuse, An Intervening Septa Is Later
by 5th Month Of Intrauterine Life, It also disappears
3) EXTERNAL GENITALIA
DHT No Testosterone
Lead To
No In Utero Exposure To
Testosterone In Males (46xy)
Lead To
Investigations 29:59
Management 34:37
Strassman’s Metroplasty
(Distension Medium)
ETIOLOGY
• Compartment IV
- Hypothalamic defect
- Kallmann syndrome - absence of production of GnRH & craniopharyngioma
- Hypogonadotropic hypogonadism
• Compartment III
- Pituitary gland defects
- Hypoprolactinemia
- Hypothyroidism
- Pituitary tumors
• Compartment II
- Ovary defects
- Hypergonadotropic hypogonadism
- Ovarian agenesis
- Ovarian dysgenesis – Turner’s syndrome
• Compartment I
- Uterine defects
- Absent uterus - Mullerian agenesis
EMBRYOGENESIS
Cryptomenorrhea 06:18
• Imperforate hymen
- Eugonadotropic eugonadism
- Phenotype - Female
- Karyotype - 45 XX
- Gonads - Ovary → Estrogen
- Uterus - Present
• Clinical presentation
- Primary amenorrhea
- Cyclical pain abdomen
- Acute retention of urine
- PR- uterus is felt
• Gonadal dysgenesis
• SRY gene mutation
• Karyotype – 46XY
• Streak gonads →
- No estrogen → SSC absent
- No testosterone → Wolffian duct regress
- No AMH → Mullerian duct (uterus present)
• Mx
- Hormone replacement therapy (E + P)
- IVF with donor oocytes
• At Mayer–Rokitansky–Küster–Hauser Syndrome
• Karyotype - 46xx
• Gonad - Ovary → Estrogen
• SSC - Well developed
• Phenotype - Female
• Absence of uterus, cervix, upper 2/3rd vagina, fallopian tube
• Exeternal genitalia - Female
• PR - Not felt
• Dx : USG
• Associated skeletal & renal anomalies
• Rx : Vaginoplasty just before marriage
- Mechanical dilatation with Trank dilator
- Williams vulvo vaginoplasty
- McIndoe vaginoplasty
• IVF - followed by surrogacy
AIS 15:25
Causes 17:21
• Pituitary
- Prolactinoma
- FSH, LH < 5
• Craniopharyngioma – Tumor of connecting pathway
• Hypothalamic
- Kallman syndrome - gene Kal1 mutation
- No GnRH production
- No olfactory placodes - anosmia
- Male > Female
- Hypogonadotropic hypogonadism
- Female karyotype - 46xx
- Phenotype - Female
- Ovary present - No estrogen
- SSC not developed
- Uterus present
- External genitalia - Female
- Tall Height
- Rx : Inj. Pulsatile GnRH, Inj. HCG, Inj. FSH
Secondary Amenorrhea
DEFINITION :
Causes : Post Tb
Overzealous Dec
C/F : Amenorrhea
IOC : HSG = Honeycomb Appearance
Gold Standard : Hysteroscopy
Mx : Hysteroscopic adhesiolysis
Cu – T (To prevent
re-adhesion)
Estrogen + Progesterone
Compartment 2 – Ovary
MC cause = PCOS
Premature Ovarian Failure Savage Syndrome
AMH : (<1)
Compartment 3 - Pituitary
RX DOC : Cabergoline
NOTE : DOC in infertility & pregnancy : Bromocriptine
SHEEHAN’S SYNDROME
- Athletes
- Excess exercise Leptin
GABA → Pulsatile = Amenorrhea
- Eating disorders GnRH
- Stress
- Pseudocyesis
WORK UP
→ 1st – UPT
→ Serum, TSH, Serum PRL
→ Progesterone challenge test
5 days of medroxy progesterone acetate & withdraw
Hypothalamo Ovarian
pituitary failure
Q) Secondary amenorrhea after 3months of abortion is due to? (Serum FSH = 6IU/L)
a) Sheehan's Syndrome
b) Fresh pregnancy
c) Premature ovarian failure
d) Asherman's syndrome
PATHOPHYSIOLOGY
• Insulin resistance
• Increase insulin & IgFI → Theca cell hypertrophy → Inc. testosterone
• Increase in free testosterone → Fat cells
• In fat cells → Less potent estrone
• Estrogen → +ve feedback on LH
• Inc. estrogen → dec. FSH
- Defect in follicular maturation
- Anovulation
• LH to FSH ratio = 3 : 1
• To curb the insulin resistance - metformin
• Peripheral conversion (-) - Weight loss
CLINICAL PRESENTATION
ACANTHOSIS NIGRICANS
INVESTIGATION
• FSH
• 75 gm gtt
• Fasting lipids every 2 yrs
• Vit.d measurement
• Insulin resistance calculation - serum fasting blood sugar / serum fasting insulin
• A valve of less than 4.5 thickness resistance
MANAGEMENT
• COCP
- Cycles regularise
- Inc. SHBC
- Helps reducing hirsutism
- Reduced menstrual blood loss
• Withdrawal bleeding
- After 30-45 days of amenorrhea
- Inc. medroxy porigesterone pacetase x 5-7 days
HORMONAL REVIEW
Hirsutism 16:06
• MC cause PCOS
• Other causes – (adrenal, adenoma), adrenal carcinoma, testosterone producing
ovarian tumors, drugs, CAH
• Investigation;
1. Serum testosterone (ferrimen gallaway scoring) - < 150 ngm→ PCOS
2. >150 ngm → USG, DHEA
3. Increase in serum 17hydroxy progesterone (21alpha hydroxylase
deficiency)
NOTE : If age of woman > 35years & has inability to conceive inspite of 6 months of
Ovarian : MC PCOS
HISTORY INVESTIGATIONS
- EARLIEST SIGN
Subnuclear basal vacoulation
OTHER TESTS
1) Clomiphene citrate
2) Letrozole, Anastrozole, Tamoxifene
3) Gonadotrophins
Enclomiphene
CLOMIPHENE CITRATE
Zuclomiphene
Testosterone Estrogen
No negative feedback Increased FSH Increased FSH
Visual disturbances
Ovarian cancers
Multiple pregnancies
GONADOTROPHINS
Q) A patient treated for infertility with clompihene citrate presents with sudden onset
of abdominal pain & distension with ascites, the probable cause is :
a) Uterine repture
b) Ectopic pregnancy rupture
c) Multifetal pregnancy
d) Hyperstimulation syndrome
VEGF 1) PCOS
2) Young girls
Damage to vessel wall
Rx Symptomatic treatment
HSG
LAPROSCOPIC
CHROMOPERTUBATION Methylene blue dye used
ADVANTAGE DISADVANTAGE
• Method of sterilization – Reversal best with clips (1 cm) > Falope rings (3 cm) >
Modified pomeroy > Cautery
• Length of tube > 4cms
• Isthmo-isthmic anastomosis
• Age <35yrs
Q) Lady with infertility with B/L tubal block at cornea ; best management is :
a) Laproscopy & Hysteroscopy
b) Hydrotubation
c) IVF
d) Tuboplasty
Ans : c) IVF
CERVICAL FACTORS
Seminiferous tubules
Epididymis
Vas deferens
NORMAL ANATOMY
Ejaculatory duct
CAUSES :
Testicular : • Trauma
• Torsions
• Tumors
• Kline felter syndrome
• Heat radiation
• Varicocele
• Cryptorchidism
Agglutation <10%
Vitality = 58%
Rx
Clomiphene citrate
Also given
Inj FSH
Ans : a) Normospermia
AZOOSPERMIA
Leukocytes
N
Culture S. Testosterone S. Testosterone S. Testosterone (n)
- IUI - ICSI
- IVF - PICSI
- ZIFT
- GIFT
IUI
Swim up
Procedure – Semen washed Swim down
Density gradient
MAX – 6 Trials
SUCCESS RATE – 10-15%
IVF
Ans : c) 16-18mm
STEPS : • Ovarian stimulation with gonadotrophins & folliculate monitoring
• Oocyte retrieval (Ovum pickup) done through TVS guided needle
• Fertilization : 50,000 to 1.5 lakh sperms are put on each oocyte
retrieved
• Embryos kept in incubator for 48-72hrs
• Embryo transfer (ET) on D3 (72h) after oocyte retrieval
• Generally, 3-4 embryos are transferred in the uterine cavity via
catheter & deposited 1.5-2cms below fundus
• Success rate of IVF per cycle is 50%
ICSI
Q) A 36yr old woman attends the infertility clinic. She is of (N) weight & gives H/O
regular menstrual cycles. However, her periods are heavy & are associated with
seven pain that outlasts hey periods. Hormonal tests reveal (N) LH, FSH, PRL & D1
progesterone levels. She recently had laprscopy & dye test that showed pelvic
adhesions with an absence of dye spill in both fallopian tubes. Her partner's semen
analysis is (N). Next step ?
a) ICSI
b) IUI
c) IVF
d) OI with gonadotrophins
Ans : c) IVF
Contraception
Type of Birth control 00:22
• Progesterone is thermogenic
• After ovulation, temp raises by 0.5°c which persist for 3 days
• Safe period begins from 4th day (after ovulation) to last days of next period
• Perfect use failure rate : 1/HWY (WHO 2015)
BELLAGIO CRITERIA
All postpartum women in whom :
• Spermicides
• Hole condom
• Diaphragm
• Cervical cap
MALE CONDOM
Types
NON-CONTRACEPTIVE USES
DIAPHRAGM
1) Prolapse
2) Retroversion
3) VVF
4) Badly eroded cervix
5) Recurrent UTI
DIAPHRAGM
CERVICAL CAP
SPERMICIDAL AGENTS
Ans : a, b
OTHERS : Benzalkonium
Octoxynol
Cyproterone acetate
Monophasic Multiphasic
Quadriphasic – Qlaira
AMOUNT OF ESTROGEN
TYPE OF PROGESTERONE
₹2
• Anovulation
• Endometrial thinning
• Cervical mucus thickening
• Start on D1 of cycle / within 5 days of cycle X OD daily at same time for 21 days
POSITIVE BENEFITS
• E+P
E : EE 20gm
P : Norelgestromin 150gm
• Apply patch for 3 weeks followed by 1 week patch free
• Advantage :
- Better Compliance
• Disadvantage :
- Less Effective In Obese
NUVA RING
P – Etonogestral 120Gm
E – Ee 15Gm
• Advantage :
- Better Compliance
- No Systemic S/E
• Disadvantage :
- Leucorrhea
INJECTABLE CONTRACEPTIVES
DEPORMEDROXYPROGESTERONE NORETHISTERONE
ACETATE ENANTHATE
(Anthara)
ADVANTAGE DISADVANTAGE
1-6 CAPSULES
NORPLANT LNG
11-2 capsules
• Implants
IMPLANON – 67 mg of Etonogestral released in 3yrs
• IUCDS - Least failure rate of 0.5 HWY
- Radio opaque = NEXAPLANON
IUCDS
Endometrial thinning
Cu → Increasing Fallopian Tube
Cervical mucus
Motility
Spermicidal Thickening
Fb Reaction
C/I
Cx :
1) MC – Increased bleeding
2) Pain – MC reason for removal
3) Expulsion
4) Misplaced IUD d/t perforation (1 in 1000)
5) Infection (within 2months) within 7-9 weeks Actinomyces
6) Ectopic pregnancy
Clinical
1st Ix : Usg
Myometrium Peritoneum
Could’nt Be Removed
TERMINATE CONTINUED
GYNE FIX –
FEMALE STERILIZATION
Least Fr – Uchida
• Minilaprotomy Fr of Pomeroy – 0.2 Hwy
REVERSAL
BEST = CLIP
RING
POMEROY
LEAST =
COAGULATIO
N
TIMING OF TUBECTOMY
• Should be married
• Age : 22years - 49yeaes
• Should have atleast one child > 1yr age
• Spouse / partners must not have undergone sterilization in the past
Menopause & HRT
Menopause 00:27
• Earlier menopause ;
1. Nulliparous women
2. Tobacco smokers
3. Hysterctomized women
SYMPTOMS
DX CRITERIA
• Cessation of menstruation
• Menopausal symptoms
• Vaginal cytology 100/0/0
• Serum esterdiol < 20pg/ml
• Serum FSH and LH > 40 miU/ml
HORMONE REPLACEMENT THERAPY (RX)
• Risk
1. CHD
2. Breast cancer (> 5yrs)
3. VTE
4. Cholecystitis
5. Ovarian cancer (> 10yrs)
• Use minimum possible dose - max 5 yrs
• Contraindications
1. Thrombosis / Thromboembolism
2. + Liver disease
3. Ischemic heart disease
4. Breast cancer
5. Migraine with aura
6. Diabetes mellitus with vasculopathy
7. Severe Hypertension > 160/110 mm Hg
• Alternative for HRT
Osteoporosis treatment :
- Bisphosphonates (first line)
- E+P
- Raloxifine
- Tibolone
- Denosumab
- Teriparitide : Recombinant PT
- Calcium
- DEXA Scan for BMD
CLASSIFICATION
• Uterine
1. Submucosal
2. Intramural (70% & MC)
3. Subserosal
• Extrauterine
1. Cervical
2. Abdomen
3. Broad ligament
FIGO CLASSIFICATION
• 0 : Pedunculated intracavitary
• 1 : SM, < 50% intramural
• 2 : SM, > 50% intramural
• 3 : Intramural but contacts endometrium
• 4 : Intramural
• 5 : Subserosal, > 50%
• 6 : Subserosal, < 50% IM
• 7 : Subserosal pedunculated
• 8 : Others, cervical abdominal
• Hybrid – 2 to 5
ETIOLOGICAL FEATURES
• Protective factors
1. Exercise
2. Smoking
3. Menopause
4. Multiparity
• Changes
1. Degeneration - MC hyaline degeneration
2. Red degeneration - MC in pregnancy, c/s - red beefy appearance
3. C/P - fever & pain, MC in 2nd trimester
CLINICAL PRESENTATION
• Asymptomatic
1. Regular supervision
2. Surgery - Dx uncertain, pedunculated subserosal, unexplained infertility
• Symptomatic
1. Medical
2. Surgery
• Medical
1. Bleeding - Tranexamic acid, NSAIDs, COCP, progesterone
2. NSAIDS - To reduce pain
3. Decrease in size, pain & bleeding - GnRh analogues, danazole, gestrinol,
mifipristone
• Surgical
1. Myomectomy - Only in nulliparous fibroid
2. Minimal invasive surgery
3. Hysterectomy
• Prerequisite
1. Husband semen analysis - N
2. Endometrial biopsy to rule out cancer
3. Consent for Hysterectomy
RISK FACTORS
• Nulliparous
• Early menarche, Late menopause
• Short cycle
• Family H/o
• High socio economic status
• Obesity
• Late marriage
• Late child birth
• Mullerian anomalies
• Imperforated hymen
• Transverse vaginal septum
PROTECTIVE FACTORS
• Pregnancy
• Lactation
• Multiparous
• Exercise
• Smoking
PATHOGENESIS 03:35
CLINICAL PRESENTATION
SIGNS
Management 09:45
• Expectant
- Asymptomatic
- Pregnancy
- Menopausal
• Medical
- Temporary
- Symptomatic
• Surgical
• Pseudo-menopause drugs
SURGERY
• Indication
- Non responsive to medical Mx
- Acute intolerable pain
- Bowel / Urinary injury
- Chocolate cysts
• Rx
- Adhesiolysis
- Fulguration of implants - laser / cryoscope
- LUNA Hysterectomy & B/L salphingo opheractomy
TRICHOMONAS VAGINITIS
• Pregnancy
- 1st trimester - Metronidazole pessary
- 2nd & 3rd trimester - Metronidazole 2gm stat dose or
- 250 mg TDS x 5 days
Candidiasis 03:29
• Clinical presentation
- Curdy white discharge
- Cottage cheese discharge
- Pruritis +++
Bacterial 05:38
Cervicitis 08:01
CHLAMYDIA
• Etiology
- Chlamydia trachomatis - Obligate intracellular organism
- Preferential infection - Columnar & Transitional epithelium
• Clinical features
- Asymptomatic (80%)
- Mucopurulent endocervical discharge
- Urethral syndrome - dysuria, frequency, pyuria, no bacteria
- Pelvic pain
- Postcoital bleeding / intermenstrual bleeding
• Investigations
- Nucleic acid amplification test
- First void urine sample / vaginal swab
- PCR
- Culture on McCoy cells / Hela cells
• Rx
- Doxycycline 100mg BID x 7days or azithromycin 1mg single dose
- Both have similar results
- Treat partners simultaneously
• In pregnancy
- Azithromycin, No Doxycycline
- Azithromycin - 1g in a single dose or Amoxicillin 500mg TID x 7days
GONORRHEA
• NAAT
- On urine & endocervical discharge
- First void morning urine sample preferred
- Sensitive & specific
• Rx
- Single dose Inj Ceftriaxone 125mg IM stat or
- Cefixime 400 mg oral stat or
- Ciprofloxacin 500mg stat
- To treat Chlamydia - Add Doxycycline / Azithromycin
- If pregnant - Cephalosporin regimen
- Allergic to beta-lactam antibiotics - 2g spectinomycin IM
PAINFUL
• Herpes
- HSV2
- Vesicles
- Multiple
- Erythematous base
- Edge - erythematous
- LN - B/L tender
- DOC - Acyclovir 400mg TDS x 7-10days
• Chancroid
- H. ducreyi
- Papule
- Multiple
- Greenish exudate
- Edge - undermined
- LN - U/L tender
- DOC - Azithromycin 1gm PO
PAINLESS
• Granuloma inguinal
- Klebsiella granulomatosis
- Papule
- Single / Multiple
- Red velvety base bleeds on touch
- Edge - elevated
- Pseudo Bubo
- DOC - Doxycycline 100mg OD x 21 day
Endometrial Hyperplasia and Endometrial Cancer
Endometrial Hyperplasia 00:30
Risk factor-estrogen
Dysplastic Cells
3-6 month
Endometrial biopsy
Endometrial cancer/hyperplasia 05:10
Family History
• Routine surveillance may consist of yearly USG and endometrial biopsy commencing
at the age of 30-35
• Best method to prevent endometrial cancer in patients of HNPCC is prophylactic
hysterectomy and oophorectomy
Types 10:00
Type 1 Type 2
Symptoms 11:40
Check
Endometrial thickness
In Premenopausal InPostmenopausal
If ET > 12mm If ET >4mm (Figo ET >5mm)
Endometrial Biopsy :
Thickened echogenic and heterogenous in echo tecture and contains tiny cystic foci
Surgical Staging:
Grading:
Management 20:14
Stage 1b
< 2CM > 2CM
TAH + BSO TAH + BSO
+ TAH +BSO
Pelvic LN dissection
Pelvic and Paraaortic in dissection
Vault irradiation
Rt Doxorubicin
Post OP whole pelvic radiotherapy
Cisplatin
Adriamycin
Ovarian Cancer
Q) Ovarian tumors commonly arise from :
a) Stroma
b) Surface epithelium
c) Germinal epithelium
d) Endoderm
Classification 01:17
Etiology 07:06
RISK FACTORS
• Nulliparous
• Early menarche
• Polymenorrhea
• Ovulation induction agents
• Talc & asbestos exposure
• FAMILY HISTORY :
OVARIAN BREAST
CANCER CANCER
• Asymptomatic
• Nausea, Vomiting
• Early satiety
• Weight loss
• Abd. distension/ Abd. mass
Investigations 11:57
• Mutliloculated • Uniloculated
• Thick septations > 7mm • Absent/Thin septations < 7mm
• Heterogenous • Homogenous
• Atleast 4 capillary structures • Smooth surface
on surface
• Increased vascularity • Increased vascularity
• Ascites • Absent
• LN mets • Absent
• Omental caking • Absent
Q) Marker for granulose cell tumor :
a) CA 19-9
b) CA 50
c) Inhibin
d) CA 125
Ans : c) Inhibin
TUMOR MARKERS
Management 18:50
- Staging Laprotomy
Stage IC – IC - Cytoreductive/Debulking Sx
Post OP Chemotherapy =
3 Cycles of Chemo
Surgery
3 Cycles of Chemo
FOR GENERAL CELL & SEX CORD STROMAL TUMORS
Staging Laprotomy
• Bleomycin
• Etoposide
• Cisplatin
Ca 125
< 35 IU > 35 IU
W&W Sx
• HPV infection
• Predisposing factors for Ca. cervix (PGI Dec 08)
- Multiple sex partners
- Genital warts
- HPV 16, 18
• HPV 16 & 18
- High risk
- Most common
- 16 - CA cervix & squamous cell carcinoma
- 18 - most-specific, associated with adenocarcinoma cervix
VACCINATION
• Given - 9 to 26 years
• Can be given upto 45 years
• 3 doses : 0, 1-2months, 6months
WHO SAGE
DYSPLASIA
• Increase in stiffness
• Decrease of cytoplasm
• Mitotic figures & nuclear atypia increases
PATHOPHYSIOLOGY
KOILOCYTES
Screening 11:43
• PAP smear
• LBC - Liquid Based Cytology
• HPV DNA testing - best screening method
• VIA - Visual Inspection under acetic acid
• VILI - Visual Inspection under lugots iodine
• VIA
- Most cost-effective method
- Low resource setting
• Hybrid capture method can reliably detect the high-risk HPV types within hours
• Can be done from 25 yrs
VIA
• Lugol’s iodine
• Examination after 1-2 mins
• Normal cervix - Mahogany brown
• CA cervix - unstained
BETHESDA SYSTEM OF INTERPRETATION
• Specimen type
• Specimen adequacy
• General categorization
• Automated review
• Ancillary testing
• General categorization
- -ve for intraepithelial lesion / malignancy
- Other : see interpretation / result
- Epithelial cell abnormality : specify squamous / glandular
Organisms 18:33
TRICHOMONAS VAGINALIS
CANDIDA
CLUE CELLS
ACTINOMYCES
• Trichomonas vaginalis
• Fungal organisms morphologically consists with candida spp
• Shift in flora suggestive of bacterial vaginosis
• Bacteria morphologically consistent with actinomyces spp
• Cellular changes consists with Herps simplex virus & cytomegalovirus
SQUAMOUS CELL
GLANDULAR CELL
• Atypical
• Endocervical cells (NOS or specify in comments)
• Endometrial cells (NOS or specify in comments)
• Glandular cells (NOS or specify in comments)
• Endocervical cells favour neoplastic
• Glandular cells favour neoplastic
• Endocervical adenocarcinoma in situ
• Adenocarcinoma
• Endocervical
• Endometrial
• Extrauterine
• Not otherwise specified (NOS)
• Ascus;
- Repeat cytology
- At 6, 12 months
- If –ve -> routine screening
• Ascus → Colposcopy
• HPV DNA testing
- +ve → Colposcopy
- -ve → Repeat cytology at 12 months
• Post CIN Rx
- HPV test - every 5 yr
- VIA - for 20 yrs
- If cervix & uterus removed - no screening
• Confirmatory methods
- Visible lesion -> punch biopsy
- Microscopic lesion -> colposcopy guided biopsy
CONE BIOPSY
• Indication Dx
1. Limits of lesion not visible in colposcopy
2. The TZ junction not seen
3. Endocervical curettage - histological findings are +ve
4. Microinvasive carcinoma or adenocarcinoma - suspected
5. Lack of correlation between cytology, biopsy and colposcopy results
• Therapeutic
- Cancer in situ in young females
- Cancer cervix stage 1A1 in young females
- Severe cervical erosion nor responding to medication / cauterisation
• Mx
- Do HPV DNA test & PAP smear every 6 months
- If abnormalities persists for 2 yrs -> ablative / excisional procedure
CA Cervix 30:53
• 4 cardinal symptoms
1. Irregular vaginal bleeding
2. Post-coital bleeding
3. Pelvic pain
4. Foul smelling vaginal discharge
• 4 cardinal signs
1. Cauliflower-like hard growth indurated
2. Fixed
3. Friable
4. Bleed on touch
• Complications
- Pyometra
- Uremia (MC cause of death)
- Fistula (VVF)
• RT
1. Brachytherapy
2. External beam radio therapy
3. Intensity modulated radiotherapy
MANCHESTER TECHNIQUE
CONSERVATIVE SURGERY
Etiology 06:23
Classification 09:16
UTERINE DESCENT
SYMPTOMS
Complications 14:31
DECUBITUS ULCER
ACRIFLAVIN (epithelialisation)
BETADINE (antisepsis)
Treatment 17:25
Pessary
I. Conservative
Surgery
II. Radical
Ans :
PESSARY
INDICATIONS
LIMITATION
3) Purandare's Cervicopexy
• Sling is tied from anterior aspect of cervix
to posterior rectus sheath
S/E : Enterocele
Tension free trans of obturator tape > Transvaginal tape > Burch colposuspension
(Paraurethral tissue are anchored to
iliopectineal ligament)
Fistula 35:12
VESICOVAGINAL FISTULA MC