Pocket Tutor Gynaecology Jodi Keane, Manda Raz, Shavi Fernando
INDEX
Note: Page numbers in bold or italic refer to tables or figures respectively.
A
Abdomen 33, 116
acute 161
Abdominal cavity 166, 245
Abdominal cramps, lower 165
Abdominal pain
cyclic 43
symptoms of 159
Abdominal palpation 34
Abdominal pressure 214
Abuse
physical 25, 30
sexual 25, 30
Acetic acid 228, 229
Acne 75
Acquired bleeding disorder 89
Activated partial thromboplastin time 87
Acute respiratory distress syndrome 159
Adapalene 83
Adenocarcinoma 238
Adenomyosis 68, 101
Adrenal androgen 45
production 46
Adrenarche 46
menarche 45
Amenorrhoea 70
causes of secondary 71
complete 74
eugonadotropic causes of 74
hypogonadotropic 70
causes of 76
physiological 71
causes of 72
primary 70
secondary 70
Amlodipine 67
Amsel's criteria 129
Anaemia 28, 86
chronic 28
Androgen
effects of 47
elevated 82
production of 52
Androstenedione 80
Anosmia 75
Anterior abdominal wall 16
anatomy 15
Anti-adrenal antibodies 74
Anti-androgen 83, 141
Anti-coagulant medication 89
Antidepressants, tricyclic 215, 217
Anti-phospholipid syndrome 171
Anti-sperm antibodies 135
Antral follicle count 81
Aortic dissection, risk of 73
Appendicectomy 30
Arteriovenous malformation 97
Artificial insemination 156
Asherman syndrome 153
Aspiration catheter 40
Assisted reproductive technology 156
complications of 159
Atrophic vulvovaginitis 130, 131
Auto-immune ovarian failure 74
Autonomic pelvic nerves 12, 14, 14
Axillae 47
B
Bacterial vaginosis 128
investigations 128
management 129
Bartholin's gland 116
Benzoyl peroxide 83
Beta-human chorionic gonadotropin 38
Bimanual palpation 34
Bimanual vaginal examination 34, 36
Biopsy 127
Bi-temporal hemianopia 75
Bladder 208
lesions 212
pressure sensors 213
trigone 186
Bleeding
abnormal 77
first trimester 160
heaviness, disorders of 69
inter-menstrual 117
menstrual 28
post-coital 117, 236
Blood loss
large volumes of 33
symptoms of 167
Blood pressure 193
Body
habitus 32
mass index 43, 55, 177
system 79
Bone mass 186
Bony pelvis 6, 7
greater 9
lesser 6
Bowel surgery 30
Breast
bud 54
cancer 191, 246
development of 49
growth 45
Breastfeeding 67
Bromocriptine 77
C
Cabergoline 77
Caesarean scars 166
Cancer
antigen 38
colorectal 86, 191
gynaecological 31, 221
non-epithelial 246
staging 224
and treatment, principles of 224
treatment 225
Candida 124
glabrata 125, 127
infections 125
Candidal discharge 125
Candidiasis 127
Carbohydrate consumption 82
Carcinoembryonic antigen 38
Cardiac disease 30
Cardiovascular disease 85, 191
Cell
cancers, transitional 214
clear 245
Central nervous system 54, 79
Central precocious puberty 53
Cervical 228
cytology 234
disease 28
environment 34
intra-epithelial neoplasia 233
motion tenderness 36, 118
secretions 125
smear 229
transformation zone 232
Cervical biopsy 233, 234
small 14
Cervical cancer 224, 238
assessment of 39
incidence of 230
Cervical screening 29
and cancer 230
methods 231
test 77, 87, 179, 221
Cervicitis, suspicion for 222
Cervix 3, 50, 95, 113, 116, 166
Chandelier sign 114
Chemotherapy 72, 249
Chlamydia 29, 77, 116, 118, 126, 140, 236
trachomatis 115, 116
Chloe's hormonal profile 44
Chloe's younger sister 44
Cholecystectomy 30
Choriocarcinoma 38, 221
Chorionic villi, hydatidiform swelling of 169
Chromosomal causes 61
Chromosomal genital abnormalities 64
Chronic pelvic pain 30, 31, 99, 108
management 111
Clitoris 11
Clomiphene citrate 84, 156
Coeliac disease 74, 86
Cognition 33
Coitus, vaginal lubricants for 195
Cold-knife conisation 235
Colposcopy 227, 229, 231
Combined oral contraceptive pill 82, 83, 90, 137, 138, 140, 142
Complete androgen insensitivity syndrome 58, 59, 61, 63, 64
diagnosis of 44
Condom 137, 143, 144
broken 150
male 138, 140
Cone biopsy 235
Congenital abnormalities 61
Congenital adrenal hyperplasia 55
Congenital disorder 43
Congenital hypothalamic malformation 75
Conjunctiva 116
Contraception 29, 82, 136, 148
emergency 149, 150
long-acting 146
methods of 29
natural methods 137
pearl index 136
permanent 97
short acting 137, 138
Contraceptive
category of 145
methods 29
pill 73
Copper intrauterine device 89, 148, 151
Corpus luteum, demise of 24
Cough 214, 240
Craniosacral outflow 14
C-reactive protein 37, 114, 123
Creatinine 160, 198
Cushing syndrome 75
Cyclical pelvic pain 66
Cyclooxygenase 101
Cyproterone acetate 82, 83, 141
Cystectomy 246
Cystic fibrosis 155
Cystitis cystica 214
Cystoscope, flexible 214
Cystoscopy 213, 214
D
Darifenacin 217
Decidua functionalis 23
Dehydroepiandrosterone sulphate 46, 53, 81
Delayed puberty 57
differential diagnosis 57
history and examination 57
investigations 61
management of 61, 62
Deoxyribonucleic acid 29, 231
Depot medroxyprogesterone acetate 145
Dermatitis, general 130, 131
Dermoid cysts 246
Desmopressin 90, 217
Desvenlafaxine 192
Developmental syndromes 63
Diabetes 80
mellitus, type 2 221
Dianne 82
Diaphragm 138, 140, 141
positioning of 141
Diclofenac sodium 96
Diethylstilbestrol 65
Dihydrotestosterone 83
Disc disease 111
Discharge 130
Donor sperm 156
Drugs
anti-androgenic 82
anti-muscarinic 217
Duloxetine, trial of 217
Dysgerminoma 246
Dyslipidaemia 188
Dysmenorrhoea 99102, 104, 130, 147
examination 102
features of 102
history 102
investigations 103
management 103
primary 48, 100, 101
secondary 100
Dyspareunia 130
Dysplasia 234
development of 231
higher risk of 232
high-grade 226, 232
severity of 233
Dysuria 197
history of 113
E
Ectopic endometrial implants 101
Ectopic pregnancy 31, 165, 166
diagnosis 167
management 167
risk of 115, 122
Eflornithine 83
Eisenmenger's syndrome 173
Ejaculatory dysfunction 154, 157
Electrolyte 76, 13, 198
Embryonic tissue 169
Endocervical swabs 34
Endocrine 79
Endogenous oestrone 238
Endometrial adenocarcinoma 223, 238
Endometrial biopsy 87, 243
Endometrial cancer 191, 240
clinical features 240
investigations and diagnosis 241
management 241
metastasises 240
Endometrial cycle 21, 23
Endometrial glands 23
Endometrial hyperplasia 33, 68, 84, 88, 90, 178
risk factor for 97
treatment of 85
Endometrial polyps 152
Endometrial tissue 40
Endometriosis 41, 66, 101, 105, 106, 153
deep infiltrating 106
history and examination 107
investigation 107
management 107
pathophysiology of 105, 106
sites 105
superficial 104, 106, 107
Endometrium 23
layers 22
End-organ complications 198
Ephedrine 155
Epigastric vessels, inferior 19
Epilepsy 143
Epiphyses 52
Epithelial ovarian cancer 38, 245
Erector spinae 10
Erythematous vaginal tissue 125
Ethinyl oestradiol tablets 70
Etonogestrel 115
Eugonadotropic delay 59
Extragenital tissue 113
Extra-uterine disease 244
F
Facial hirsutism 75
Faecal incontinence 207
Fallopian tube 3, 50, 51, 100, 116, 245
removal of 241
Female genital development, physiology of normal 50
Female genital tract 50, 61
development 1
Female reproductive tract 43
Femoral nerve 12, 13
Fertility
and contraception 130
low natural 144
management 136
Fetal anomaly, termination for 173
Fetal malformation 84
Fever 197
Fibroid 40, 68, 153
pre-existing 242
types of 91
Finasteride 83
Fitz–Hugh–Curtis syndrome 120, 121
Flank pain 197
Fluconazole 127
Fluid intake, moderate 216
Fluorouracil 132
Follicle-stimulating hormone 37, 44, 45, 48, 53, 58, 72, 76, 80, 155, 177
Fragile X syndrome 72, 73
G
Gabapentin 192
Galactorrhoea 75
Gamma-aminobutyric acid 193
Gardnerella vaginalis 128
Gastrointestinal irritation 82
Gastrointestinal system 109
Genetic
male fetus 59
problems 61
syndromes 57, 63
Genital complaints 113
Genital conditions 126
Genital diseases 113
management 114
Genital organs, external 1, 3
Genital region 113
Genital skin 129
Genital symptoms 26
treatment of 194
Genital tract
development of 1
examination of lower 227
Müllerian-derived 59
upper 50
Genitalia 47
development of
external 1
internal 1
external 4, 11, 32
internal 3, 50
Genitourinary tract 186
Germ cell 246
tumours 246, 249
Gestational diabetes 84
Gestational neoplasias 221
Gestational trophoblastic disease 160, 169
Glycated haemoglobin 81
Gonadotropin 44
Gonadotropin-releasing hormone 19, 45, 47, 48, 53, 72, 98
Gonorrhoea 29, 77, 116118, 126, 140
Granulosa tumours 246
Gynaecological assessment, part of 38
Gynaecological oncology, principles of 221
Gynaecological surgical incisions 18
Gynaecological system 109
H
Haematological tests 37
Haematuria 197
Haemoptysis 240
Haemorrhage, intra-abdominal 168
Hair
follicles 82
head 47
Headache 178
Heavy menses 28
Hepatitis 140
B 115
C 115
Herbal pills 177
Herpes simplex virus 115, 118
Hormonal therapy 187
Hormonal treatments 29
Hormone
anti-Müllerian 81
low follicle-stimulating 70
luteinising 19, 37, 45, 48, 53, 58, 70, 73, 76, 80
pills 142
replacement 54, 221
therapy 73
thyroid-stimulating 53, 76, 81
Horseshoe kidney 74
Human chorionic gonadotropin 76, 114, 123, 155
Human immunodeficiency virus 115, 140
Human papillomavirus 29, 132, 231, 237
dependent malignancy 226
infection with 226
screening 231
Hydatidiform mole 221
Hymen, imperforate 58, 59, 66
Hyper-androgenism 38
Hypergonadotropic amenorrhoea 71, 72, 72
causes of 73
Hypergonadotropic hypogonadism 60
Hypergonadotropic women 61
Hyperplasia 77
development of 189
Hyperprolactinaemia 75, 76
Hypertension 221
severe 178
Hypogastric nerve 14
Hypogonadotropic delay 59
Hypomenorrhoea 69
Hypothalamic dysfunction 70
Hypothalamic-pituitary
axis 45
ovarian 47, 48
axis 19
Hypothyroidism 89
Hysterectomy 90, 92
abdominal 93
approaches
contraindications 94
indications 94
types of 93
Hysteroscopic procedures 91
Hysteroscopy 243
diagnostic 40
I
Idiopathic ovarian failure 72
Imidazoles 127
Imipramine 155
Immune thrombocytopaenic purpura 87
Implanon 145, 146
NXT 147
In vitro fertilisation 158
Incontinence, investigation of 212
Infection 178, 236
types of 116
Infertility 84, 122, 135, 151
causes of 154
couple factor of 156
female factor 151
male factor 151, 154
treatment for 153
tubal factor 152
uterine causes of 153
Inflammatory bowel disease 86, 111
Inguinal lymph nodes 229
Inherited chromosomal abnormalities 171
Insulin sensitiser 83
Internal genital
organs 1, 3
systems 50
Intra-abdominal pathology 34, 41
Intra-cytoplasmic sperm injection 154, 158, 158
Intra-peritoneal uterosacral ligaments 206
Intra-uterine adhesions 153
Intra-uterine contraceptive device 86
Intra-uterine device 14, 75, 145, 147
levonorgestrel 145, 146
mirena 145, 147
multiload copper 147
Intra-uterine growth restriction 53
Intra-uterine insemination 154, 157
Intra-uterine pathology 34
Intra-uterine system 77, 111, 189
Intra-venous pyelogram 239
Invasive testing 213
Iron deficiency 28, 68
anaemia 69, 86
Iron supplementation 67
Irregular menses, separating 77
Irregular periods 28
Ischial tuberosities 8
Isolated premature thelarche 55
Isotretinoin 83
J
Joint pain 183
K
Kallmann syndrome 75
L
Lactate dehydrogenase 243
Laparoscopic abdominal operations 30
Laparoscopic hysterectomy 93, 241
Laparoscopic tubal ligation 148
Laparoscopy
diagnostic 41
incision 19
Leiomyosarcoma 242
Letrozole 84, 156
Leucocytosis 37
Lichen sclerosis 126, 129131
Lichen simplex 130, 131
Limb nerve plexus traversing pelvis 12
Liver function test 76, 123, 160
Lower limb, nerve plexuses to 11
Low-molecular-weight heparin 31
Lubricant, water-based 36
Lugol's iodine solution 228, 231
Lumbosacral plexus 11, 13
Lymph node 85
dissection 229
M
Male factor infertility, causes of 154
Mass, abdominal 43, 197
Mastalgia 188
McCune-Albright syndrome 54
Medroxyprogesterone acetate 96
Menarche 47
Menopausal hormone therapy 187, 191, 248
Menopausal phase 182
Menopausal symptoms 57, 60, 184, 192
Menopausal vasomotor 104
Menopause 25, 27, 135, 177, 180, 200
caused by 178
clinical features 182
clinical investigations 178
diagnostic approach 178
genitourinary features of 184
hormonal therapy 187
options 190
risks and benefits of 191
management 178
non-hormonal methods 189
phases 181
physiology of 179
sequelae of 185
surgical 184
symptoms of 29, 177
transition 179
early 183
Menorrhagia 26, 37, 6769, 85, 95, 96, 147
assessment 86
consequence of 68
functional 86
causes and management 86
investigation of 87
management for 89
structural causes and management 88
treatment of 88
Menses 130
breasts without 57
Menstrual cycle 19
disorders of 67, 69
disturbance 69
fraction of 67
management 68
normal 19
number of 67
regular 47
Menstrual history 27
Menstrual period, last 27
Menstrual problems 66
Menstruation 142
Mental health disorders 31
Metabolic complications 82
Metastases 238, 248
Metastatic disease, diaphragms for 248
Metformin 83, 198
Methotrexate 168
Metromenorrhagia 69
Metrorrhagia 69, 77
assessment 77
management 77
Metrostaxis 95, 96
causes of 97
treatment of 96
Mid-line fusion 4
problems 5
Mifepristone 174
Minipill 144
Mirena 145
Miscarriage 31, 165
complete 163
diagnosis of 165
incomplete 163
increased 84
management 166
missed 163
recurrent 31
septic 163
threatened 163
types of 163, 164, 165
Molar pregnancy
complete 169, 170
partial 169, 170
Morbid adhesion formation 122
Müllerian agenesis 58, 59
Müllerian duct 3, 50, 51, 51, 65
abnormalities of 4
formation 66
fusion 65
Müllerian fusion, problems in 65
Müllerian genesis problems 66
Müllerian inhibiting substance 50, 51
Müllerian system, mal-development of 4
Müllerian-inhibiting substance 3
Multi-disciplinary chronic pain 99
Muscle 15
abdominis 15
bones 99
lateral 15
pelvic 10
perineal 9
pyramidalis 15
Musculoskeletal system 109
Mycoplasma 116, 118, 126
genitalium 114, 115
N
Nausea 165
symptoms of 159
Neisseria gonorrhoeae 115
Nerve 16, 99
injury 11
Neurological disease 215
Neurological injury 207
Neurological symptoms 54
Neurological system 109
Nipple discharge 75
No sugar pills 144
Nodal metastases, risk of 229
Nodular tender uterosacral ligaments 105
Non-consensual sex 117
activity 99
Non-hormonal treatment 192
Non-invasive testing 212
Non-sexually acquired infections 124
Non-steroidal anti-inflammatory drugs 90
Non-verbal rapport 26
Norethisterone 96, 188
Nucleic acid amplification test 116, 126
Nystatin 127
O
Obesity 75
Oblique muscles, external and internal 10
Obstructive sleep apnea 82
Obturator nerve 12, 13
Oestradiol 37, 70, 74
patches 70
Oestriol 194
Oestrogen 19, 21, 79, 141, 190, 217
concentrations 47
levels of 19
loss 186
causes 185
pre-menopausal 73
production of 52, 72
Oestrogen-only hormone replacement 240
Office endometrial sampling 40
Oligomenorrhoea 78
cause of 78
Oncology, gynaecological 221
Oocytes 20
Oral anti-acne 83
Oral contraceptive 48, 54, 70, 77, 83, 111
Oral glucose tolerance test 81
Oral isotretinoin 82
Oral progesterone 68, 97
Osteoporosis 186
Ovarian cancer 244
clinical features 245
diagnosis 246
management 248
prognosis 249
subtypes of 244
Ovarian cycle 20, 21
follicular phase 21
luteal phase 22
Ovarian endometriomas 105
Ovarian follicles 79
Ovarian follicular pool 179
Ovarian hyperstimulation
controlled 157
syndrome 159
Ovarian torsion 114
Ovary 85, 166
development of 1
Ovulation induction 156
Ovulatory dysfunction 183
Oxybutynin 217
Oxytrol 217
P
Pain
acute 99
and bleeding 130
Palpable abdominal mass, development of 60
Pap smear 29
Parental pubertal age 54
Pederson speculum 35
Pelvic
anatomy 6
bones 10
cavity, part of 6
lymph node 223, 241
radiation 72
somatic nerves, intrinsic 11
Pelvic floor 9, 9, 10
function 207
injury, causes of 200
muscles 8, 207, 208
surgery 207
Pelvic inflammatory disease 29, 119, 123, 152, 167
clinical features 120
diagnostic approach 120
investigations 122, 123
management 122
types 120
Pelvic nerve 10
parasympathetic 14
Pelvic organ 34, 39
normal 34
ovaries 34
tubes 34
uterus 34
Pelvic organ prolapse 197, 199
clinical features 201
epidemiology 199
investigations 204
management 204
non-surgical treatments 205
pathophysiology 199
quantification system 201
surgical treatments 206
types 199
Pelvic pain 31, 98, 113, 130
causes of chronic 109
disorders 69
treatment of chronic 110
Pelvic ultrasound 44, 243
aids 71
Pelvis 9, 34, 39
contents of lesser 8
greater 9
Perianal skin 11
Peri-menopausal
phase 182
women 67
Perineum 11
Peripheral tissues 59
Peripheral vascular disease 85
Pessary types 205
Pfannenstiel incision 18
Pharynx 116
Pipelle 40
endometrial biopsy 84, 223
Pituitary adenoma 75
Pituitary gland 157
Pituitary-hypothalamic-ovarian axis 98
Placenta accreta 97
Polycystic ovarian morphology 28, 33, 71, 74, 78, 79, 141, 238
Polycystic ovarian syndrome 78, 81
clinical features of 79
history and examination 79
investigations in 80
management 81
pathophysiology 78
pharmacological treatment of 83
Polyenes 127
Polymenorrhoea 95
Polymerase chain reaction 123, 126, 132, 237
Polyps 40, 68
Post-coital bleeding, assessment of 237
Post-menopausal
phase 182
women 205, 219
Post-oophorectomy 246
Post-partum pituitary ischaemic injury 75
Post-termination contraception 173
Pouch of Douglas 120
Pregnancy 67
complication 171
of unknown location 161
strain of 75
Premature gonadal failure 44
Premature puberty 52, 53
differential diagnosis 52
examination 54, 55
history 52
investigations 54
management 55
Pre-menopausal
phase 180
women 248
Pre-menstrual spotting 77
Pre-menstrual syndrome 97
features of 98
Pre-pubertal population 70
Progesterone 19, 21, 37, 141, 142
absence of 184
implant 145
low levels of 98
natural 188
only pill 139, 144
pill, high-dose 150
Progestogen 190
Prolactin 72
Prolactinoma 76, 157
Prolapse
examination 201
signs 202
site 201
stages 201, 203
surgical treatments for 206
symptoms of 202, 205
types of 200, 201
Prostaglandin 101
Proton pump inhibitor therapy 248
Pruritus 130
Pseudo-ephedrine 155
Psychosocial consequences 52
Psychosocial transition 43
Pubertal delay, types of abnormal 58
Pubertal development
normal range of 46
progress of 52
Puberty 43
abnormal 56
disorders of 43, 52
peripheral
precocious 53
premature 52
physiology of normal 45
Pubic hair, minimal 43
Pubic lice 126
Pubic symphysis, inferior margin of 7
Pulmonary embolism 191
Pulmonary hypertension 173
Q
Q-tip test 212
Quadratus lumborum 10
R
Rectal bleeding 222
Rectum 116
Rectus abdominis 10
Recurrent pregnancy loss 170
management 172
pathophysiology 170
Recurrent urinary tract infection 218
diagnosis 218
management 219
pathophysiology 218
Renal disease 30
Reproduction 135
management 136
Reproductive transition, late 100
Rifampicin 143
Rotterdam criteria 80
Ruptured ectopic pregnancy 36, 114, 161, 167
S
Saline hysterography 40
Saline infusion 41
Salpingostomy 168
Sarcoma 242
Scars, surgical 34
Sciatic nerve 12
Scrotal incisions 149
Semen analysis 135, 155
Septum, vertical 51
Serum oestrogen 47
Sex cord-stromal tumours 246
Sex steroids 37
Sexual function 26
Sexual hair growth 45
Sexual history, part of 30
Sexual intercourse 115
Sexual pain 26
Sexual problems 66
Sexually transmitted infection 29, 87, 115, 118, 123, 126, 237
clinical features 117
common 118
diagnostic approach 117
epidemiology 116
investigations in 123
pathophysiology 116
principles of management 119
types 116
Sheehan syndrome 75
Shock, hypotensive 75
Sinovaginal bulb 51
Six-pack appearance 15
Skin 47, 79
injury to 99
Solifenacin 217
Somatic nerves 11
Speculum 34
bivalve 35
examination 32, 34
Sims 35
types of 34, 35
Sperm abnormalities 154
Spironolactone 83
Spotting 236
Squamous intra-epithelial lesion
high-grade 234
low-grade 234
Stress
incontinence 209
levels of 43
ulceration 248
Stress incontinence management 215
conservative therapies 216
medical therapies 216
surgical therapies 218
Stroke, myocardial infarction 97
Structural causes 65
Sub-mucous fibroids 152
Swyer syndrome 61, 62, 64
Syphilis 115, 140
Systemic symptoms, treatment of 187
T
Tachycardia 86
Tanner staging 49
Tendons 99
Termination of pregnancy 172
counselling 173
management 174
medical 174
pathophysiology 173
surgical 174
Testosterone 80
exogenous 155
Tetracycline antibiotics 83
Thelarche 47, 54
menarche 45
Therapeutic indwelling catheter 198
Thyroid 89
function tests 87
Thyroxine, free 76
Tolterodine 217
Topical anti-acne 83
Topical oestriol 194
Tranexamic acid 67, 96
Transvaginal ultrasound 39
Transverse septum 51
Trichomonas 116, 118, 126
infects 116
vaginalis 115
Trophoblastic hyperplasia 169
Tubal ligation 148, 152
with filshie clips 149
with pomeroy procedure 149
Tubal occlusion 153
Tubo-ovarian abscess 114
Tumour 54
advanced stage 248
early-stage 229, 248
gynaecological 38
mucinous 246
Turner syndrome 57, 61, 62, 64, 72
U
Ulipristal acetate 150
Undescended testes 57
Urea
and creatinine 76, 123
electrolytes 160
Urethra 116, 186, 198, 208
contraction 207
sphincter, internal 207
Urge incontinence 216, 217
management 215
conservative therapies 215
medical therapies 215
Urinary dysfunction 197
Urinary frequency 121
Urinary hygiene 219
Urinary incontinence 207
epidemiology 209
history 209
normal continence 207
pathophysiology 209
Urinary luteinising hormone 152
Urinary sepsis 121
Urinary sphincter tone 217
Urinary tract infection 198
Urinary urgency 216
management of 215
pharmacological therapy for 217
Urine 123
mid-stream specimen of 204
Urodynamics 213
Urogenital sinus 50
fusion 66
Urological system 109
Uterine 153
agenesis 59
anatomy 17
anomalies 40
cancers 238
types of 240
cavity 145
contractions 24
diagnosis of 154
enlargement 66
perforations 92
prostaglandin production 48
synechiae 40
Uterine muscle cancers 242, 243
clinical features 242
diagnosis 243
management 244
Uterine sarcoma 39
risk factor for 243
Uterus 3, 17, 50, 51, 86, 100, 116, 242
enlarged 57
formation of 51
relations of 17
V
Vagina 51, 113, 116
developing 51
formation of 51
upper 3, 50
Vaginal bleeding 165
Vaginal cancer 226228
Vaginal dilator, long-term 242
Vaginal discharge 26
Vaginal dysplasia 227, 228
Vaginal fourchette, posterior 36
Vaginal hydrators 194
Vaginal hysterectomy 93
Vaginal mucosa 205
Vaginal oestradiol 194
Vaginal oestrogen
consists of 216
therapy, role for 215
Vaginal ring (NuvaRing) 139, 143, 144
Vaginal septum, transverse 5
Vascular system 109
Vasectomy 149
Vasomotor symptom 180, 183, 193
cause of 191
Venlafaxine 192, 193
Venous thromboembolism 92, 140, 191
Verbal rapport 26
Vertical fusion 5
problems 5
Visceral pain 14
Vital signs 33
Vitamin E 193
Vomiting 165
von Willebrand disease 87
Vulva 113, 226
Vulval cancer 226, 228, 230
Vulval dysplasia 228
Vulval neoplasia 126, 127, 132
Vulvar dermatoses 129
Vulvodynia 99
Vulvoscopy 127
Vulvovaginal irritation, mild 128
Vulvovaginitis 126
W
Warfarin 31
White blood cell count 123
Wolffian duct 3, 50, 51, 51
×
Chapter Notes

Save Clear


First principleschapter 1

 
1.1 Introduction
A thorough understanding of pelvic anatomy and normal physiological transitions during the reproductive phase is required to be able to competently care for girls and women throughout their lifespan.
This chapter outlines basic knowledge of gynaecological anatomy and the reproductive cycle that you will require as a foundation for further knowledge.
 
1.2 Normal (embryological) development of the genital tract
 
Key events
The development of the female genital tract has three key embryologic events. These are the differentiation of the gonad into an ovary, female differentiation of internal genital organs and female differentiation of external genital organs (Figure 1.1).
zoom view
Figure 1.1: Female genital tract development. (a) Development of the ovaries; (b) Development of internal genitalia and (c) Development of external genitalia.
2
zoom view
3The embryologic gonad forms an ovary in the female fetus and a testicle in the male fetus. The testicle produces Müllerian-inhibiting substance (MIS), which inhibits the development of female internal genitalia in males (see below).
The ovary does not produce MIS. The fetal ovary also forms all primordial ova that the female will have throughout her future lifespan. New oocytes are not created past this point.
The internal genital organs are pluripotent in early fetal development and contain the Müllerian ducts and Wolffian ducts, both of which are closely associated with the embryonic kidney. The Müllerian ducts can develop into female internal genitalia (fallopian tubes, uterus, cervix and upper vagina), while the Wolffian ducts can develop into male internal genitalia.
The external genital organs include the labia majora, labia minora, clitoris and lower vagina. These have precursor structures (genital tubercle and labioscrotal folds) that respond to either fetal oestrogen or testosterone to differentiate into female or male external genital organs, respectively.
 
Developmental sequence
Both internal and external genital organ development is guided by sex steroid production from the gonad together with the presence or absence of MIS.
 
Internal genitalia
In a normal female fetus, the absence of testosterone and MIS causes the Wolffian ducts to regress and the Müllerian ducts to fuse in the mid-line, forming the upper vagina, cervix and uterus. The uppermost parts do not normally fuse and remain separate on either side of the uterus as the fallopian tubes (Figure 1.2). The lowermost part fuses with the developing lower vagina from the external genital organs and the vagina is canalised (opened) (Figure 1.3).
This principle of mid-line fusion, followed by vertical fusion with the developing external genitalia, is fundamental to understanding normal internal genital anatomy and how errors in this process can lead to failure of development of one side, failure of mid-line fusion for all or part of the Müllerian duct and failure of vertical fusion with the external genital organs with anatomical obstruction.4
zoom view
Figure 1.2: Mid-line fusion.
It is also possible for the lower genital tract to erroneously connect with the alimentary tract and form a common exit termed the ‘cloaca’.
 
External genitalia
The external genitalia develop from the fetal genital tubercle and labioscrotal folds. Oestrogen results in the urethra remaining posterior to the developing clitoris and not running through the genital tubercle, as it differentiates (as occurs in a male fetus). Similarly, the labioscrotal folds do not meet in the mid-line and form labia, which meet posterior to the developing vagina.5
zoom view
Figure 1.3: Vertical fusion.
zoom view
Figure 1.4: (a) Mid-line fusion problems and (b) Vertical fusion problems – transverse vaginal septum.
6
zoom view
The lower vagina meets and fuses with the upper part of the vagina formed by the internal genitalia and the dividing tissue breaks down (canalises) to form a patent vaginal canal (Figures 1.1 and 1.3).
 
1.3 Pelvic anatomy
 
Bony pelvis
The pelvis comprises four bones: two innominate bones laterally and the sacrum and coccyx posteriorly. They are held together by strong ligaments and covered by muscle and fascia. Each innominate bone has three parts, which fuse together by puberty: (1) the wide ileum, located laterally; (2) the ischium, inferior, and the bone used to sit; and (3) the pubis, which meets the opposite side in the mid-line at the pubic ramus, the most anterior part of the bone (Figure 1.5).
The pelvic cavity is the space bounded by the bones of the pelvis. It is divided into the greater (false) and lesser (true) pelvises.
 
Lesser bony pelvis
The lesser pelvis, which contains the bladder and reproductive organs, is the part of the pelvic cavity between the pelvic inlet and the pelvic outlet (Figure 1.6).7
zoom view
Figure 1.5: (a and b) Bony pelvis. The lesser pelvis lies between the pelvic inlet and the pelvic outlet. The greater pelvis is above the pelvic inlet.
The pelvic inlet is the aperture bordered by the superior margin of pubic symphysis (anteriorly), the arcuate line of each ileum (laterally) and the sacral promontory (posteriorly).
The pelvic outlet is the aperture bordered by the inferior margin of pubic symphysis (anteriorly), the inferior rami of pubis and ischial tuberosities (anterolaterally), the sacrotuberous ligaments (posterolaterally) and the tip of the coccyx (posteriorly).8
zoom view
Figure 1.6: Contents of lesser pelvis. The internal genital organs lie within the pelvic inlet and outlet. The external genitalia lie below the outlet.
The lesser pelvis is lined laterally by fascia over the pelvic bones, levator muscles of the pelvic floor and the muscles of the pelvic floor (below). Due to upright positioning and the challenges of expanding to accommodate birth of a fetus, this is the largest potential hernial portal in the body and disorders are common.9
 
Greater bony pelvis
The bones of the greater pelvis, situated superior to the pelvic inlet, include the ilium and ala of sacrum. Mobile contents of the abdominal cavity including the small bowel and some large bowel sit within the greater pelvis. The greater pelvis is bounded by the abdominal wall anteriorly, the L5 or S1 vertebrae posteriorly and the iliac fossae posterolaterally.
 
Perineum and pelvic floor
The perineum lies inferior to the pelvis (and pelvic floor) and refers to the surface area of the body which sits on a bicycle seat. It is bounded by the symphysis pubis anteriorly; the inferior pubic rami, inferior ischial rami and sacrotuberous ligaments laterally; and the coccyx posteriorly. The anterior half contains the external genitalia and the posterior half contains the anus.
Separating the perineum and the pelvis is a muscular and ligamentous diaphragm known as the pelvic floor, which is traversed by the urethra, vagina and rectum (Figure 1.7). The principal muscle forming the pelvic floor is the levator ani. This thin, yet strong, muscle helps to support the pelvic viscera and is innervated by the pudendal nerve.
zoom view
Figure 1.7: Pelvic floor and perineal muscles.
10The perineum is divided by an imaginary line passing through the ischial tuberosities into a urogenital triangle anteriorly and an anal triangle posteriorly (Figure 1.8).
 
Pelvic muscles, nerves and vasculature
 
Muscles
The pelvic bones provide attachment for major muscle groups involved in movement of the lower limb (e.g. psoas, iliacus, rectus femoris, sartorius, adductors, gluteals, piriformis), spine and trunk (e.g. rectus abdominis, erector spinae, quadratus lumborum, external and internal oblique muscles) and pelvic floor (above).
The muscles of the pelvic floor are more relevant to gynaecology, as they are damaged in parturition and relevant in gynaecological repair.
 
Nerves
The nerves of the pelvis can be divided into somatic (under voluntary control) and autonomic (involuntary – sympathetic and parasympathetic function) as well as those which supply the organs and tissue of the pelvis and those that pass through to innervate the lower limb.
zoom view
Figure 1.8: Genital and anal triangles of the perineum.
11Somatic nerves include the pudendal nerve. Autonomic nerves carry sympathetic supply via the hypogastric and sacral nerves and parasympathetic supply via the pelvic nerve.
These nerves are important to gynaecologists, as they may be injured by gynaecologic procedures and parturition (childbirth).
Nerve injury This is graded by severity into neuropraxia, axonotmesis and neurotmesis, meaning compression with conduction disruption, division of the axons and division of the entire nerve in order of increasing severity. Neuropraxia recovers spontaneously with remyelination as does axonotmesis although this takes longer. Neurotmesis requires surgical repair to achieve any recovery of function and this is usually incomplete. Most gynaecologic injuries are neuropraxias and axonotmesis.
Nerve plexuses to lower limb Many major plexuses and lower limb peripheral nerves also pass to the lower limb via the pelvis. These include the lumbosacral plexus formed from the dorsal rami of nerve roots L1-S3 with a small contribution from T12 and its main branches, the sciatic nerve, femoral nerve and obturator nerve. This plexus lies within the psoas muscle and its branches arise from this muscle and arc through the pelvic sidewalls and out through sacral foramina and under the inguinal ligament into the anterior, medial and posterior lower limb (Figure 1.9).
Branches of the lumbosacral plexus with relevance of gynaecology and their significance are tabulated in Table 1.1.
Intrinsic pelvic somatic nerves The most important intrinsic nerve of the pelvis is the pudendal nerve. This arises from the sacral component of the lumbosacral plexus and has sensory supply of the external genitalia, clitoris, perineum, perianal skin and motor supply to the external urethral (voluntary) sphincter and external anal (voluntary) sphincter.
It is damaged in parturition and this damage can be permanent with stretch and ischaemic injury caused by prolonged compression by a fetal head in second stage leading to loss of perineal sensation, sexual sensation and urinary and faecal incontinence.12
zoom view
Figure 1.9: Limb nerve plexus traversing the pelvis.
Note:
Femoral nerve (L2-L4): Exists pelvis under inguinal ligament anteriorly. Innervates hip flexors and knee extensors
Obturator nerve (L2-L4): Exists pelvis through obturator foramen. Innervates muscles of medial thigh
Sciatic nerve (L4-S3): Exists pelvis through greater sciatic foramen posteriorly. Innervates posterior thigh and muscles of leg and foot
Autonomic pelvic nerves The autonomic nervous supply includes sympathetic and parasympathetic innervation.13
Table 1.1   Branches of the lumbosacral plexus relevant to gynaecology.
Nerve
Supply
Relevance
Lateral cutaneous nerve of thigh
Skin on lateral thigh
Can be compressed with blade of retractor during laparotomy
  • Iliohypogastric
  • Ilioinguinal
  • Supra-pubic skin sensation
  • Medial thigh and parts of external genitalia sensation
  • Both: Motor to lower transversus abdominis and internal oblique muscles
  • Can be injured during laparotomy by compression with retractor or cut with lateral extension of Pfannenstiel incision
  • Both nerves pass within external/internal oblique muscle and are vulnerable to stretch or transection when these muscles are stretched or cut for access
Genitofemoral
Upper medial thigh, labia majora and mons pubis sensation
Can be injured during groin node dissection
Femoral nerve
  • Motor to some hip flexors and medial rotators and knee extensors
  • Sensory to anteromedial thigh, medial foot and leg (via saphenous branch)
  • Injured by stretch with excessive hip extension/knee flexion during laparoscopy – weakness of hip flexion, knee extension and numbness in sensory distribution
  • Can also be compressed by deep retractor blade during hysterectomy
Obturator nerve
  • Motor to adductors of thigh
  • Sensory to medial thigh
  • Injured in pelvic lymph node dissection, if care is not taken to preserve the nerve, which runs through the middle of the lymph node complex
  • Also injured with transobturator tape procedures for urinary incontinence
14
zoom view
Figure 1.10: Autonomic pelvic nerves.Source: Gest TR. (2000). Learning Modules – Medical Gross Anatomy: Introduction to Autonomics. [online] Available from https://anatomy.elpaso.ttuhsc.edu/modules/intro_autonomics_2_module/autonomics_12.html. [Last accessed from August, 2021].
The sympathetic supply of the body is carried along the sides of the vertebral canal as a sympathetic plexus whereas the parasympathetic supply exits at two sites, cranially as the vagus nerve and sacrally as the pelvic nerve (called craniosacral outflow) (Figure 1.10).
Sympathetic innervation is responsible for inhibition of defecation and urination. Parasympathetic innervation is responsible for facilitation of these processes. Parasympathetic innervation controls genital arousal changes and orgasm.
The autonomic pelvic nerves include the hypogastric nerve, the sacral and the pelvic splanchnic nerves. They form the inferior hypogastric plexus deep to the peritoneum in the pre-sacral space and supply sympathetic and parasympathetic innervation to the distal rectum, bladder and genital organs, notably including the cervix, which feels visceral pain via fibres carried in the pelvic nerve.15
Sympathetic fibres are carried in the sacral splanchnic nerves from the sympathetic trunk and parasympathetic fibres arise from S2-S4 and are carried in the pelvic nerve.
 
Anterior abdominal wall anatomy
The anterior abdominal wall is composed of muscles, nerves, vessels and fascia. It is the site of common incisions for laparoscopy and open surgery, and connects to the pelvic bones. A knowledge of anatomy of the anterior abdominal wall is required to perform safe pelvic surgery.
 
Muscles
The major muscles forming the anterior abdominal wall are grouped into mid-line and lateral muscles.
Mid-line muscles These are the rectus abdominis and pyramidalis muscles. Together, they make up over half the anterior abdominal wall.
The rectus abdominis muscle extends from the lower costal cartilages superiorly to the pubic crest inferiorly. It is anchored transversely by attachment to the anterior layer of the rectus fascia at tendinous intersections. These fibrous bands give rise to the so-called ‘six-pack’ appearance of the tensed rectus abdominis. The rectus fascia ends at the anatomical landmark known as the arcuate line, where there is a change in arrangement of the layers forming the anterior abdominal wall; this means that incisions made for a caesarean section do not encounter the posterior rectus sheath because it does not exist below the umbilicus (Figure 1.11).
The pyramidalis muscle, which is absent in 20% of people, is anterior to the inferior part of the rectus abdominis and attaches to the anterior pubis. The pyramidalis muscle ends in and tenses the linea alba, the thick mid-line formed by fusion of the two bilateral aponeuroses of the abdominal muscles. The linea alba is wide superior to the umbilicus and then tapers inferior to it.
Lateral muscles These are the external oblique, internal oblique and transverse abdominis muscles.16
zoom view
Figure 1.11: Anterior abdominal wall.
Their fleshy bodies become aponeurotic, as they approach the lateral border of the rectus abdominis muscle. These muscles also contribute to the structure of the inguinal ligament.
 
Nerves
Innervation of the anterior abdominal wall derives from the T7 down to the L1 nerve roots. T7-L1 spinal nerves travel inferiorly and medially giving rise to lateral and anterior cutaneous nerves that traverse the fibres of the abdominal wall muscles to reach the skin.
 
Vessels
The anterior abdominal wall is supplied with blood from three sources:
  1. Inter-costal and sub-costal arteries (direct branches of the aorta)17
    zoom view
    Figure 1.12: Uterine anatomy.
  2. Superior epigastric arteries (terminal branches of the internal thoracic artery)
  3. Inferior epigastric arteries (terminal branches of the external iliac arteries)
 
Organs
The pelvis contains key organs in the genitourinary and gastrointestinal systems, as distal extensions for excretion as well as true intrinsic pelvic organs. The main organs of the pelvis are the uterus and fallopian tubes, ovaries and the bladder and rectum.
 
Uterus
Before pregnancy, the uterus measures 8 cm long. This increases to 38 cm by the time a normal pregnancy reaches term, at which stage the uterus lies just under the sternum. The uterus comprises a fundus, two lateral cornua, a body, an isthmus and a cervix (Figure 1.12).
Relations The relations of the uterus are:
  • Anteriorly: The uterovesical pouch, separating it from the bladder and loops of the small intestine
  • Posteriorly: The rectouterine pouch (of Douglas), separating it from the rectum
  • Laterally: The fallopian tubes, ovaries, blood vessels and nerves, all embedded in the broad ligament; the ureters pass lateral to the uterus and inferior to the uterine vessels18
zoom view
Figure 1.13: Common incisions.
The uterus receives blood predominantly from two large uterine arteries, which arise from the internal iliac arteries. The uterine arteries anastomose with terminal branches of the ovarian arteries (direct branches of the aorta).
 
Gynaecological surgical incisions
 
Pfannenstiel incision
This is a slightly curved horizontal incision made at the pubic hairline (Figure 1.13). A Joel–Cohen incision is slightly higher and horizontal. Both are frequently used. At the level of a routine Pfannenstiel incision, below the arcuate line of the rectus fascia, the following structures are encountered, from superficial to deep:
  • Skin
  • Superficial fatty (Camper's) fascia
  • Superficial membranous (Scarpa's) fascia
  • Rectus fascia (the rectus sheath) enclosing the rectus abdominis muscle
  • Pre-peritoneal fat and parietal peritoneum
  • The bladder (if it is not empty)
 
Mid-line Incision
This incision is made through the linea alba. It is a clean and rapid way to access the abdomen because of the absence of blood vessels and nerves in the linea alba.
Mid-line incisions are usually made below the umbilicus; however, when wide abdominal access is required, they are 19extended above the umbilicus. This is rare in benign gynaecology, but common in cancer surgery.
 
Laparoscopy incision
This is a keyhole incision made to insert a camera or laparoscopic surgical tool into the abdomen, particularly for gynaecological operations. Common laparoscopic incision sites are umbilical, supra-pubic and lateral abdominal.
Care is needed to avoid damaging peripheral nerves and vessels that cross the area of incision or insertion. In particular, this applies to the inferior epigastric vessels with lateral port sites – these should be visualised using the primary entry laparoscope and the planned lateral port entries made away from their path on the internal surface of the anterior abdominal wall. They are visible as pulsatile structures through the parietal peritoneum.
The urinary bladder is also emptied to avoid injury with supra-pubic port insertion.
 
1.4 Normal menstrual cycle
 
Hypothalamic-pituitary-ovarian axis
The hypothalamic-pituitary-ovarian (HPO) axis involves each of these organs, which act together to produce reproductive hormones, initiate puberty and regulate the menstrual cycle.
The arcuate nucleus of the hypothalamus secretes pulsatile gonadotropin-releasing hormone (GnRH), which travels in the portal circulation to the anterior pituitary gland. Here, it stimulates the release of follicle-stimulating hormone (FSH) and luteinising hormone (LH). These then act directly on the ovary to produce oestrogen and progesterone (Figure 1.14).
Throughout most of the menstrual cycle, oestrogen and progesterone provide negative feedback on the pituitary gland and hypothalamus, reducing GnRH secretion and reducing the release of FSH and LH. At low levels of oestrogen, LH secretion from the pituitary gland is suppressed but at higher concentrations of oestrogen, LH secretion is stimulated.20
zoom view
Figure 1.14: The HPO axis.
(FSH, follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; HPO, hypothalamic-pituitary-ovarian; LH, luteinising hormone)
Therefore, once a dominant follicle develops and starts to produce more oestrogen (see ovulatory cycle below), an LH ‘surge’ is triggered, which ultimately results in ovulation.
 
Ovarian cycle
The number of oocytes that a female possesses rapidly declines throughout development. At 20 weeks of gestation, a female human fetus contains 6–7 million oocytes. At birth, she has 1–2 million oocytes and by puberty, 300,000 oocytes. Of these, only 400–500 oocytes will actually reach the stage of ovulation. Menopause occurs when the effective ovarian oocyte supply is depleted, with menopausal ovaries containing mostly dense stroma with interspersed rare oocytes. Unlike sperm, new oocytes cannot be created.21
zoom view
Figure 1.15: Ovarian and endometrial cycles.
The ovarian cycle is divided into two phases (Figure 1.15). The follicular phase (from menstruation to ovulation), which lasts for 10–14 days and the luteal phase (from ovulation to menses), which lasts for 14 days.
 
Follicular phase
At the beginning of the menstrual cycle, ovarian hormones (oestrogen and progesterone) are low. Following the demise of the corpus luteum, the withdrawal of progesterone negative feedback results in an increase in FSH. This results in the recruitment of ovarian follicles, with each follicle 22producing some oestrogen, which in turn causes endometrial proliferation.
As the growing follicles produce inhibin B and more oestrogen negative feedback is exerted on the pituitary gland. This causes a reduction in FSH by the mid-point of the follicular phase. One follicle becomes dominant and grows further, smaller follicles are not able to survive low FSH and stop growing. As the oestrogen concentration progressively increases towards the end of the follicular phase, positive feedback starts and an LH ‘surge’ occurs, triggering ovulation 24–36 hours later.
 
Luteal phase
At ovulation, oestrogen decreases. The remaining cells from the ruptured follicle form the corpus luteum, which secretes oestrogen, inhibin A and mostly progesterone. Progesterone increases significantly after ovulation. The increase in progesterone, oestrogen and inhibin A result in a decline in FSH and LH (negative feedback). In the absence of fertilisation, the corpus luteum demises after 14 days, causing a decline in progesterone and oestrogen. This removes the negative feedback on the hypothalamus and pituitary gland, resulting in an increase in FSH and re-commencement of the cycle.
zoom view
Figure 1.16: Endometrium layers.
23
 
Endometrial cycle
Occurring concurrently with the ovarian cycle, the endometrium is prepared to receive a fertilised oocyte (zygote). In the absence of implantation, menstruation occurs. This is the endometrial cycle.
The endometrium is composed of layers (Figure 1.16). The most superficial layer is the decidua functionalis, which comprises the most superficial two-thirds of the endometrium. This layer is very responsive to reproductive hormones and is the part of the endometrium that sheds with menses. It is comprised of the stratum spongiosum (deep layer) and the stratum compactum (superficial layer).
Deep to the decidua functionalis is the decidua basalis. This is the source of endometrial regeneration after menses. This layer has no significant monthly proliferation and is relatively unresponsive to hormones.
The endometrial cycle is divided into two phases that coincide with the phases of the ovarian cycle (Figure 1.15).
The proliferative phase begins after the onset of menses on day 1 of the cycle. Following this, the endometrium is approximately 1–2 mm thick. The increasing oestrogen released by the developing follicles results in mitotic proliferation of the decidua functionalis. The endometrial glands change from being straight, narrow and short into being long and tortuous glands preparing it for implantation. The cell type changes from low columnar into pseudo-stratified, with dense stroma containing minimal vascular structures. It is now ready for the secretory phase.
The secretory phase begins 48–72 hours following ovulation. The increased progesterone from the corpus luteum results in the secretion of protein-rich eosinophilic products from endometrial glands. There is a progressive decline in endometrial oestrogen receptor number, resulting in less proliferation. There is a shift to secretion from glycogen-containing glands on days 19–20 with maximal secretion occurring 6–7 days after ovulation. The endometrium is now ready for the blastocyst.24
In the absence of implantation, the endometrial stroma remains unchanged until post-ovulatory day 7. At this point, endometrial spiral arteries lengthen and coil. At day 24, eosinophilia is visible in the peri-vascular stroma. Two days before menses, there is infiltration with polymorphs, which signals the onset of menses.
The demise of the corpus luteum results in a fall in oestrogen and progesterone as mentioned earlier. This causes spiral artery spasm and ischaemia of the endometrium. There is secretion of proteolytic enzymes, which further destroys the decidua functionalis. Secretion of prostaglandin F2α (PGF2α) results in vasoconstriction with further artery spasm and ischaemia as well as uterine contractions (cramps). Menstruation ensues.