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Essentials of Gynecology
Sabaratnam Arulkumaran, V Sivanesaratnam, Alokendu Chatterjee, Pratap Kumar
PART ONE: GENERAL GYNECOLOGY
1:
Embryology and Developmentof the Female Genital Tract
INDIFFERENT EMBRYO
Indifferent Gonad
Mesonephric (Wolffian) Ducts
Paramesonephric (Müllerian) Ducts
Urogenital Sinus
FEMALE GONADAL DIFFERENTIATION
Development of the Ovary
FEMALE GENITAL DUCT DIFFERENTIATION
Development of the Uterus
Development of the Fallopian Tubes
Development of the Vagina
Development of the External Genitalia
2:
Disorders of the Development of Müllerian System
ANOMALIES OF THE FEMALE REPRODUCTIVE TRACT
Clinical Problems
Diagnosis in Infancy or Childhood
Hymenal Obstruction
Surgical Procedure for Imperforate Hymen
Surgical Management of Vaginal Agenesis
Preoperative Evaluation
Surgical Techniques for Vaginal Agenesis
Uterus Didelphys, Non-obstructed (Fig. 2.5)
Bicornuate Uterus
Surgical Techniques for Bicornuate Uterus
Septate Uterus (Fig. 2.3)
Surgical Management of Septate Uterus
Postoperative Management
CONCLUSION
3:
Ovulation and Menstruation
INTRODUCTION
OVULATION AND MENSTRUATION
Ovarian Cycle
Follicular Phase
Luteal Phase
Endometrial Cycle
Menstrual Phase
Proliferative Phase
Secretory Phase
FEEDBACK OSCILLATION OF THE HYPOTHALAMO-PITUITARY OVARIAN SYSTEM
Follicular Growth Phase
Preovulatory Surge of LH and FSH Causes Ovulation
Postovulatory Secretions of Ovarian Hormones and Depression of Pituitary Gonadotropins
PRACTICE POINTS
Clinical Features of Normal Menstruation
Clinical Correlation for Ovulation Induction
Physiologic Basis for Use of Combined Oral Contraceptive Pills
4:
Gynecological History and Examination
INTRODUCTION
HISTORY TAKING
Name, Age, Parity and the Place of Residence
Presenting Symptom
History of Presenting Complaint
Abnormal Menstrual Bleeding
Abdomino-pelvic Mass
Pelvic Pain
Lump at the Vulva
Vaginal Discharge
Menstrual History
Contraceptive History
Past Obstetric History
Past Gynecological History
Past Medical/Surgical History
Drug History/Allergies
Social History
Sexual History
GENERAL EXAMINATION
Abdominal Examination
Bimanual Examination
Position
Technique of Bimanual Examination
Rectal Examination
Rectovaginal Examination
CONCLUSION
5:
Pediatric Gynecology
INTRODUCTION
NORMAL ANATOMY AND PHYSIOLOGY
Anatomical Findings in the Newborn
Examination of the Prepubertal and the Newborn
The Premenarchal Girls
Collection of Specimens
AMBIGUOUS GENITALIA16
Diagnosis
Etiology of Ambiguous Genitalia
The XX Newborn
XY Newborn
46 XY/XO Newborn
Sex Assignment for Rearing
GONADAL DYSGENESIS
VULVOVAGINAL DISORDERS
Labial Adhesions
Treatment
Vulvitis
Conditions that Cause Vulvitis
PHYSIOLOGIC DISCHARGE
Premenarchal Vaginal Discharge
Common Sources for Vaginal Irritation or Discharge
Sexual Abuse as a Cause for Vaginal Discharge 3
VIRAL INFECTIONS
URETHRAL PROLAPSE
FOREIGN BODIES
Methods to Rule out a Foreign Body
IMPERFORATE HYMEN
PRECOCIOUS PUBERTY
Classification29,30
Other Disorders of Premature Sexual Maturation (Gn-independent)
GnRH-Dependent Precocious Puberty
GnRH Independent Precocious Puberty
Diagnosis of Precocious Puberty
Aims of Diagnosis
Differential Diagnostic Steps
Physical Diagnosis
Laboratory Diagnosis:
Treatment of Precocious Development
Forms of Precocious Puberty
OVARIAN CYSTS
Types
Clinical Presentation
Diagnosis
Other Condition Associated with Cysts
Management
SUMMARY
6:
Adolescent Gynecology
INTRODUCTION
PHYSIOLOGY OF PUBERTY
EXAMINATION OF THE ADOLESCENT GIRL
Preparation for Examination
Breast Examination
DELAYED PUBERTY
ABSENT OR PARTIAL VAGINA
SECONDARY AMENORRHEA/OLIGOMENORRHEA
ABNORMAL UTERINE BLEEDING
Menstruation
Premenstrual Syndrome
Various Drugs Used in Management
PELVIC PAIN AND RECURRENT ABDOMINAL PAIN
Acute Pain
Chronic Pelvic Pain
Cyclic Pain
Dysmenorrhea
PELVIC INFLAMMATORY DISEASE
Vulvovaginal Complaints
Pruritis Vlvae
Causes not Associated with Vaginal Discharge
Vaginal Discharge
Physiological Discharge
Pathological Discharge
OVARIAN ENLARGEMENTS IN ADOLESCENT GIRL
Non-neoplastic Enlargements of the Ovary
Follicular Cyst
Neoplastic Enlargement of Ovary
Dysgerminoma
Endodermal Sinus (yolk sac) Tumor
Choriocarcinoma
Embryonal Cell Carcinoma
Granulosa Cell Tumor
POLYCYSTIC OVARIAN SYNDROME (PCOS)
Menstruation
Pregnancy
Treatment
EATING DISORDERS
ATHLETIC ADOLESCENTS
TURNER'S SYNDROME
CONGENITAL ADRENAL HYPERPLASIA (CAH)
Puberty and Menstruation
Sexuality
CYSTIC FIBROSIS
EPILEPSY
Menstruation
CHILDHOOD CANCER SURVIVORS
Radiation
Chemotherapy
ADOLESCENT PREGNANCY
TERMINATION OF PREGNANCY
SEXUALLY TRANSMITTED DISEASE (STD)
SEXUAL ABUSE
SUMMARY
7:
Dysmenorrhea
INTRODUCTION
DEFINITION
INCIDENCE
RISK FACTORS FOR DYSMENORRHEA
Menstrual Factors7
Parity
Diet
Exercise
Cigarette Smoking
Psychological
CLASSIFICATION OR TYPES
Primary Dysmenorrhea
Pathogenesis
Clinical Features3
General Measures
Specific Measures
Membranous Dysmenorrhea
Secondary Dysmenorrhea
Etiology
Clinical Features
On Examination
Management
Differential Diagnosis
Recent Advances in Management
CONCLUSION
8:
Abnormal Uterine Bleeding
INTRODUCTION
DEFINITION OF DUB
PATHOPHYSIOLOGY
Normal Menstruation
Abnormalities in Menstrual Cycle
Pathogenesis of Dysfunctional Uterine Bleeding
CLINICAL PRESENTATIONS OF ABNORMAL UTERINE BLEEDING
Vaginal Bleeding in Prepubertal Girls
Points in Diagnosis
Abnormal Uterine Bleeding in Adolescent Girls
Points in Diagnosis
Abnormal Uterine Bleeding in the Reproductive Age Group
Points in Diagnosis
Abnormal Bleeding in Perimenopausal Women
Post-menopausal Bleeding
Points in Diagnosis
TREATMENT MODALITIES IN DUB
Non-steroidal Anti-inflammatory Drugs for Heavy Menstrual Bleeding
Dosage
Antifibrinolytic Agents
Dosage
Cyclical Progestogens for Heavy Menstrual Bleeding
Dosage
In Ovulatory Cycles
Combined Oral Contraceptive Pills for Heavy Menstrual Bleeding
Dosage
Progesterone/Progestogen Releasing Intrauterine Devices for Heavy Menstrual Bleeding
Agents Used
Estrogen for the Control of Acute Heavy Bleeding
Dosage
Danazol
GnRH Analogues
Desmopressin
Endometrial Resection and Ablation for Heavy Menstrual Bleeding
Dilatation and Curettage
Hysterectomy
Principles
Endometrial Hyperplasia
CONCLUSION
9:
Amenorrhea and Oligomenorrhea
INTRODUCTION
PHYSIOLOGY OF MENSTRUATION
Endocrine Causes of Menstrual Abnormalities
Endometrial Pathology Causing Menstrual Abnormalities
Systemic Diseases
AMENORRHEA
Physiology of Menarche
Primary Amenorrhea
Causes
Clinical Approach to Primary Amenorrhea (Figure 9.1)
Clinical Features of Some Common Conditions Associated with Primary Amenorrhea
Management of Primary Amenorrhea
Secondary Amenorrhea
Causes
10:
Reproductive Health
ADOLESCENT HEALTH
Sexuality and Fertility
Uncontrolled Fertility
Unsafe Abortion
Pelvic Inflammatory Disease (PID)/ Sexually Transmitted Disease (STD)
Childbirth and Maternal Mortality
CONCLUSION
11:
Endometriosis and Adenomyosis
INTRODUCTION
ENDOMETRIOSIS
Definition
Sites
Incidence
Prevalence
Etiology
Metastatic Theories
Metaplasia Theories
Pathophysiology
Symptoms
Signs
Diagnosis
Staging
Management and Prognosis
Is the Patient Infertile?
Is the Patient Symptomatic and How Old is the Patient?
Surgical Treatments
Medical Treatments
ADENOMYOSIS
PRACTICE POINTS
Endometriosis
Adenomyosis
12:
Pelvic Inflammatory Disease (PID)
INTRODUCTION
NATURAL BARRIERS TO PID
Vulnerability to PID
PATHOLOGY (Figure 2.1)
Acute PID
Chronic PID (Tubo-ovarian Mass)
CLINICAL FEATURES OF PID
Acute PID
Symptoms
Signs
Laboratory Investigations
Chronic PID
Symptoms
Signs
Differential Diagnosis
TREATMENT
Acute PID
Indications for the Hospitalization in PID
Indications for Discharge from the Hospital in those with PID6
Treatment Plans for Hospitalized Women
Medical Management
Treatment of PID
Surgical Treatment
Treatment of Chronic Pelvic Inflammatory Disease
Uncommon Complications of Chlamydia and Gonorrhea
13:
Sexually Transmitted Diseases
INTRODUCTION
DEFENSE MECHANISM OF FEMALE GENITAL TRACT (Table 13.1)
Variations in the Efficiency of Defense Mechanisms
With Age
With Menstruation
During Puerperium
SEXUALLY TRANSMITTED DISEASES (STDs)
Chlamydial Infection
Organism
Pathology
Clinical Features
Investigations
Treatment
Gonorrhea
Organism
Pathology
Incubation Period
Clinical Features
Acute Gonorrhea
Lower Genital Tract
Upper Genital Tract Infection (Pelvic inflammation)
Chronic Gonorrhea
Investigations
Treatment
Trichomonas vaginalis Vaginitis
Organism
Clinical Features
Investigations
Treatment
Vulvovaginal Candidiasis (Moniliasis)
Organism
Predisposing Factors
Clinical Features
Investigations
Treatment
Chronic Vulvovaginal Candidiasis
Treatment
Genital Ulcerative Diseases
Herpes Genitalis
Organism
Clinical Features
Recurrent Herpes
Pregnancy with Herpes
Investigations
Treatment
Follow-up
Syphilis
Organism
Clinical Presentation
Syphilis in Pregnancy
Investigations
Treatment of Syphilis
Chancroid
Organism
Clinical Features
Investigations
Treatment
Lymphogranuloma Venereum (LGV)
Clinical Features
Investigations
Treatment
Granuloma Inguinale
Organism
Clinical Features
Investigations
Treatment
Genital Warts (Condyloma Acuminata)
Organism
Clinical Features
Treatment
14:
HIV in Obstetrics and Gynecology
INTRODUCTION
PATHOPHYSIOLOGY
HIV IN GYNECOLOGY
Sexually Transmitted Diseases
Candidiasis
Pelvic Inflammatory Disease (PID)
Herpes Simplex Virus (HSV)
Human Papilloma Virus (HPV)
Invasive Cervical Cancer
Contraception
HIV AND PREGNANCY
Interventions to Reduce MCT of HIV
HIV TESTING AND COUNSELING
15:
Benign Lesions of the Genital Tract
INTRODUCTION
CLASSIFICATION
Benign Lesions of the Vulva
Lichen Sclerosus
Squamous Cell Hyperplasia
Other Dermatoses
Vulval Ulcers
Benign Tumors of the Vulva
Cystic Lesions
Bartholin's Cyst
Nonepithelial Tumors
Benign Lesions of the Vagina
Gartner's Cyst
Inclusion Cysts
Benign Lesions of the Cervix
Cervical (Erosion)
Cervical Ectropion
Congenital
Acquired
Cervical Cyst
Endometriotic cysts
Benign Lesions of the Uterus: Fibroids (Myomas)
Classification and Pathophysiology
Intramural, Subserosal, Submucosal and Cervical
Microscopic Appearance
Expectant Management
Medical Management
Benign Tumors of Ovary
Physiological Cysts
Pathological Cysts or Benign Ovarian Neoplasms
Clinical Features
Differential Diagnosis
Investigations
Management
Surgery
16:
Contraception and Sterilization
INTRODUCTION
METHODS AVAILABLE
Abstinence
Rhythm or Calendar Method, Basal Body Temperature Method, Ovulation (Billing's) Method, Symptothermal Method or Ovulation Predictor Test
Coitus Interruptus or Withdrawal Method
Barrier Method
Lactational Amenorrhea Method
Hormonal or Steroidal Contraceptives
Combined Oral Contraceptives Pill (COCP)
Progestogen-only Pill
Depo or Injectable Progestogens
Implant
Intrauterine Contraceptive Device (IUCD)
Sterilization
Male Sterilization
NONCONTRACEPTIVE BENEFIT OF COMBINED ORAL CONTRACEPTIVES
PRACTICAL CONSIDERATION IN PRESCRIBING CONTRACEPTION
Contraception for the Elderly
Contraception for the Teenagers
Postcoital/Emergency Contraception
TERMINATION OF PREGNANCY
17:
Psychosexual Problems and Sexual Dysfunction
INTRODUCTION
PHYSIOLOGY OF HUMAN SEXUAL FUNCTION
ASSESSMENT OF THE PATIENT
Obtaining a Sexual Problem History
Clinical Examination
SEXUAL DYSFUNCTION IN THE FEMALE
Inhibited Sexual Desire
Failure to Achieve Orgasm
Dyspareunia
VAGINISMUS/APAREUNIA
SPECIAL CIRCUMSTANCES
Sexual Assault
Pregnancy
Menopause
CONCLUSION
18:
Pelvic Organ Prolapse
DEFINITION AND INCIDENCE
CLASSIFICATION
ETIOLOGY
ANATOMY OF THE PELVIC FLOOR
Viscero-fascial Layer
Levator Ani Muscles
SECONDARY ANATOMICAL CHANGES
SYMPTOMS
CLINICAL EVALUATION13
Urethra
Bladder
Cervix/vaginal Cuff
Cul-de-sac
Rectum
Perineum
DIFFERENTIAL DIAGNOSIS
TREATMENT OF PELVIC ORGAN PROLAPSE
Expectant Management
Surgical Management
Repair of Anterior Vaginal Wall Defects
Operations for Uterovaginal Prolapse
Operations for Vault Prolapse
Repair of Posterior Vaginal Wall Defect
Conservative Management
SUMMARY
19:
Urinary and Fecal Incontinence (Including Fistulae)
INTRODUCTION
URINARY INCONTINENCE
Genuine Stress Incontinence (GSI)
Definition
Clinical Features
Incidence
Pathogenesis
Diagnosis
Treatment
Detrusor Instability
Definition
Incidence
Etiology
Symptomatology
Diagnosis
Treatment
Other Causes of Incontinence
Retention with Overflow
Epispadias
Miscellaneous Causes
Urinary Fistulae
Introduction
Definition
Etiology
Diagnosis
Management
FECAL INCONTINENCE
Fecal Fistulae
CONCLUSION
20:
Breast and the Gynecologist
INTRODUCTION
MASTALGIA
Causes
Treatment
Drug Therapy
NIPPLE DISCHARGE
BREAST LUMPS
Macrocysts
Galactocele
Fibroadenoma
BREAST CANCER
Risk Factors (Table 20.4)
Pregnancy and Breast Lumps
American Cancer Society Guidelines for Preventive Breast Care
Role of Obstetrician and Gynecologist
Hormone Replacement Therapy and the Breast
Tissue Specific HRT Agents
Benefits of lactation
Enhancement/Suppression of Lactation
Suppression of Lactation
Breast Problems during Lactation
Breast Engorgement
Mastitis
Abscess
Galactocele
Nipple Abnormalities
SUMMARY
21:
Gynecological Operations
ABDOMINAL HYSTERECTOMY
Types of Abdominal Hysterectomy
Subtotal Hysterectomy
Total Abdominal Hysterectomy
Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy
Radical Hysterectomy (Wertheim's Hysterectomy)
Indications for Abdominal Hysterectomy
Preoperative Preparations for Hysterectomy
Choice of Incision
Prophylactic-oophorectomy at the Time of Hysterectomy
Steps of Abdominal Hysterectomy
Postoperative Care after Hysterectomy
Postoperative Complications
Hemorrhage
Postoperative Fever
Urinary Tract Injuries
Wound Dehiscence and Infection
Bowel Injuries
Deep Venous Thrombosis
Remote Complications
Vaginal Operations
Principles
Surgical Technique
Vaginal Hysterectomy
Anterior Repair/Anterior Colporrhaphy
Posterior Repair/Posterior Colpoperineorrhaphy
Postoperative Care
Complications
LAPAROSCOPY
Definition
General Guidelines
Indications for Laparoscopy
Diagnostic Laparoscopy
Operative Laparoscopy
Contraindications
Techniques of Laparoscopy
HYSTEROSCOPY
Procedure for Hysteroscopy
Indications for Hysteroscopy
Complications of Hysteroscopy
22:
General Surgical Problems in Gynecology
INTRODUCTION
CATEGORIES OF GENERAL SURGICAL PROBLEMS IN GYNECOLOGY
Diagnostic Considerations in Lower Abdominal Pain
Extra-abdominal General Surgical Problems in Pregnancy
Anorectal Diseases
Acute Perianal Pain
Venous Disorders
Operative Surgical Considerations
Ureteric Injuries
Bowel Injuries
Key Points
Vascular Injuries
CONCLUSION
PART TWO: REPRODUCTIVE ENDOCRINOLOGY AND ASSISTED CONCEPTION
23:
Puberty
INTRODUCTION
ENDOCRINE CHANGES OF PUBERTY
PHYSICAL CHANGES OF PUBERTY
Timing and Sequence of Pubertal Phenotypic Changes
Clitoris
Factors Affecting Menarche
PSYCHOLOGIC CHANGES OF PUBERTY
Common Problems Associated with Adolescence
SUMMARY OF PUBERTAL EVENTS
24:
Disorders of Ovulation
INTRODUCTION
DISORDERS OF OVARIES
Polycystic Ovarian Syndrome (PCOS)
Incidence
Definition
Mechanism
Clinical Signs and Symptoms
Investigations
Management
Laparoscopic ovarian drilling
Primary Failures
Premature Ovarian Failure
Resistance Ovarian Failure
Gonadal Agenesis
Disorder of Anterior Pituitary
Hyperprolactinemia
Disorder of Hypothalamus
Hypogonadotrophic Hypogonadism
Obesity
Hormonal Test
25:
Polycystic Ovarian Disease
INTRODUCTION
PATHOPHYSIOLOGY
PUBERTY AND PCOS
Mechanism of Onset of PCOS during Puberty (Fig. 25.1)
Insulin and the Mechanism of Anovulation in Polycystic Ovarian Syndrome
Role of Hyperinsulinemia in the Pathogenesis of PCOS (Fig. 25.2)
DIAGNOSIS
Important Clinical Features
APPROACH TO INFERTILITY IN A PATIENT WITH PCOS
Weight Loss
Insulin Sensitizing Agents
Metformin12
Mechanism of Action of Metformin
Ovulation Induction Methods
Clomiphene Citrate13
Human Menopausal Gonadotrophin14
GnRH Therapy
Surgical Induction of Ovulation
SUMMARY
26:
Hirsutism
DEFINITION
HYPERTRICHOSIS
PATHOPHYSIOLOGY
ETIOLOGY
Endocrine Causes
Non-endocrine Causes:
DIAGNOSIS
TREATMENT
27:
Intersex
INTRODUCTION
SEXUAL DIFFERENTIATION OF THE FETUS
DEFINITION OF INTERSEX
Genetic Sex Disturbances
Turner's Syndrome
Klinefelter Syndrome
Hermaphrodites
Testicular Feminization Syndrome
Other Intersex Syndromes
Hormonal Differentiation Disturbances
Androgen Insensitivity
Kallman's Syndrome
Congenital Adrenal Hyperplasia
Variant of CAH
Psychosocial Sex-deviations
Cryptorchidism
V. Castration
DIAGNOSIS OF INTERSEX
MANAGEMENT OF INTERSEX
Gonadal Dysgenesis
Testicular Feminization
Hermaphrodite
Congenital Adrenal Hyperplasia
Cryptorchidism
28:
Infertility
INTRODUCTION
CAUSES OF INFERTILITY
Male Factor Infertility
Tubal Factor
Ovulatory Dysfunction
Unexplained Infertility
Other Causes
ASSESSMENT OF THE INFERTILE COUPLE
INVESTIGATION OF THE INFERTILE COUPLE
Investigation of the Sperm Factor
Investigation of the Egg Factor (ovulation)
Investigation of the Uterus and Fallopian Tubes
TREATMENT OPTIONS
Induction of Ovulation
Intrauterine Insemination
In Vitro Fertilization (IVF, “test tube treatment”)
Intracytoplasmic Sperm Injection (ICSI)
CONCLUSION
29:
Menopause and Hormone Replacement Therapy
INTRODUCTION
DEFINITIONS
ENDOCRINOLOGY OF MENOPAUSE
SIGNS AND SYMPTOMS OF MENOPAUSE
Short-term Problems
Medium-term Problems
Long-term Problems
Other Effects of Estrogen Deprivation
MANAGEMENT OF A POSTMENOPAUSAL WOMAN
Hormone Replacement Therapy
Treatment Modalities
Delivery Systems
Action of Estrogen
Benefits of HRT
Newer Benefits of HRT
Side Effects of HRT
HRT and Bleeding
HRT and the Vascular System
HRT and the Breast
Estrogen and Bone
Estrogen and Brain
Contraindications to HRT Use
Tibolone
Role of Calcium
Non-HRT Treatment for Menopausal Symptoms
Present Recommendations for HRT
PART THREE: GYNECOLOGIC ONCOLOGY
30:
Gynecological Cancer Screening
INTRODUCTION
CERVICAL CANCER
Papanicolao Smear
Taking a Cervical Smear
Significance of Endocervical Cells in Smear
False Negative Smears
Liquid-based Cytology
Automated Cytological Screening
The Bethesda System (TBS)
ADENOCARCINOMA
Who are the Women “at risk”?
What should the Pap Smear Screening Interval be?
When should Screening Stop?
The Abnormal Smear—What is the Next Step?
Other Methods of Screening for Cervical Cancer
OVARIAN CANCER
Serum Tumor Markers
Ultrasound
Pelvic Examination
Multi-modal Strategy
What then is the Current Status of Ovarian Cancer Screening?
ENDOMETRIAL CANCER
Cytology
Endometrial Biopsy
Ultrasonography (TVS)
CONCLUSION
31:
Preinvasive and Invasive Cancer of the Cervix
INTRODUCTION
Preinvasive Lesions of the Cervix
The Concept of Cervical Intraepithelial Neoplasia
Pathology
Etiology of Cervical Cancer
Natural History of Cervical Carcinoma
Management of CIN
Radical Electrocoagulation Diathermy
Cryosurgery
CO2 Laser Ablation
Large Loop Excision of the Transformation Zone (LLETZ)
Excisional Conisation
Cold-knife Conisation
Laser Excisional Conisation
Hysterectomy
Adenocarcinoma in situ (AIS)
Invasive Carcinoma of the Cervix
Clinical Staging
Pathology
Management
Stage 1A (Microinvasive Carcinoma)
Stage 1B and Early 2A
Adjuvant Treatment
Stage IIa
Stage IIb
Stage IIIa and IIIb
Stage IVa
Stage IVb
Special Situations
Cervical Stump Carcinoma
Bulky Stage 1B2 and Stage 2A Carcinoma of the Cervix
Fertility Sparing Surgery
Cervical Cancer in Pregnancy
Follow-up
32:
Ovarian Cancer
INTRODUCTION
EPIDEMIOLOGY
ANATOMY
MODE OF SPREAD
ETIOLOGICAL FACTORS
SCREENING FOR OVARIAN CANCER
PREVENTION OF OVARIAN CANCER
CLASSIFICATION OF OVARIAN NEOPLASMS
DIAGNOSIS
Symptoms and Signs
Examination
Preoperative Evaluation
Biochemical
Imaging
Endoscopy
Breast Examination
STAGES OF OVARIAN CANCER
TREATMENT OF OVARIAN CARCINOMA
Staging Laparotomy
Surgery for Early Well-encapsulated Epithelial Ovarian Carcinoma
Surgery for Ovarian Carcinoma with Local Extension (Figs 32.1 and 32.2)
Surgery for Ovarian Carcinoma with Disseminated Intraperitoneal Disease
Place of Chemotherapy
Massive Ovarian Cyst
“Second Look” Surgery
Secondary Salvage Surgery
CONCLUSION
33:
Uterine Malignancy
INTRODUCTION
EPIDEMIOLOGY AND RISK FACTORS
PATHOLOGY
Endometrial Hyperplasia
HISTOLOGY
SPREAD OF THE DISEASE
PROGNOSTIC FACTORS
CLINICAL FEATURES
DIAGNOSIS
STAGING
Screening
MANAGEMENT
Surgery
Radiotherapy
Cytotoxic Therapy
Hormonal Therapy
Hormone Replacement Therapy (HRT)
Recurrent Disease
Conclusion
Uterine Sarcomas
Leiomyosarcomas
Endometrial Stromal Tumors
Malignant Mixed Müllerian Tumor
CONCLUSION
34:
Vulvar Cancer
INTRODUCTION
Etiology
Squamous Cell Carcinoma
Clinical Presentation
Diagnosis
Pattern of Spread
Lymph Node Metastases
Staging
Management
Management of Early Vulvar Cancer
Incision
Modified Twombley-Ulfelder Technique
Special Situations
Lymphatic Mapping
Other Vulvar Malignancies
Malignant Melanoma of Vulva
Verrucous Carcinoma
Basal Cell Carcinoma
Bartholin's Gland Carcinoma
Vulvar Sarcomas
Transitional Cell Carcinoma
Summary
35:
Gestational Trophoblastic Neoplasia
INTRODUCTION
HYDATIDIFORM MOLE
Clinical Features
Diagnosis of Molar Pregnancy
Management of Molar Pregnancy
Follow-up
Contraception after Molar Pregnancy
Partial Hydatidiform Mole (phm) (Fig. 35.3)
Invasive Mole
PROPHYLAXIS AGAINST CHORIOCARCINOMA
Selective Preventive Chemotherapy
Role of Prophylactic Hysterectomy
PLACENTAL SITE TUMOR (PST)
CHORIOCARCINOMA
Genital Tract Manifestations
Amenorrhea
Vaginal Bleeding
Intraperitoneal Hemorrhage
Vaginal Metastasis
Extragenital Manifestations
Management of Choriocarcinoma
Chemotherapy
Side Effects of Chemotherapy
Cerebral Metastases
Role of Surgery
Future Pregnancies
CONCLUSION
36:
Radiotherapy and Chemotherapy in Gynecological Malignancies
RADIOTHERAPY
Radiation Physics
The Gray
Radiobiology
Radiotherapy Techniques
Radiation Damage
Early Reactions
Late Complications
Safety Precautions
Radiotherapy in Gynecological Malignancies
Cervical Cancer
Endometrial Cancer
Ovarian Cancer
Cancer of the Vulva
Cancer of the Vagina
Trophoblastic Tumors
CHEMOTHERAPY
Cellular Biology
Basic Principles of Chemotherapy
Classification
Single Agent vs Combination Chemotherapy
Sequential Therapy
Duration of Chemotherapy
Chemotherapy in Gynecological Malignancies
Cervical Cancer
Endometrial Cancer
Ovarian Cancer
Cancer of the Vulva and Vagina
Trophoblastic Disease
CONCLUSIONS
37:
Palliative Care
INTRODUCTION
SYMPTOM MANAGEMENT
Pain Control
Opioid Analgesia
Neuropathic Pain
Invasive Techniques for Pain Control
Alternative Therapies
Nausea and Vomiting
Dry Mouth/Oropharynx
Constipation
Diarrhea
Intestinal Obstruction
Ascites
Fistulae
Obstructive Uropathy
Hypercalcemia
Lymphedema
Terminal Care
CONCLUSION
INDEX
TOC
Index
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