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Essentials of Gynecology
Sabaratnam Arulkumaran, V Sivanesaratnam, Alokendu Chatterjee, Pratap Kumar
SECTION 1: GENERAL GYNECOLOGY
1:
Embryology and Development of 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, Nonobstructed (Fig. 2.5)
Bicornuate Uterus
Surgical Techniques for Bicornuate Uterus
Septate Uterus (see 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
Demographic Details
PRESENTING COMPLAINT
HISTORY OF PRESENTING COMPLAINT
MENSTRUAL HISTORY
CONTRACEPTIVE HISTORY
PAST OBSTETRIC HISTORY
PAST GYNECOLOGICAL HISTORY
PAST MEDICAL/SURGICAL HISTORY
DRUG HISTORY/ALLERGIES
SOCIAL HISTORY
SEXUAL HISTORY
SUMMARY
GENERAL EXAMINATION
ABDOMINAL EXAMINATION
GYNECOLOGICAL EXAMINATION
POSITION
TECHNIQUE OF BIMANUAL EXAMINATION
Inspection of the External Genitalia
Visualization of the Vagina and Cervix Using a Speculum
BIMANUAL EXAMINATION OF THE UTERUS AND THE ADNEXAE
RECTAL EXAMINATION
RECTOVAGINAL EXAMINATION
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 Discharge3
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
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 Vulvae
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
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
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
Postmenopausal Bleeding
Points in Diagnosis
TREATMENT MODALITIES IN DUB
Nonsteroidal 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 Analogs
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 (Fig. 9.1)
Clinical Features of Some Common Conditions Associated with Primary Amenorrhea
Management of Primary Amenorrhea
Secondary Amenorrhea
Causes
Prognosis
10:
Reproductive Health
ADOLESCENT HEALTH
FEMALE GENITAL MUTILATION (FGM)
OBESITY AND OVERWEIGHT
FERTILITY CONTROL
UNSAFE ABORTION
PELVIC INFLAMMATORY DISEASE (PID) AND SEXUALLY TRANSMITTED INFECTIONS (STIs)
CHILDBIRTH AND MATERNAL MORTALITY
How Can We Make Pregnancy Safer?
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
Introduction
Presentation
Investigations
Management
12:
Pelvic Inflammatory Disease (PID)
INTRODUCTION
NATURAL BARRIERS TO PID
Vulnerability to PID
PATHOLOGY (FIG. 12.1)
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
EPIDEMIOLOGY
NATURAL HISTORY OF PROGRESSION OF HIV INFECTION
Modes of Transmission
Course of Infection
SCREENING FOR HIV: FOR WHOM
HIV ANTIBODY TESTING
Effect of HIV on Pregnancy
Risk Factors for Vertical Transmission
PREGNANCY AND ANTIRETROVIRAL THERAPY
Prescribing Antiretroviral Therapy in Pregnancy
Side Effects/Toxicity of Antiretroviral Drugs
MODE OF DELIVERY
INTRAPARTUM MANAGEMENT
In Case of a Vaginal Delivery
In Case of Elective Cesarean Section
Management of the Neonate
HIV AND GYNECOLOGICAL CONDITIONS
Cervical Dysplasia
HIV Infected Women and Contraception
HIV and Menstruation
HIV and Subfertility
15:
Benign Lesions of the Genital Tract
INTRODUCTION
BENIGN LESIONS OF VULVA
Classification
Lichen Sclerosis
Squamous Cell Hyperplasia
Other Dermatoses
Disorders of Pigmentation
BENIGN TUMORS OF VULVA
Cystic Lesions
Nonepithelial Tumors
Epithelial Tumors
Ectopic Tissue
BENIGN LESIONS OF THE VAGINA
BENIGN LESIONS OF THE CERVIX
BENIGN TUMORS OF UTERUS
Signs and Symptoms
Classification and Pathophysiology
Intramural, Subserosal, Submucosal and Cervical
Microscopic Appearance
Expectant Management
Hysterectomy
Myomectomy
Principle of Myomectomy
Endoscopic Surgical Methods
Hysteroscopy
Medical Management
UTERINE POLYPS
BENIGN TUMORS OF OVARY
Physiological Cysts
Follicular Cyst
Corpus Luteal Cyst
Pathological Cysts or Benign Ovarian Neoplasms
Benign Germ Cell Tumors
Benign Epithelial Tumors
Benign Sex Cord Stromal Tumors
Feminizing Functional Mesenchymomas
Virilizing Mesenchymomas
Tumors Arising from the Connective Tissue of the Ovary
Clinical Features
Differential Diagnosis
Complications of Ovarian Tumors
Investigations
Management
Surgery
16:
Contraception and Sterilization
CLASSIFICATION OF CONTRACEPTIVE AGENTS
Reversible (Temporary)
Traditional
Barrier
Hormonal Contraceptives
Intrauterine Devices
Failure Rates in First Year of Use4
TRADITIONAL METHODS
Natural Family Planning Method (Periodic Abstinence)
Coitus Interruptus (Withdrawal)
Postcoital Douche
Lactational Amenorrhea Method
Mechanism of Action
Barrier Methods
Male Condoms
Reasons for Failure
Disadvantages
Vaginal Diaphragms
Advantages
Disadvantages
Side Effects
The Cervical Cap
Advantages Over Diaphragm
Disadvantages
Female Condom
Advantages
Disadvantages
Spermicidal Preparations
Advantages
HORMONAL CONTRACEPTIVES
Combined Oral Contraceptive (COC) Pills
Mechanism of Action
Systemic and Metabolic Effects
Noncontraceptive Beneficial Effects
Side Effects
Major
Absolute Contraindications9
Drug Interactions
Pill Taking
Missed Pills
Reproduction after Discontinuation of COCs
PROGESTERONE ONLY PILLS (MINIPILLS)
Transdermal Patch
Vaginal Ring
Injectable Contraception
Advantages
Disadvantages
Beneficial Effects
Combined Injectable Contraceptives
Contraceptive Implants
Advantages
Disadvantages
Emergency Contraception (Postcoital Contraception)
Methods
Mechanism of Action
Other Methods
Intrauterine Devices (IUDs)
TYPES OF INTRAUTERINE DEVICES
Unmedicated or Inert IUDs
Copper Containing IUDs
Others
Hormone Releasing Intrauterine Devices (Intrauterine Systems)
Mechanism of Action
Contraindications: Absolute
Relative Contraindications
Timing
Technique of Insertion (Fig. 16.4)
Complications
Delayed Complications
IUD Removal
Beneficial Effects of IUDs
SURGICAL STERILIZATION
Female Sterilization
Minilaparotomy
Procedure
Complications of Minilaparotomy
Contraindications
Advantages
Disadvantages
Laparoscopic Sterilization
Procedure
Complications
Contraindications
Advantages
Disadvantages
Vaginal Approach
Transcervical Approach
Advantages
Disadvantages
Long-term Complications of Sterilization Procedures
Health Benefits of Female Sterilization
Male Sterilization
Complications
Reversibility
NEWER METHODS
Male Hormonal Method
Immunocontraception
Genetic Research
HIV and Contraception20
Adolescent Girls
Contraception for Women more than 35 and Perimenopausal Women
17:
Psychosexual Problems and Sexual Dysfunction
INTRODUCTION
FEMALE SEXUALITY
PRESENTATION OF SEXUAL DIFFICULTIES
Categorization of Female Sexual Disorders
DEFINITIONS OF SEXUAL DISORDERS IN WOMEN
Desire Disorders
Orgasmic Disorder
MANAGEMENT
Questions
Use of Questionnaires
Sexual History
INVESTIGATIONS
TREATMENT
Pharmacological Interventions
Physical Interventions
Psychosexual Medicine
PARTNERS
PHASES OF LIFE
Adolescence
Reproductive Years
Sexually Transmitted Diseases
Infertility
Termination of Pregnancy
Childbirth
Colposcopy
Menopause and Aging
Cancer
Sexual Abuse
Role of the Internet
CONCLUSION
18:
Pelvic Organ Prolapse
DEFINITION AND INCIDENCE
CLASSIFICATION
ETIOLOGY
ANATOMY OF THE PELVIC FLOOR
Viscerofascial 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
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
21:
Instruments Used in Obstetrics and Gynecology
SIM'S VAGINAL SPECULUM (FIG. 21.1)
Uses
CUSCO'S VAGINAL SPECULUM (FIG. 21.2)
Uses
Advantages
Disadvantage
SIM'S ANTERIOR VAGINAL WALL RETRACTOR (FIG. 21.3)
Uses
UTERINE SOUND (FIG. 21.4)
Uses
Diagnostic
Therapeutic
Complications
VULSELLUM FORCEPS (FIG. 21.5)
Uses
Disadvantages
TENACULUM (FIG. 21.6)
Use
Complications
CERVICAL DILATORS
Hegar's Dilator (Fig. 21.7)
Uses
Mathew-Duncan Dilator (Fig. 21.8)
Uses
Complications
UTERINE CURETTE
Sim's Double Ended Uterine Curette (Fig. 21.9)
Uses of Sharp Curette
Diagnostic Conditions
Therapeutic Conditions
Uses of Blunt Curette
SUCTION CANNULA (FIG. 21.10)
Uses
Complications
MANUAL VACUUM ASPIRATOR (FIG. 21.11)
Uses
Advantage of Manual Vacuum Aspirator over Electric Vacuum Aspirator and D & C
AYER'S SPATULA (FIG. 21.12)
Uses
PUNCH BIOPSY FORCEPS (FIG. 21.13)
Uses
ENDOMETRIAL BIOPSY CURETTE (FIG. 21.14)
Indication of Use
Disadvantage
Advantage
RED RUBBER CATHETER (FIG. 21.15)
Indications
FOLEY'S CATHETER (FIG. 21.16)
Indications
Obstetrics
Gynecology
Complications
LEECH WILKINSON'S CANNULA (FIG. 21.17)
Indications for Use
SHIRODKAR'S HOOK (FIG. 21.18)
Uses
PESSARY (HODGE, SMITH OR RING PESSARY)
Smith-Hodge Pessary
Ring Pessary (Fig. 21.19)
Indications
Complications of Pessary
DOYEN'S RETRACTOR (FIG. 21.20)
Indications
RICHARDSON'S TETRACTOR
Uses
EPISIOTOMY SCISSORS (FIG. 21.21)
UMBILICAL CORD CUTTING SCISSOR (FIG. 21.22)
KOCHER'S ARTERY FORCEPS (FIG. 21.23)
Uses
GREEN-ARMYTAGE'S FORCEPS (FIG. 21.24)
Uses
BABCOCK'S FORCEPS (FIG. 21.25)
Uses
FORCEPS (FIG. 21.26)
Prerequisites for Outlet Forceps Application
Indications of the Forceps
Fetal Indications
Maternal Indications
Labor
Complications
Maternal
Fetal
VACUUM DELIVERY (VENTOUSE)
MALMSTROM CUP (FIG. 21.27)
VACUUM EXTRACTOR
Indications for the Ventouse
Contraindications for Ventouse
Prerequisites
SPONGE HOLDING FORCEPS (FIG. 21.28)
Uses
PINARD'S FETAL STETHOSCOPE (FIG. 21.29)
Indications
LAMINERIA TENT
22:
Ultrasound and Color Doppler in Gynecology
INTRODUCTION
UTERINE LESIONS
3-D OF ENDOMETRIUM
ENDOMETRIAL VOLUME
ENDOMETRIAL PERFUSION
OVARIAN LESIONS
OTHER ADNEXAL LESIONS
ENDOMETRIOSIS
PARAOVARIAN CYSTS
OVARIAN DERMOID CYSTS
OTHER OVARIAN MASSES (FIGS 22.1.25 AND 22.1.26)
ACKNOWLEDGMENTS
NORMAL FEMALE PELVIS
UTERUS
OVARIES
FOLLICULOGENESIS
FALLOPIAN TUBES
POUCH OF DOUGLAS
ULTRASOUND OF THE UTERUS
DISEASES OF THE MYOMETRIUM
DISEASES OF THE ENDOMETRIUM
DISEASES OF THE UTERINE CAVITY
ADENOMYOSIS (FIGS 22.2.12 TO 22.2.15)
Ultrasonographic Appearance
MYOMETRITIS
MYOMETRIAL CALCIFICATIONS
LEIOMYOMA (SEE FIGS 22.2.17 TO 22.2.20)
ARTERIOVENOUS MALFORMATION (SEE FIGS 22.2.20 AND 22.2.21)
Rare Condition
ENDOMETRITIS
ENDOMETRIAL HYPERPLASIA
ENDOMETRIAL POLYP (SEE FIGS 22.2.24 AND 22.2.25)
ENDOMETRIAL CARCINOMA
ENDOMETRIAL FLUID
INTRAUTERINE CONTRACEPTIVE DEVICES (SEE FIG. 22.2.28)
SYNECHIAE (ASHERMAN SYNDROME)
SONOHYSTEROGRAPHY (FIGS 22.2.29 TO 22.2.32)
ULTRASOUND AND PUERPERIUM
DISEASES OF CERVIX
VAGINA
OVARIAN SONOGRAPHY
Functional Cysts
OVARIAN VASCULAR LESIONS
OVARIAN NEOPLASMS
FUNCTIONAL CYSTS
SURFACE EPITHELIAL INCLUSION CYSTS
RETE CYSTS
HYPERREACTO LUTEINALIS
OVARIAN HYPERSTIMULATION SYNDROME
POLYCYSTIC OVARIAN SYNDROME
OVARIAN REMNANT SYNDROME
PARATUBAL, PARAOVARIAN CYSTS
ENDOMETRIOSIS
PELVIC INFLAMMATORY DISEASE
PERITONEAL INCLUSION CYSTS
OVARIAN VASCULAR LESIONS
OVARIAN NEOPLASMS
GERM CELL TUMORS
SEX CORD—STROMAL TUMORS
METASTATIC TUMORS
EVALUATION OF AN OVARIAN MASS
GESTATIONAL TROPHOBLASTIC DISORDERS
PELVIC KIDNEY
23:
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
Le Fort's Operation (Colpocleisis)
Shirodkar's Abdominal Sling Operation
Purandare Cervicopexy (Abdominal Cervicopexy)
LAPAROSCOPY
Definition
General Guidelines
Indications for Laparoscopy
Diagnostic Laparoscopy
Operative Laparoscopy
Contraindications
Techniques of Laparoscopy
Veress Needle and Primary Trocar Insertion (Close Laparoscopy)
Umbilical Trocar Insertion
HYSTEROSCOPY
Procedure for Hysteroscopy
Indications for Hysteroscopy
Complications of Hysteroscopy
24:
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
25:
Genital Tuberculosis
INTRODUCTION
INCIDENCE
PATHOLOGY
CLINICAL FEATURES
Diagnosis
Blood Picture
Chest X-ray
Mantoux or Tuberculin Test
Endometrial Aspirate, Biopsy or Curettage
Polymerase Chain Reaction
Imaging Modalities
CT Scan
MRI
Hysterosalpingogram (HSG)
Laparoscopy
Hysteroscopy
Analysis of the Ascitic Fluid
Treatment
Medical
Surgery
26:
Uterine Displacements including Retroversion and Uterine Inversion
UPWARD DISPLACEMENT OF THE UTERUS
LATERAL DISPLACEMENT OF THE UTERUS1
RETROVERSION
Degrees of Retroversion2
SYMPTOMS OF RETROVERSION
DIAGNOSIS
Differential Diagnosis
MANAGEMENT
RETROVERTED GRAVID UTERUS
UTERINE INVERSION
ACUTE INVERSION
PREVENTION OF PUERPERAL INVERSION
MANAGEMENT
CHRONIC INVERSION
Diagnosis
Management
27:
Endoscopy in Gynecology
INTRODUCTION
INDICATIONS OF LAPAROSCOPIC SURGERY
CONTRAINDICATIONS
EQUIPMENT (FIG. 27.7)
TECHNIQUE OF LAPAROSCOPY
Procedure
COMPLICATIONS OF LAPAROSCOPY
Advantages of Laparoscopic Surgery Over Conventional Surgery
Disadvantages
HYSTEROSCOPY
Introduction
Indications
Instruments in Hysteroscopy (Fig. 27.19)
Timing of Hysteroscopy
Technique
Complications
Contraindications
SECTION 2: REPRODUCTIVE ENDOCRINOLOGY AND ASSISTED CONCEPT
28:
Puberty
INTRODUCTION
PHYSIOLOGY OF PUBERTY
FACTORS INFLUENCING PUBERTY
PHYSICAL CHANGES OF PUBERTY
Breast Development (Thelarche)
Pubic Hair Development (Pubarche)
Auxiliary Hair Development
Timing and Sequence of Pubertal Phenotypic Changes
PSYCHOLOGIC CHANGES OF PUBERTY
COMMON PROBLEMS ASSOCIATED WITH ADOLESCENCE
29:
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
30:
Polycystic Ovarian Syndrome
INTRODUCTION
PATHOPHYSIOLOGY
PUBERTY AND PCOS
Mechanism of Onset of PCOS during Puberty (Fig. 30.1)
Insulin and the Mechanism of Anovulation in Polycystic Ovarian Syndrome
Role of Hyperinsulinemia in the Pathogenesis of PCOS (Fig. 30.2)
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
31:
Hirsutism
DEFINITION
HYPERTRICHOSIS
PATHOPHYSIOLOGY
ETIOLOGY
Endocrine Causes
Nonendocrine Causes
DIAGNOSIS
TREATMENT
32:
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
33:
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
34:
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
SECTION 3: GYNECOLOGIC ONCOLOGY
35:
Gynecological Cancer Screening
INTRODUCTION
CERVICAL CANCER
Papanicolaou 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
36:
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
37:
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 37.1 and 37.2)
Surgery for Ovarian Carcinoma with Disseminated Intraperitoneal Disease
Place of Chemotherapy
Massive Ovarian Cyst
“Second Look” Surgery
Secondary Salvage Surgery
CONCLUSION
38:
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
39:
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 (Fig. 39.17)
Other Vulvar Malignancies
Malignant Melanoma of Vulva
Verrucous Carcinoma
Basal Cell Carcinoma
Bartholin's Gland Carcinoma
Vulvar Sarcomas
Transitional Cell Carcinoma
Extramammary Paget's Disease of the Vulva
SUMMARY
40:
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. 40.3)
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
Extragenital Manifestations
Management of Choriocarcinoma
Chemotherapy
Side Effects of Chemotherapy
Cerebral Metastases
Role of Surgery
Future Pregnancies
CONCLUSION
41:
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
CONCLUSION
42:
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
INDEX
TOC
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