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Jeffcoate's Principles of Gynaecology
Narendra Malhotra, Jaideep Malhotra, Pratap Kumar, Neharika Malhotra Bora, Parul Mittal
CHAPTER 1:
A Clinical Approach to Gynaecology
INTRODUCTION
PSYCHOSOMATIC AND SOCIOLOGICALASPECTS OF GYNAECOLOGY
CLINICAL METHODS
History
Symptoms
Trivial Symptoms
Pain
Menstrual Function
Menarche and Standard Menstrual Habit
Menstrual Symptoms
Last Menstrual Period
Associated Symptoms
PHYSICAL EXAMINATION
General
Breasts
Abdomen
Examination of a Mass Per Abdomen
Inspection
On Palpation
Pelvic Examination
Prerequisites
Vaginal Examination
How do We Describe the Size of a Uterus?
Rectal Examination
Combined Rectal and Vaginal Palpation
The Findings
The Position of the Patient for Pelvic Examination
How to Get the Patient to Relax
SPECIAL TESTS AND ACCESSORY AIDS TO DIAGNOSIS
Ancillary Services
Cytology: Vaginal, Cervical, Uterine, Peritoneal
Colposcopy and Colpomicroscopy
Examination Under Anaesthesia
ENDOMETRIAL SAMPLING PROCEDURES
Endometrial Biopsy: Outpatient (Office) Curettage
Endometrial Aspiration
Curettage
Culdocentesis and Culdotomy
Tubal Patency Tests
Hysterosalpingography
Sonosalpingography
Laparoscopic Chromotubation
Ultrasonography
TRANSVAGINAL SONOGRAPHY
TRANSRECTAL SONOGRAPHY
COLOUR DOPPLER
ENDOSCOPY
LAPAROSCOPY
HYSTEROSCOPY
COMPUTED TOMOGRAPHY
MAGNETIC RESONANCE IMAGING
CHAPTER 2:
Anatomy
INTRODUCTION
VULVA
Individual Structures
Mons Veneris and Labia Majora
Perineum
Labia Minora
Clitoris
Vestibule
Hymen
Vestibular Bulb
Bartholin’s Glands (Greater Vestibular Glands)
Changes in the Vulva with Age and Parity
Relations
Vascular Connections
Arterial
Venous
Lymphatic
Innervation
VAGINA
General Description
Structure
Epithelium
Fascia and Muscle
Changes in the Vagina with Age and Parity (Fig. 2.11, Table 2.1)
The Supports of the Vagina
The Relations of the Vagina
Anterior
Posterior
Lateral
Superior
Vascular Connections
Arterial
Venous
Lymphatic
Innervation
UTERUS
General Description
Structure
Special Features of Each Part of the Uterus
Corpus (Including Fundus)
Isthmus
Cervix
Changes in the Uterus with Age and Parity
The Position of the Uterus
The Supports of the Uterus
The Relations of the Uterus
Anterior
Posterior
Lateral
Vascular Connections
Arterial
Venous
Lymphatic
FALLOPIAN TUBES
General Description
Interstitial or Intramural Part
Isthmus
Ampulla
Infundibulum
Structure
Relations
Superior
Inferior
Posterior
Anterior
Lateral
Vascular Connections and Innervation
OVARY
General Description
Structure
Relations
Changes with Age and Parity
Vascular Connections
Arterial
Venous
Lymphatic
Innervation
URETHRA AND BLADDER
General Description
Structure
Sphincter Mechanism
Relations of the Urethra and Bladder
Posterior
Anterior
Lateral
Vascular Connections
Arterial
Venous
Lymphatic
Innervation
URETER
General Description
Relations
Vascular Connections
Arterial
Venous
Lymphatic
SIGMOID COLON
General Description
Structure
Relations
Anterior
Posterior
Vascular Connections
Arterial
Venous
Lymphatic
Innervation
RECTUM AND ANUS
General Description
Structure
Relations
Anterior
Posterior
Lateral
Vascular Connections
Arterial
Venous
Lymphatic
Innervation
PELVIC PERITONEUM AND LIGAMENTS
Peritoneal Pouches
Broad Ligament
Round Ligament
Ovarian Ligament
Uterosacral Ligament
PELVIC MUSCULATURE
Levator Ani
Pubococcygeus
Iliococcygeus
Ischiococcygeus (Coccygeus)
The Pelvic Part of Piriformis Muscle
The Perineal Muscles and Triangular Ligament
PELVIC FASCIA AND CELLULAR TISSUE
Transverse Cervical (Cardinal or Mackenrodt’s) Ligaments
Uterosacral Ligament
Pubocervical Fascia
THE SUPPORTS OF THE GENITAL ORGANS
Uterus
Vagina
BLOOD VESSELS OF THE PELVIS
Arteries
Ovarian Artery
Common Iliac Artery
External Iliac Artery
Internal Iliac Artery
Uterine Artery
Vaginal Artery
Internal Pudendal Artery
Superficial and Deep External Pudendal Arteries
Veins
LYMPHATIC DRAINAGE
Vulva and Perineum
Vagina
Cervix
Corpus Uteri
Fallopian Tube and Ovary
Urethra and Bladder
Sigmoid Colon
Anus and Rectum
INNERVATION OF PELVIC ORGANS
Somatic Nerves
Autonomic Nerves
Sympathetic
Parasympathetic
Fallopian Tubes and Ovaries
CHAPTER 3:
Ovarian Functions
INTRODUCTION
PRODUCTION OF OVA
Primordial Follicles
Preantral Follicle
Two-cell Two-gonadotrophin Theory
Follicular Phase
Maturation of the Ovum
Meiotic Arrest of Oocyte and Resumption
Rupture of the Follicle—Ovulation
Luteal Phase
Follicular Atresia
OVARIAN HORMONES
Oestrogens
Production
Receptors
Actions
Skeletal System
Progesterone
Production
Actions (Fig. 3.23)
Relaxin
Inhibin, Activin and Follistatin
PITUITARY HORMONES
Posterior Lobe Hormones
Anterior Lobe Hormones
Follicle-stimulating Hormone
Catecholoestrogens
PITUITARY-HYPOTHALAMIC RELATIONS
Gonadotrophin-releasing Hormone
PITUITARY-OVARIAN RELATIONS (CONTROL OF OVULATION)
HORMONE LEVELS AND ASSAYS
CHAPTER 4:
Menstruation and Other Cyclical Phenomena
NORMAL MENSTRUAL CYCLE
ENDOMETRIAL CYCLE
Menstrual Endometrium
Proliferative Phase
Secretory Phase
Preparation for Implantation
Phase of Endometrial Breakdown
CORRELATION OF ENDOMETRIAL AND OVARIAN CYCLES
Hormonal Variations
UTERINE BLEEDING
Menstruation
Anovular Menstruation
The Mechanism of Bleeding from the Endometrium
THE MYOMETRIAL CYCLE
CYCLICAL CHANGES IN THE TUBE
THE CERVICAL CYCLE
THE VAGINAL CYCLE
CYCLICAL, METABOLIC, VASCULAR and psychological Changes
CHAPTER 5:
Clinical Aspects of Menstruation and Ovulation
MENSTRUATION
General Description
General Disturbances Associated with Menstruation
Management of Normal Menstruation
The Artificial Deferment or Advancement of Menstruation
THE MENOPAUSE AND THE CLIMACTERIC
Definition and Age
Physical Changes
Psychological Changes
Climacteric (Menopausal) Symptoms
Neurotic and Psychotic
Gastrointestinal
Cardiovascular
Osteoporosis
Genital and Sexual
Urinary
Others
The Management of the Menopause and of Climacteric Symptoms
General
Medical
Hormone Replacement Therapy
Nonhormone Replacement Therapy Regimens
Alternative Therapy for the Menopause
ABNORMAL MENOPAUSE
Premature Menopause
Late Menopause
Artificial Menopause and Climacteric
Surgical Menopause
Radiation Menopause
Follicle-Stimulating Hormone and Luteinising Hormone in a Menopausal Woman
Follicle-stimulating Hormone
Luteinising Hormone
OVULATION
Ovulation and the Menopause
Ovulation and Lactation
Diagnosis of Ovulation
Analysis of Symptoms
Cyclical Bleeding
Ovulation Pain (Mittelschmerz)
Ovulation Bleeding or Discharge (Mittelblüt)
Premenstrual Mastalgia
Temperature Changes
Endometrial Changes
Changes in Cervical Mucus
Vaginal Smears
Hormone Assays
Ultrasound
Direct Observation
Ovarian Dysfunction
Treatment
Treatment of the Cause
The Induction of Ovulation
Hypothalamic-Releasing Factors (GnRH)
GnRH Agonists and GnRH Antagonists
Surgical Procedures
Suppression of Ovulation
Disease
Drugs and Other Therapeutic Agents
Irradiation
Oestrogens and Progestogens
Androgens
Danazol
Analogues of Hypothalamic-Releasing Factors
CHAPTER 6:
Puberty and Adolescent Gynaecology
PUBERTY AND ADOLESCENCE
Definition and Description
Management of Adolescence: Sex Education
Abnormalities of Puberty and Adolescence
Obesity
Menstrual Disorders
Delayed Puberty
Precocious Puberty
Causes
Constitutional
Disease in the Regions of the Midbrain, Hypothalamus and Pituitary
Oestrogenic Tumours of the Ovary
Adrenal Cortical Tumours
Androgenic Tumours of Ovary
Ectopic Gonadotrophin Production
Management
Prolactin
Hyperprolactinaemia
Clinical Features of Hyperprolactinaemia
Causes of Hyperprolactinaemia
Management
PUBERTY MENORRHAGIA
Aetiopathology
Causes of Puberty Menorrhagia
Management of Puberty Menorrhagia
CHAPTER 7:
Conception
FERTILISATION OF THE OVUM
EARLY DEVELOPMENT OF THE OVUM
IMPLANTATION OF THE OVUM INTO THE UTERUS
FORMATION OF FOETUS AND MEMBRANES
HORMONAL CONTROL OF EARLY PREGNANCY
The Corpus Luteum of Pregnancy
Placental Hormones, Enzymes and Proteins
Gonadotrophins
Human Placental Lactogen
Progesterone
Oestrogens
CHAPTER 8:
Spontaneous Abortions (Including Recurrent Loss)
INTRODUCTION
SPONTANEOUS ABORTIONS
PATHOLOGY OF SPONTANEOUS ABORTIONS
Mechanism of Abortion
CLINICAL VARIETIES OF SPONTANEOUS ABORTIONS
Threatened Abortion
Clinical Picture
Prognosis
Treatment
Inevitable Abortion
Clinical Picture
Treatment
Cervical Abortion
Clinical Picture
Treatment
Incomplete Abortion
Clinical Picture
Ultrasonography
Treatment
Complete Abortion
Clinical Picture
Ultrasound
Missed Abortion
Clinical Picture
Signs
Investigations
Complications
Treatment
Septic Abortion
Clinical Picture
Complications
Treatment
RECURRENT EARLY PREGNANCY LOSS
Aetiology (Fig. 8.6)
Coagulation Investigations
Endocrinologic Investigations
Immunologic Investigations
Parental Cytogenetic Investigation
CHAPTER 9:
Ectopic Pregnancy
INTRODUCTION
Definition
FREQUENCY OF ECTOPIC PREGNANCY
SITES OF ECTOPIC PREGNANCY
Above Downwards
Frequency
AETIOLOGY OF ECTOPIC PREGNANCY
Use of Intrauterine Contraceptive Devices
Smoking
Assisted-Reproductive Techniques
Surgical Obstruction (Tubal damage)
Tubal Surgery
Salpingitis Isthmica Nodosa
Prior Ectopic Pregnancy
Developmental Errors of the Tube
Overdevelopment of the Ovum—External Migration of the Ovum
ECTOPIC PREGNANCY IN FALLOPIAN TUBES
Sites
Reactions of the Tube
Reactions of the Uterus
General Reactions
Discharge of the Ovum into the Lumenof the Tube—Tubal Abortion
Pregnancy Outcome
Tubal Rupture
Chronic Ectopic Adnexal Mass
Foetal Survival to Term
Clinical Features
Symptoms and Signs
Chronic Ectopic Pregnancy
Acute Clinical Picture
Classical Triad
Differential Diagnosis
Diagnosis
Tests and Aids to Diagnosis
Ectopic Finding/Heterotrophic (Colour Doppler)
Uterine Findings (Fig. 9.8)
Extrauterine Findings (Figs 9.9A to D)
Management and Treatment Options
Laboratory Tests
Treatment
Treatment of Shock
Surgical
Salpingotomy
Salpingectomy and Salpingo-Oophorectomy
Role of Laparoscopy
Medical Management of Ectopic Pregnancy
Systemic Methotrexate Treatment Regimens (Table 9.1)
Multiple-Dose Regime
Single-Dose Regimen
Contraindications to Methotrexate Treatment
Criteria for Medical Management of Ectopic Pregnancy
Expectant Management
OVARIAN PREGNANCY
Pathology
Clinical Features; Differential Diagnosis
Treatment
CORNUAL PREGNANCY
Pathology
Clinical Features; Differential Diagnosis
Treatment
CERVICAL PREGNANCY
ABDOMINAL PREGNANCY
Pathology
Clinical Features
Diagnosis
Treatment
INTRALIGAMENTARY PREGNANCY
CHAPTER 10:
Gestational Trophoblastic Disease
EPIDEMIOLOGY
TYPES OF TUMOURS
Aetiology
HYDATIDIFORM MOLE
Incidence
Pathology
Clinical Features
Diagnosis
Ultrasound
Human Chorionic Gonadotrophin
Dangers
Treatment
Further Management
Gonadotrophin Assays
Contraception
Indications for Chemotherapy after Hydatidiform Mole
Persistent Trophoblastic Tumour
PERSISTENT GESTATIONAL TROPHOBLASTIC TUMOUR
Nonmetastatic Disease
Placental Site Trophoblastic Tumour
Metastatic Disease
Incidence
Pathology
Clinical Features
Staging
Diagnosis
Treatment
Chemotherapy
Surgery
Radiotherapy
Results
Summary of Management of GTN
Subsequent Pregnancies
CHAPTER 11:
Breast Function and its Disorders
BREAST DEVELOPMENT
Stages of Breast Development at Puberty
Tanner’s Staging
Endocrine Control of Female Breast
DEVELOPMENTAL ANOMALIES OF BREAST
Congenital Anomalies
Modification of Physiological Response
Faulty Sexual Development
Anatomic Changes
Physiological Changes
Breast Feeding and Lactation
Special Conditions
Breast Diseases in Lactation
Failure of Lactation
SUPPRESSION OF LACTATION
DRUGS AND LACTATION
Endocrine Disorders (Galactorrhoea and Breast Atrophy)
Galactorrhoea
Pathophysiology of Galactorrhoea
Causes of Galactorrhoea (Table 11.9)
Clinical Features
Diagnosis
Table of Levels
Treatment
Breast Atrophy
Classification
Aetiology
Clinical Features and Evaluation
Laboratory Tests
Management
BENIGN BREAST CONDITION
Fibrocystic Changes
Proliferative Changes
Fibroadenoma
Phyllodes Tumour
Superficial Thrombophlebitis
Mastitis
Duct Ectoria
Fat Neurosis
SCREENING FOR BREAST DISEASES
Risk Factors
Genetics (Familial)
Reproductive Factor
BENIGN BREAST DISEASE
Diet/Obesity/Alcohol
Hormones and Breast Cancers
Ionising Radiation
Screening Strategy
Breast Self-Examination
Clinical Examination by Physician
Screening Mammography
Breast Cancer Screening
BREAST CANCER
Prognostic Factors
Axillary Lymph Node Status
Tumour Size
Histologic Grade
Oestrogen and Progesterone Receptors
HER 2/neu
P-53
Clinical Features
Modalities and Tests
Treatment of Breast Cancer (Table 11.17)
Mastectomy
Breast Conservation Therapy
Management of the Axilla
Sentinel Lymph Node Biopsy
Systemic Treatment
Metastatic Disease
Radiation Therapy
CHAPTER 12:
Development of the Urogenital System
INTRODUCTION
THE GONAD
WOLFFIAN SYSTEM
MÜLLERIAN DUCTS
MESENTERIES AND LIGAMENTS
DEVELOPMENT OF THE VAGINA, BLADDER AND URETHRA
DEVELOPMENT OF THE VULVA
CHAPTER 13:
Malformations and Maldevelopments of the Genital Tract
INTRODUCTION
MÜLLERIAN DUCT ANOMALIES
Absence or Incomplete Development of Both Müllerian Ducts (Class I)
Pathology
Clinical Aspects
Absence or Incomplete Development of One Müllerian Duct (Class II)
Pathology
Symptoms
Diagnostic Signs
Treatment
Imperfect Fusion of the Müllerian Ducts
Pathology
Uterus Didelphys (Class III)
Bicornuate Uterus (Class IV)
Septate and Subseptate Uterus (Class V)
Septate and Subseptate Vagina
Arcuate Uterus (Class VI)
Deformities in Combination (Figs 13.2 and 13.5)
DES-related Anomalies (Class VII)
Cause
Symptoms
Menstrual
Menorrhagia
Spasmodic Dysmenorrhoea
Failure to Contain Flow
Coital
Dyspareunia
Bleeding
Obstetrical
Infertility
Cornual Pregnancy
Site of the Conceptus
Sacculation of the Uterus
Abortion and Premature Labour
Malpresentation
Inefficient Uterine Action
Obstructed Labour
Diagnostic Signs
Treatment
Duplication and Diverticula of Müllerian Ducts
Incomplete Canalisation of Müllerian Ducts—Congenital Gynatresia
Sites
Cervical Atresia
Vaginal Atresia
Pathology
Clinical Features
Differential Diagnosis
Treatment
OVARY
Absence or Underdevelopment
Accessory and Supernumerary Ovaries
Failure of Descent
Ovotestis
FALLOPIAN TUBE
UTERUS
Absence
Hypoplasia
Types
Causes
Clinical Features
Diagnosis
Treatment
Cochleate Uterus
Pathology
Clinical Features
Treatment
Conical Cervix and Pinhole os
Congenital Hypertrophy of Cervix
VAGINA
Absence
Pathology
Clinical Features
Treatment
Vaginal Hypoplasia
Congenital Atresia and Stricture
Septate and Subseptate Vagina
Double Vagina (Duplication)
VULVA
Absence, Gross Underdevelopment and Duplication
Hypoplasia
Bifid Clitoris (Diphallus)
Hypertrophy of the Clitoris
Abnormalities of the Hymen
Atresia of the Labia Minora
Hypertrophy of the Labia Minora (Spaniel Ear Nymphae)
Pathology
Symptoms
Treatment
Asymmetry of the Labia Minora
ERRORS ARISING IN CONNECTION WITH THE CLOACA
MALFORMATIONS OF THE URINARY TRACT
Epispadias and Ectopia Vesicae
Urethral Diveticula
Accessory and Aberrant Ureter (and kidney)
Absence of One Kidney and Ureter
Fusion of the Kidneys—Horseshoe Kidney
Pelvic Kidney
CHAPTER 14:
Sex Determination, Asexuality and Intersexuality
INTRODUCTION
PHYSIOLOGICAL CONSIDERATIONS
INTERSEX
SEX DETERMINATION IN THE FOETUS AND ITS ANOMALIES
CHROMOSOMAL SEX
Errors in Sex Chromosome Division and Distribution
Chimaerism and Dispermy
Sex Chromatin Pattern
The Chromosomal Sex Drive
Ovotestis
Streak Gonads, Gonadal Aplasia and Hypoplasia
SEX CHROMOSOMAL INTERSEX
Turner’s Syndrome (First described in 1957 by Henry Turner)
Characteristics
Other Syndromes and Karyotypes Associated with Streak Gonads
Triple X Syndrome (47XXX)
Primary Micro-Orchidism: Klinefelter’s Syndrome (47XXY)
The YY Syndrome
Other Genetic Influences
AUTOSOMAL INTERSEX
Constitutional Hirsutism
Testicular Feminsing Syndrome
GONADAL INTERSEX
The Organising Power of the Gonad
HORMONAL INTERSEX
Congenital Adrenal Hyperplasia
Other Causes of Hormonal Intersex
Combinations of Chromosomal, Genetic and Gonadal Causes of Intersex
PSYCHOLOGICAL SEX
Transvestism
Trans-sexuality
SEX OF REARING
THE MANAGEMENT OF ABERRATIONS OF SEX PRESENT AT BIRTH
Diagnosis
Investigations
Treatment of Intersex
SPECIALISED TREATMENT SCHEDULES
Testicular Feminisation Syndrome
Male Hermaphroditism
True Hermaphroditism
Turner’s Syndrome
Principles of Surgical Therapy
INTERSEX DEVELOPING AFTER BIRTH
FEMINISM
Manifestations
Sex Organs
Secondary Sex Characters
Personality and Outlook
Libido
Causes
Physiological
Genetic and Constitutional
Psychological
Androgen Deficiency
Oestrogenism
Diseases of the Pituitary, Hypothalamus and Midbrain; Hyperthyroidism
Drugs
Treatment
Virilism
Manifestations
Sex Organs
Secondary Sex Characters
Hair
Personality and Outlook
Libido
Causes
Constitutional
Psychological
Oestrogen Deficiency
Excessive Androgen Stimulus
The Administration of Androgens
Adrenal
Ovary
Diseases of the Pituitary, Hypothalamus, Midbrain and Base of Skull
Drugs
Diagnosis
Treatment
Surgical
Medical
Hormonal
Oestrogen
Medroxyprogesterone Acetate
GnRH Agonists
Corticosteroids
Antiandrogens
Cosmetic
CHAPTER 15:
Injuries
FOREIGN BODIES IN THE GENITAL TRACT
Vagina
Types and Sources
Therapeutic Agents
Contraceptive Devices
Articles Inserted by the Patient or Entering Accidentally
Instruments for Inducing Abortion and Labour
Articles of Toilet and Hygiene
Vaginal Calculus
Effects
Treatment
Uterus
Types and Sources
Effects
Treatment
Other Organs and Tissues
VAGINAL BURNS
Causes
Effects
Treatment
DIRECT TRAUMA TO VULVA AND VAGINA
Abrasions from Clothing
Cuts and Lacerations
Accidents
Coitus
Spontaneous
Childbirth
Haematoma of the Vulva and Vagina
DEFECTIVE OR DEFICIENT PERINEUM
Pathology
Symptoms
Treatment
COMPLETE PERINEAL TEAR
Pathology
Symptoms
Treatment
Results
LACERATION OF THE CERVIX
Types and Causes
Obstetrical Injuries
Surgical Injuries
Complications and after Effects
Cervical Ectropion
Distortion and Scarring of the Cervix
Clinical Features
Treatment
RUPTURE AND PERFORATION OF THE UTERUS
Rupture
Perforation
BROAD LIGAMENT HAEMATOMA
Pathology
Causes
Clinical Features
Treatment
GENITAL TRACT FISTULAS
Vaginoperineal
Faecal
Tubointestinal
Uterointestinal
Vaginointestinal, Perineointestinal
Causes
Congenital Malformation
Foreign Bodies (Vagina, Bowel or Peritoneal Cavity)
Obstetrical Injury
Operation Injury
Extension of Disease
Radiotherapy
Clinical Features: Diagnosis
Treatment
Urinary
Types
Causes
Congenital Malformations
Accidents
Operative Injury
Obstetrical Injury
Extension of Disease Processes
Radiotherapy
Clinical Features and Diagnosis
Menouria
Treatment
Conservative Treatment
Surgery for Ureteric Fistulas
Surgery for Uterovesical Fistulas
Surgery for Vesicovaginal Fistulas
Surgery for Urethrovaginal Fistulas
Surgery for Complicated Fistulas
Prevention of Fistulas
Pregnancy after Cure of Vaginal Fistulas
ACQUIRED ATRESIA AND STENOSIS OF THE GENITAL TRACT
Pathology
Causes
Senility
Operative and Other Injuries
Vulva
Vagina
Cervix
Corpus Uteri
Fallopian Tube
Radiotherapy
Infections and Epithelial Disorders
Vulva
Vagina
Uterus
Fallopian Tube
Tumours
Effects
Retention of Discharge
Apareunia and Dyspareunia; Inferility
Dystoda
Urinary Symptoms
Treatment
CHAPTER 16:
Pelvic Organ Prolapse
UTERINE AND VAGINAL PROLAPSE
Supports of Uterus (Figs 16.1A and B and Table 16.1)
Upper Tier
Middle Tier
Lower Tier
Types
Uterine (Uterovaginal) Prolapse
Baden-Walker Halfway System
Vaginal Prolapse
Anterior Compartment Defects
Middle Compartment Defects
Posterior Compartment Defects
Complications
Hypertrophy of the Cervix
Elongation of the Supravaginal Cervix (Fig. 16.2B)
Congestion and Oedema (Fig. 16.8)
Glandular Hypertrophy (Adenomatous Change)
Obstructive Lesions of the Urinary Tract
Infection of the Urinary Tract: Renal Failure
Incarceration of the Prolapse
Carcinoma of the Cervix or Vagina
Genital Prolapse and Pregnancy
Aetiology
Predisposing Factors
Congenital or Developmental Weakness of the Supports
Injury Sustained During Childbirth
Surgical Injury
Atrophy of Supporting Tissues at the Climacteric
Activating Factors
Symptoms
A Sensation of Swelling or Fullness in the Vagina
A Dragging Discomfort in the Lower Abdomen and Pelvis
Urinary Symptoms
Frequency
Difficulty in Emptying the Bladder
Stress Incontinence
Difficulty in Emptying the Rectum
Backache
Discharge
Physical Signs
Differential Diagnosis
Prevention
During Labour and the Puerperium
At Hysterectomy
Treatment
Physiotherapy
Pessary Treatment
Ring
Donut
Inflatoball
Gellhorn
Shaatz
Gehrung
Incontinence Pessaries
Complications
Operative Treatment
Indications
Preoperative Management
Types of Operation
Anterior Colporrhaphy
Steps of Anterior Colporrhaphy
Enterocele Repair
Posterior Colpoperineorrhaphy
Vaginal Hysterectomy with Anterior Colporrhaphy and Posterior Colpoperineorrhaphy
Other Operations
Abdominal Sling Operations
Operations for Vaginal Prolapse after Hysterectomy
Results of Operations
Stress Incontinence
Dyspareunia
Failed Operations
Pregnancy after Repair Operations
Amputation of the Cervix
Colporrhaphy
PROLAPSE OF THE OVARIES
CHAPTER 17:
Other Displacements of the Uterus
INTRODUCTION
UPWARD DISPLACEMENT OF THE UTERUS
Causes
Treatment
LATERAL DISPLACEMENT OF THE UTERUS
Causes
Treatment
FORWARD DISPLACEMENT OF THE UTERUS
BACKWARD DISPLACEMENT OF THE UTERUS
Definitions
Retroversion
Retroflexion
Frequency
Causes
Developmental (Congenital)
Prolapse
Tumours and Adhesions
Puerperal
Symptoms
Spasmodic Dysmenorrhoea
Pelvic Congestion Syndrome
Low Backache and Pelvic Pain
Rectal Symptoms
Dyspareunia
Infertility
Abortion
Physical Signs
Differential Diagnosis
Management and Treatment
Prevention
Replacement of the Uterus and Insertion of a Pessary
Principles of Treatment
Indications for Insertion of a Pessary
Pessary Test
During Pregnancy
Technique of Replacement of the Uterus
Size of Pessary, Management of Pessary
Operative Treatment for Retrodisplacement
Indications
Techniques
RETROVERTED GRAVID UTERUS
Outcome and Effects
Spontaneous Correction of the Position of Uterus
Impaction of the Uterus
Pathology
Diagnosis
Treatment
Sacculation of the Uterus
Management of the Uncomplicated Retroverted Gravid Uterus
INVERSION OF THE UTERUS
Acute Inversion
CHRONIC INVERSION
Puerperal
Pathology
Clinical Features
Treatment
Senile Inversion
Inversion due to Pedunculated Tumour
CHAPTER 18:
Torsion of Pelvic Organs
TORSION OF THE NORMAL ORGANS
Uterus
Tube and Ovary
TORSION OF ABNORMAL ORGANS
Uterus
Pedunculated Leiomyoma
Tube
Ovary
AETIOLOGY
Unusual Mobility of Organs
Pregnancy and the Puerperium
Movement of the Trunk
Defaecation and Micturition
Adhesions, Bands and Tumours in Adjacent Organs
Idiopathic
DIFFERENTIAL DIAGNOSIS
TREATMENT
CHAPTER 19:
Infections Including STD
THE NATURAL DEFENCES OF THE GENITAL TRACT
Defence Mechanisms
Vulva
Vagina
Cervix
Uterus
Variations in the Efficiency of Defence Mechanisms
With Age
With Menstruation
During the Puerperium
Types of Infecting Organisms
SEXUALLY TRANSMITTED DISEASES
Syphilis
Aetiology
Clinical Features
Latent Syphilis
Diagnosis
Treatment
Gonorrhoea
Pathology and Clinical Features
Diagnosis
Treatment
Chancroid (Soft Sore)
Pathology and Clinical Features
Diagnosis
Treatment
OTHER SEXUALLY TRANSMITTED INFECTIONS
Human Immunodeficiency Virus Infection and Acquired Immune Deficiency Syndrome
Pathology
Clinical Features
Diagnosis
Treatment
Genital Human Papillomavirus
Pathology and Clinical Features
Chlamydia Trachomatis Infections
Pathology
Clinical Features
Diagnosis
Treatment
Lymphogranuloma Venereum (LGV)
Clinical Features
Diagnosis
Treatment
Genital Mycoplasmas
Pathology and Clinical Features
Diagnosis
Treatment
Granuloma Inguinale (Donovanosis)
Pathology
Diagnosis
Treatment
GENITAL TUBERCULOSIS
Aetiology
Bloodstream
Descending
Ascending
Pathology and Bacteriology
Vulva and Vagina
Cervix
Uterus
Fallopian Tubes
Ovaries
Fistulas and Sinuses
Clinical Features
Tuberculosis of the Vulva and Vagina
Overt Tuberculosis of the Cervix
Tuberculosis of the Uterus and Adnexa
Infertility
Ectopic Pregnancy
Menstrual Disturbance
Intermenstrual Discharge
Pain
General Disturbances
Diagnosis
Treatment
General
Antibiotics
Sheffer Types of Genital TB
Surgery
Indications for Surgery
Contraindications to Surgery
Technique
SARCOIDOSIS
ACTINOMYCOSIS
SCHISTOSOMIASIS (BILHARZIA)
AMOEBIASIS
CHAPTER 20:
Infections as they Affect Individual Organs
VULVITIS
Pyogenic Infections
Infection of Abrasions and Wounds
Intertrigo: Smegma Concretions
Furunculosis
Infection of Sebaceous and Apocrine Glands
Infantile and Senile Vulvitis
Acute Simple Ulcers (Figs 20.2A to C)
Herpes Genitalis
Diagnosis and Management
Recurrent Genital (Buccal) Ulceration
Tuberculosis of the Vulva
Schistosomiasis
Noma Vulvae, Tropical Ulcer, Phagedaena
Diabetic Vulvitis
Candidiasis
Tinea Cruris (Ringworm)
Pediculosis Pubis
Elephantiasis
Other Infections
BARTHOLINITIS
Aetiology
Pathology
Clinical Features
Treatment
Technique of Marsupialisation
Technique of Excision
VAGINITIS
Vaginitis (Vulvovaginitis) in Infancy
Aetiology and Pathology
Clinical Features
Diagnosis
Treatment
Senile Vaginitis (Atrophic Vaginitis)
Aetiology and Pathology
Clinical Features and Diagnosis
Treatment
Trichomonas Vaginitis and Urethritis (Trichomoniasis)
Aetiology
Pathology
Clinical Features
Diagnosis
Treatment
Candida Vaginitis
Aetiology
Pathology and Clinical Features
Transfer of Infection
Diagnosis
Treatment
Bacterial Vaginosis
Pathology
Clinical Features
Diagnosis
Treatment
Oral Probiotic Therapy with Lactobacillus
Other Vaginal Infections
Vaginitis Emphysematosa (Colpitis Cystica)
Noninfective Vaginitis
Traumatic
Burns
Allergy; Drug Sensitivity
Idiopathic
CERVICITIS
Acute Cervicitis
Chronic Cervicitis
Aetiology
Pathology
Clinical Features
Diagnosis
Treatment
Antiseptics
Antibiotics
Cauterisation, Cryotherapy or Laser Ablation
Trachelorrhaphy
Hysterectomy
Special Forms of Cervicitis
ENDOMETRITIS
Acute Endometritis
Chronic Endometritis
Aetiology
Clinical Features
Diagnosis
Treatment
Pyometra (Pyohaematometra)
METRITIS
Aetiology
Pathology
Clinical Features
SALPINGO-OOPHORITIS
Aetiology
Ascending Infection
Puerperal and Postabortal
Tuberculous
Other Infections
Pyogenic Infection of Pelvic Peritoneum
Pathology
Resolution
Abscess Formation
Healing by Fibrosis
Hydrosalpinx
Tubo-ovarian Mass
Peritoneal Cysts and Pseudocysts
Puerperal and Postabortal Infection
Clinical Features
Acute Salpingo-oophoritis
Subacute Salpingo-oophoritis
Chronic Salpingo-oophoritis
Treatment of Acute Salpingo-oophoritis
General
Relief of Pain
Antibiotics
Surgical Treatment
Treatment of Subacute and Chronic Salpingo-oophoritis
Conservative Treatment
Surgical Treatment
OOPHORITIS
Aetiology
Pathology
Clinical Features
Treatment
PELVIC PERITONITIS
Aetiology
Pathology
Clinical Features
Treatment
PELVIC CELLULITIS
Acute and Subacute Cellulitis
Aetiology
Adjacent Infections
Pelvic Operations
Radiotherapy
Pathology
Clinical Features
Diagnosis
Treatment
Medical and General
Surgical
Prognosis
CHRONIC CELLULITIS
Aetiology and Pathology
Clinical Features
Diagnosis
Treatment
Medical and General
Nerve Block
Surgery
PELVIC INFLAMMATORY DISEASE
Aetiology
Clinical Features and Diagnosis
Sequelae
Treatment
SUPPURATIVE THROMBOPHLEBITIS OF THE PELVIC VEINS
Definition
Aetiology and Pathology
Clinical Features
Treatment
General and Medical
Anticoagulants
Surgery
CHAPTER 21:
Genital Tuberculosis
INTRODUCTION
CLINICAL PROFILE
Diagnosis
Some of the HSG Films Suggestive of Genital Tuberculosis (Figs 21.4A to F)
Pathology of Pelvic Organs
Hysterosalpingography Suggestive of Female Gential Tuberculosis (Figs 21.5 to 21.45)
CHAPTER 22:
Endometriosis and Allied States
ENDOMETRIOSIS AND ADENOMYOSIS
General Considerations
Extrauterine Endometriosis
Adenomyosis
General Pathological Considerations
Aetiology
Age
Race and Family
Social and Economic Factors
Parity
Oestrogens and Prostaglandins
Retroversion
Sites
Ovary
Pelvic Peritoneum Including the Uterovesical Pouch and the Pouch of Douglas
Outer Coat of Uterus
Round Ligament, Uterosacral Ligament and Rectovaginal Septum
Fallopian Tube
Intestine
Bladder and Ureter
Vagina and Vulva
Abdominal Wall
Lungs and Pleura
Mechanism of Origin
Endometrial Spill
Serosal Cell Metaplasia
Lymphatic and Vascular Embolism
Immunological
Immune Factors
Symptoms
Dysmenorrhoea
Abnormal Menstruation
Infertility
Dyspareunia
Pain on Defaecation
Tumour Formation
Abdominal Pain
Other Symptoms
Physical Signs
Diagnosis
Laparoscopic Findings
Treatment
Expectant
Surgery
Medical Treatment
Hormone Therapy (Table 22.4)
Oestrogens and Progestogens
Progestogens
Danazol
Gestrinone
Gonadotrophin-releasing Hormone Agonists
Progesterone Antagonists
Combined Medical and Surgical Therapy (Flow charts 22.2A and B)
Treatment of Recurrent Endometriosis
Aromatase Inhibitors
Selective Oestrogen Receptor Modulators
MOA of Aromatase Inhibitors
Assisted Reproduction and Endometriosis
ADENOMYOSIS
Pathology
Mechanism of Origin
Clinical Features and Diagnosis
Treatment
Surgical
Palliative and Medical
Medical Treatments
Levonorgestrel Intrauterine System (LNG-IUS)
ENDOSALPINGIOSIS
CERVICAL ENDOMETRIOSIS
CHAPTER 23:
Polycystic Ovary Syndrome
INTRODUCTION
Pathophysiology (Figs 23.2 to 23.5)
Pathology
Clinical, Biochemical, and Metabolic Features of PCOS
Insulin and the Mechanism of Anovulation in Polycystic Ovarian Syndrome
PUBERTY AND PCOS
Mechanism of Onset of PCOS During Puberty
Management
MENSTRUAL IRREGULARITIES
Skin Manifestations
HIRSUTISM
Alopecia
Infertility
Weight Loss
Clomiphene Citrate
METFORMIN
Mechanism of Action of Metformin
Laparoscopic Ovarian Drilling
Gonadotrophin Therapy
LONG-TERM MONITORING
CHAPTER 24:
Hirsutism
INTRODUCTION
VIRILISATION AND MASCULINISATION
Aetiology
Physiology of Hair Growth
Androgens
Causes of Hyperandrogenism
DIAGNOSIS OF HYPERANDROGENISM
History and Physical Examination
Laboratory Evaluation
Treatment
LATE-ONSET ADRENAL HYPERPLASIA
Androgen-producing Ovarian or Adrenal Tumours
Cushing’s Syndrome
Idiopathic Hirsutism
CHAPTER 25:
Epithelial Abnormalities of the Genital Tract
INTRODUCTION
VULVA
Pathology
Senile Atrophy
Lichen Sclerosus
Aetiology
Chronic Mechanical Irritation
Deficiency States
Autoimmunisation
Metabolic Upsets
Infection
Symptoms
Diagnosis
Treatment
General Treatment
Medical Treatment of the Cause
Empirical Measures
Corticosteroids
Oestrogens and Testosterone
Local Analgesia
Division of Cutaneous Nerves; Nerve Block
Vitamins
Fungicides
Other Local Applications
Vulvectomy
Vulvar and Oral Epithelial Abnormalities
Vulvar Intraepithelial Neoplasia
Incidence and Aetiology
Pathology
Squamous Intraepithelial Neoplasia
Paget’s Disease
Clinical Features
Diagnosis
Treatment
VAGINA
Vaginal Intraepithelial Neoplasia
Pathology and Aetiology
Clinical Features
Treatment
Vaginal Adenosis
CERVIX
Ectopy (Erosion)
Pathology
Aetiology
Congenital and Developmental
Hormonal
Infection
Symptoms
Discharge
Contact Bleeding
Other Symptoms
Physical Signs and Diagnosis
Treatment
Squamous Metaplasia
Squamous Cell Hyperplasia
Cervical Intraepithelial Neoplasia: Dysplasia and Carcinoma in situ
Pathology
Frequency and Significance
Diagnosis
Cervical Cytology
The Results of Cervical Cytology
Interpretation of Cervical Smears
The Significance of a Positive Cervical Smear
Value of Cytodiagnosis
Colposcopy and Colpomicroscopy
Cone Biopsy
HPV Typing
Treatment
Curative Punch Biopsy
Cryotherapy
Carbon Dioxide Laser
Loop Electrosurgical Excision Procedure (Large Loop Excision of the Transformation Zone)
Cervical Conisation
Total Hysterectomy
UTERINE CORPUS
Endometrial Hyperplasia
Pathology
Simple Hyperplasia (Cystic Glandular Hyperplasia)
Complex Hyperplasia (Adenomatous Hyperplasia)
Atypical Hyperplasia
Aetiology
Clinical Features
Treatment
Squamous Cell Metaplasia of the Endometrium
Pathology
Aetiology
Treatment
Other Forms of Endometrial Metaplasia
FALLOPIAN TUBE
CHAPTER 26:
Genital Cancers
IMPORTANCE OF GENITAL CANCER
TREATMENT AND RESULTS
PREVENTION OF PELVIC CANCER
EARLY DIAGNOSIS
Propaganda and Education of the Public
Routine Medical Examination
Cytodiagnosis
Techniques
Vaginal Cytology
Cervical Scrape
Intracervical and Intrauterine Aspiration Techniques
Peritoneal Cytology
Application of Cervical Cytology
Colposcopy
Cervicography
Ultrasound
Tumour Markers
GENERAL MANAGEMENT OF THE CANCER PATIENT
Attention to General Health
Should the Patient be Told the Diagnosis?
MANAGEMENT OF ADVANCED PELVIC CANCER
Conservative Approach
General Care
Relief of Pain
Visceral
Somatic
Haemorrhage
Swelling of the Leg
Urinary Tract Symptoms
Incontinence of Faeces
Chemotherapy
Cell Growth Cycle
Types of Drugs
Alkylating Agents
Alkylating-like Agents
Antimetabolites
Antitumour Antibiotics
Plant Products
Other Agents
Dangers
Treatment Regimens
Hormone Therapy
Radical Surgery
Exenteration
CHAPTER 27:
Tumours of the Vulva
SWELLINGS OF THE VULVA
VARICOSE VEINS
OEDEMA
RETENTION CYSTS
Sebaceous Cysts
Epidermoid Cyst; Implantation Dermoid
Hymeneal and Clitoridal Cysts
BENIGN NEOPLASMS
Condylomata Acuminata (Vulvar Warts)
MALIGNANT NEOPLASMS
Squamous Cell Carcinoma (Invasive)
Pathology
Aetiology
Spread
Diagnosis
Clinical Features
Treatment
Prevention
Surgical
Radiotherapy
Treatment of Recurrent Cancer of the Vulva
Diathermy Coagulation
Basal Cell Carcinoma
Malignant Melanoma; Sarcoma
Melanoma
Sarcoma
Metastatic Tumours
TUMOURS OF BARTHOLIN’S GLAND
Bartholin’s Cyst
Pathology
Aetiology
Clinical Features
Complications
Treatment
Neoplasms of Bartholin’s Gland
URETHRAL TUMOURS
Prolapse of the Urethra
Acute
Chronic
Diverticulum of the Urethra
Cysts of Skene’s (Paraurethral) Tubules
Urethral Caruncle
True Caruncle
Pathology
Clinical Features
Treatment
Granulomatous Caruncle or Diffuse Caruncle
Pathology
Clinical Features
Treatment
Other Urethral Papillomas
Carcinoma of the Urethra
Pathology
Clinical Features
Treatment
TUMOURS OF THE INGUINAL CANAL
CHAPTER 28:
Tumours of the Vagina
SWELLINGS OF THE VAGINA
VAGINAL CYSTS
Cysts of Vestigial Structures
Types
Müllerian
Wolffian
Others
Clinical Features
Treatment
Cyst of Skene’s Tubules
Diverticulum of Urethra
Epidermoid Cyst; Implantation Dermoid
Endometriotic Cysts
Anterior Vaginal Wall Cyst
BENIGN NEOPLASMS
Types
Papilloma
Angioma
Adenoma
Fibroma and Lipoma
Myxoid-soft Tissue Tumours
Clinical Features
Treatment
MALIGNANT NEOPLASMS
Primary
Vaginal Intraepithelial Neoplasia
Squamous Cell Carcinoma
Incidence and Aetiology
Spread
Clinical Features, Diagnosis and Staging
Histopathologic Grades (G)
Regional Lymph Nodes (N)
Distant Metastasis (M)
Treatment
Invasive Carcinoma
Surgery
Radiation Therapy
Adenocarcinoma
Melanoma
Sarcoma
Secondary
Direct Extension
Blood and Lymphatic Spread
Seeding
CHAPTER 29:
Tumours of the Cervix Uteri
ENLARGEMENTS OF CERVIX
CYSTS OF THE CERVIX
Cysts of Embryonic Tissues
ENDOMETRIOTIC OR ENDOCERVICOTIC CYSTS
Nabothian Follicles or Cysts
Pathology
Clinical Features
Treatment
BENIGN NEOPLASMS
Papilloma
Angioma and Allied Tumours
Adenoma: Adenofibroma
Pathology
Clinical Features
Treatment
Leiomyoma
CARCINOMA OF THE CERVIX
Aetiology
Age
Race
Social and Economic Factors
Coitus
Childbearing
Cervical Irritation and Infection
Oestrogens
Predisposing Histological States
Types of Cancer; Pathology
Histopathologic Types
Histopathologic Grades (G)
Adenocarcinoma
Squamous Cell Carcinoma
Spread
Direct Extension
Lymphatic Permeation and Embolism
Bloodstream
Symptoms
Physical Signs
Complications
Cervical Screening
Principles
Screening Guidelines
Age Group to be Screened
Frequency of Screening
Management of Cervical Cytology Results
Diagnosis
Cervical Biopsy
Cytodiagnosis
Colposcopy and Colpomicroscopy
Clinical Staging of Disease
Rules for Classification
Regional Lymph Nodes (N)
Distant Metastasis (M)
Prognosis
The Extent of Growth at the Time of Treatment
Site
Naked-Eye Appearance
Histology
Age
Ureteric Obstruction
Treatment of Invasive Cancer
Assessment of the Case Before Treatment
Computed Tomography
Magnetic Resonance Imaging
Radiotherapy
Techniques of Radiotherapy
External Irradiation
Intracavitary Radiotherapy (ICRT)
Interstitial Brachytherapy
Complications of Radiotherapy
Morbidity during Treatment
Late Effects
Surgery
Indications
Complications
Combined Radiotherapy and Surgery
Chemotherapy
Ultraradical Surgery and Palliation
Results
Radiotherapy
Surgery
Combined Radiotherapy and Radical Surgery
RELAPSE
Management of Patients who Relapse after Primary Treatment
Therapeutic Options for Local Relapse after Primary Surgery
Further Observation
Stump Carcinoma
Carcinoma after Simple Hysterectomy
Carcinoma of the Cervix Complicated by Other Pelvic Conditions
Carcinoma of the Cervix and Pregnancy
Carcinoma of the Cervix Associated with Uterine Leiomyomas and Ovarian Cysts
Carcinoma of the Cervix Associated with Salpingo-Oophoritis
OTHER MALIGNANT TUMOURS OF THE CERVIX
CHAPTER 30:
Tumours of the Corpus Uteri
ENLARGEMENT OF UTERUS
POLYPS
BENIGN NEOPLASMS
Adenoma
Pathology
Clinical Features
Treatment
Leiomyoma (Myoma, Fibromyoma)
Pathology
Aetiology
Associated Conditions
Sites
Symptoms
General Effects
Menstrual Disturbances
Pressure Symptoms
Symptoms Related to Pregnancy
The Effect of Pregnancy on Leiomyomas
Physical Signs
Differential Diagnosis
Treatment
Curettage or Endometrial Aspiration
Polypectomy and Vaginal Myomectomy
Abdominal Myomectomy
Laparoscopic Myomectomy
Myoma Coagulation (Myolysis)
Embolotherapy
Hysterectomy
Complications of Leiomyomas
Malignant Change
Degeneration
Haemangioma and Allied Tumours
Other Rare Benign Tumours
MALIGNANT NEOPLASMS
Carcinoma of the Endometrium
Incidence
Aetiology
Age
Parity
Race
Diabetes Mellitus and Metabolic Errors
Oestrogens: Hyperplasia of the Endometrium
Tamoxifen
Senile Endometritis and Pyometra
Pathology: General Considerations
Adenocarcinoma in situ of the Endometrium
Pathology
Invasive Carcinoma of the Endometrium
Pathology
Adenocarcinoma
Squamous Carcinoma
Spread
Direct Invasion
Lymphatic
Bloodstream
Seeding
Metastases
Clinical Features
Diagnosis
Cytodiagnosis
Endometrial Aspiration
Hysteroscopy and D&C
Transvaginal Ultrasound and Saline Infusion Sonography
CT Scan and MRI
Serum CA-125
Staging
Prognosis
Treatment
Surgery
Surgery and Radiotherapy
Radiotherapy Alone
Chemotherapy and Hormone Therapy
Treatment of Vaginal Metastases
Results and Follow-Up
Choriocarcinoma
Sarcoma of the Uterus
Pathology
Low-Grade Stromal Sarcoma (Endolymphatic Stromal Myosis)
High-grade Stromal Sarcoma
Leiomyosarcoma
Spread
Clinical Features
Treatment
Mixed Müllerian Tumours
Clinical Features
Rhabdomyosarcomas
Other Rare Uterine Tumours
Melanoma
Haemangiopericytoma
Leukaemic and Lymphadenomatous Growths; Lymphomas
CHAPTER 31:
Tumours of the Fallopian Tubes
BENIGN NEOPLASMS
SECONDARY MALIGNANT NEOPLASMS
PRIMARY MALIGNANT NEOPLASMS
Choriocarcinoma
Histopathologic Types
Histopathologic Grades
Regional Nodes (N)
Distant Metastasis (M)
Pathology
Clinical Features
Treatment
Follow-Up
CHAPTER 32:
Tumours of the Pelvic Ligaments
CYSTS OF THE BROAD LIGAMENT AND ASSOCIATED STRUCTURES
Pathology
Gärtner’s Duct
Kobelt’s Tubules
Epoophoron and Paroophoron
Complications
Clinical Features
Treatment
NEOPLASMS OF THE PELVIC LIGAMENTS AND CONNECTIVE TISSUES
NEOPLASMS OF THE PERITONEUM
Peritoneal Carcinomas
Mesotheliomas
CHAPTER 33:
Tumours of the Ovary
OVARIAN ENLARGEMENTS
DISTENSION OR RETENTION CYSTS
TYPES
Atretic Cysts
Germinal Inclusion Cysts; Walthard Inclusions
Follicular and Theca Lutein Cysts
Pathology
Chronic Hyperaemia
An Excessive Gonadotrophin Stimulus
An Abnormal Gonadotrophic Stimulus
Symptoms
Menstrual Disturbance
Treatment
Corpus Luteum Cysts
Luteoma of Pregnancy
OVARIAN NEOPLASMS
Primary Ovarian Tumours
Overview
Pathology
Epithelial Ovarian Tumours
Mutinous Cystadenoma
Endometrioid Tumours
Clear Cell (Mesonephroid) Tumours
Brenner Tumour
Undifferentiated Carcinoma
Ovarian Adenocarcinoma
Tumours of Borderline Malignancy
Sex Cord Stromal Tumours
Granulosa and Theca Cell Tumours
Androblastomas
Gynandroblastoma
Sex Cord Mesenchymal Tumour with Annular Tubules
Lipoid Cell Tumours
Germ Cell Tumours
Germ Cell Tumours with Embryonic Differentiation
Germ Cell Tumours Showing Extraembryonic Differentiation
Undifferentiated Germ Cell Tumours
Mixed Germ Cell Tumours
Connective Tissue Tumours
Fibroma
Adenofibroma
Other Benign Connective Tissue Tumours
Meigs’ Syndrome
Primary Sarcoma
Clinical Features
Age Incidence
Genetic Factors
Symptoms
Physical Signs
Diagnosis
AGE
PAIN AND TENDERNESS
Rapidity of Growth
The Consistency of the Tumour (Fig. 33.17)
Number of Tumours
Fixation of the Tumour
Ascites
Oedema of the Feet and Vulva; Varicosities
Metastases
Borderline Tumours
Complications
Torsion of the Pedicle (see Fig. 33.18)
Haemorrhage into or from a Cyst
Rupture of a Cyst
Degeneration
Infection
Intestinal Obstruction
Malignancy
Staging of Ovarian Cancer
Treatment
Ultrasound-Guided Cyst Aspiration
Paracentesis
Surgery
Indications
Types of Procedure
Conservative Surgery
Treatment of Borderline Tumours
Stage I Low-Grade, Low-Risk
Stage I High-Grade, High-Risk
Cytoreductive Surgery for Advanced-Stage Disease
Goals of Cytoreductive Surgery
Exploration
Pelvic Tumour Resection
Omentectomy
Radiotherapy
Chemotherapy
Follow-Up
Second-Look Laparotomy (SLL)
Results
Metastatic (Secondary) Ovarian Tumours
Carcinoma
Origin
Pathology
BRCA1 and BRCA2
Lynch II Syndrome
Treatment
Leukaemia and Lymphoma
Origin and Pathology
Treatment
Carcinoid Tumours
Tumours of the Ovary Associated with Carcinoma of the Body of the Uterus
OVARIAN AND PAROVARIAN TUMOURS AND PREGNANCY
Pathology
Differential Diagnosis
Treatment
A Tumour Less than 10 cm in Diameter and not Solid
A Tumour Found in the First 3 Months of Pregnancy
A Tumour Found after the Twenty-Eighth Week of Pregnancy
A Tumour Obstructing Labour
A Tumour which is Complicated
CHAPTER 34:
Chemotherapy in Gynaecological Malignancies
INTRODUCTION
CLINICAL USE OF CHEMOTHERAPY
ASSESSMENT OF RESPONSE TO CHEMOTHERAPY
CHEMOTHERAPY AND THE CELL CYCLE
STEM CELL THEORY
CELL-KILL HYPOTHESIS
THERAPEUTIC AGENTS USED IN THE TREATMENT OF GYNAECOLOGICAL CANCER
Alkylating Agents
Cisplatin and Carboplatin
Antimetabolites
Antitumour Antibiotics
Taxanes
Chemotherapy Toxicity
Bone Marrow Suppression
Nausea and Vomiting
Alopecia
Renal Toxicity
Cardiotoxicity
CHEMOTHERAPY RESISTANCE OF CANCER CELLS
POOR HOST DEFENCES
PROTECTED TUMOUR SANCTUARIES
Secondary Malignancies
ROUTE OF ADMINISTRATION
CHAPTER 35:
Radiotherapy in Gynaecological Malignancies
INTRODUCTION
THE BIOLOGICAL BASIS OF RADIOTHERAPY TREATMENT
RADIATION DOSAGE
THE THERAPEUTIC RATIO
RADIOTHERAPY MACHINES
BRACHYTHERAPY
RADIOTHERAPY IN ENDOMETRIAL CANCER
Endometrial Cancer Confined to Uterus Body
Clinicopathologic Prognostic Variables
AGGRESSIVE HISTOLOGICAL VARIANTS
RADIOTHERAPY IN CARCINOMA CERVIX
BRACHYTHERAPY IN CARCINOMA CERVIX
EXTERNAL RADIATION THERAPY TECHNIQUES
CHEMORADIATION IN LOCALLY ADVANCED CARCINOMA CERVIX
Radiotherapy
Combined Treatment with Surgery and Radiotherapy
CHAPTER 36:
Immunotherapy in Obstetrics and Gynaecology
INTRODUCTION
DEFINITION
BASICS OF IMMUNOTHERAPY
CAUSES OF FAILURE OF IMMUNOSURVEILLANCE
TUMOUR-ASSOCIATED ANTIGENS
Some Specific Tumour-Associated Antigens
HER-2/NEU
Folate-Binding Protein
MUC-1
Carcino Embryonic Antigen
p53
Sialyl–Tn
TYPES OF IMMUNOTHERAPY
Active Immunotherapy
Specific Vaccines
Nonspecific vaccines
Anti-idiotype Antibodies
Passive Immunotherapy/Adoptive Immunotherapy
Specific
Nonspecific
MONOCLONAL ANTIBODIES AS THERAPEUTIC AGENTS
Application and Uses
Anti-HER-2/NEU MOAB (Trastuzumab)
Anti-CA125 Antibodies: (B 43.14)
Bispecific Monoclonal Antibodies
Radio-Immuno Conjugates
Immunotoxins
Disadvantages of Monoclonal Antibodies
OTHER AREAS OF APPLICATION OF IMMUNOTHERAPY IN OBSTETRICS AND GYNAECOLOGY
Cancer Cervix
Vaccines in Cancer Cervix (CaCx)
Immunotherapy in Cervical Atypias and Cervical Dysplasias
Gestational Trophoblastic Disease
Endometriosis
Immunotherapy in Recurrent Pregnancy Loss
Immunotherapy in Antiphospholipid Antibody Syndrome (APAS)
Immunotherapy in Septic Shock
CHAPTER 37:
Amenorrhoea, Hypomenorrhoea and Oligomenorrhoea
AMENORRHOEA
AETIOLOGY
Physiological Amenorrhoea
Before Puberty
Adolescence
Pregnancy
Lactation
Menopause
Pathological Amenorrhoea
Hypothalamic Amenorrhoea
Pituitary Amenorrhoea
Ovarian Amenorrhoea
Uterine Amenorrhoea
Other Aetiological Factors
Endocrine Disorders
Thyroid
Pancreas
Adrenal Cortex
General Constitutional Upset and Disease
Any Acute Illness
Chronic Diseases
Nutrition
Environment
Exercise-Related Amenorrhoea
Investigation
Clinical Examination
Special Investigations
Tests for Pregnancy
Radiology
Ophthalmology
Urinalysis
Hormone Assays
Chromosome Studies
Ultrasound
Laparoscopy
Therapeutic Tests
Treatment
Treatment of the Cause
General Treatment
Hormone Therapy
Thyroid
Corticosteroids
Oestrogen and Progestogen
Clomiphene
Gonadotrophins
Clomiphene and Gonadotrophins
Gonadotrophin-Releasing Hormone Agonists
Agents Influencing the Hypothalamus
Surgical Treatment
Results
HYPOMENORRHOEA
Definition
Causes
Constitutional
Uterine
Hormonal
Nervous and Emotional
Treatment
OLIGOMENORRHOEA
Definition
Causes
Constitutional and Physiological
Hormonal
Chromosomal
Treatment
CHAPTER 38:
Abnormal and Excessive Uterine Bleeding
CLINICAL TYPES
CAUSES OF ABNORMAL UTERINE BLEEDING
General Systemic Diseases
Coagulation Defects
Endocrine Disorders; Hyperoestrogenism
Pelvic Pathology
Pregnancy States
Errors in Uterine Development Infections
Infection
Local Injury: Foreign Bodies
Displacements
Endometriosis
Tumours
Ovarian
Neoplasms
Uterine
Surface Growths
Chronic Symmetrical Enlargement of the Uterus
Deep Venous Thrombosis
Psychological Upsets
Menorrhagia
Dysfunctional Uterine Bleeding
Predisposing Factors for DUB
Ovulatory Bleeding
Polymenorrhoea and Polymenorrhagia
Anovulatory Bleeding
DIAGNOSIS
Clinical Examination
Haematological and Endocrine Evaluation
Ultrasound
Hysteroscopy
Hysterosalpingography and Sonosalpingogram
Endometrial Sampling
Magnetic Resonance Imaging
Angiography and Venography; Colour Doppler
TREATMENT
General
Medical Management
Nonhormonal Methods
Hormones
Oestrogens
Oestrogens and Progestogens
Progestogens
Treatment
Adolescents
Young Women
Premenopausal Women
Surgical Measures
Androgens
GnRH Analogues
Surgery
Curettage
MIRENA (Levonorgestrel Intrauterine Device)
Mode of Action
Side Effects
Efficacy
Endometrial Effects
TRANSCERVICAL ENDOMETRIAL RESECTION
Criteria for Transcervical Endometrial Resection
Technique
Anaesthesia
Complications
Advantages
MICROWAVE ENDOMETRIAL ABLATION
Physics
Treatment
Contraindication
Analgesia
Procedure
Safety
Global Endometrial Ablation Techniques
Hysterectomy
Radiotherapy
Advantages
Disadvantages
SPECIAL CLINICAL TYPES OF BLEEDING
Ovulation Bleeding
Clinical Features
Cause
Treatment
Prepubertal Bleeding
Precocious Puberty
Nonmenstrual Bleeding
Genital Crisis in the Newborn
Pubertal Bleeding
Perimenopausal Bleeding
Postmenopausal Bleeding
Causes
Investigation and Treatment
Menopausal Transition
Abnormal Bleeding
Evaluation
Vaginal Ultrasonography
Endometrial Sampling
Hysteroscopy with Uterine Curettage
CHAPTER 39:
Dysmenorrhoea
INTRODUCTION
PRIMARY DYSMENORRHOEA
Frequency
Aetiology
Behavioural and Psychological Factors
Muscular Incoordination and Uterine Hyperactivity
Hormone Imbalance
Prostaglandins
Other Factors
Clinical Features
Treatment
Prevention
General
Drugs
Prostaglandin Synthetase Inhibitors
Hormone Therapy
Calcium-Channel Blockers
Surgical Treatment
Laparoscopy
Dilatation of the Cervix
Injection of the Pelvic Plexus
Presacral Neurectomy (Fig. 39.1)
Results
SECONDARY DYSMENORRHOEA
Aetiology
Clinical Features
Investigations
Treatment
MEMBRANOUS DYSMENORRHOEA
OTHER CONDITIONS SIMULATING DYSMENORRHOEA
Menstrual Pain of Ovarian Origin
Corpus Luteum Haematoma
Ovulation Pain
Clinical Features
Cause
Treatment
Orthopaedic Conditions Simulating Dysmenorrhoea
CHAPTER 40:
Premenstrual Syndrome and Other Menstrual Phenomena
PREMENSTRUAL SYNDROME
Clinical Features
Aetiology
Differential Diagnosis
Treatment
General
Pyridoxine
Elimination of Fluid
Evening Primrose Oil
Serotonin Reuptake Inhibitors
Hormones
Other Drugs
Surgery
MENSTRUAL MIGRAINE
Clinical Features
Aetiology
Treatment
General
Hormone Therapy
Symptomatic
Artificial Menopause
PREMENSTRUAL MASTALGIA
Clinical Features
Cause
Treatment
RECURRENT (CYCLICAL) BUCCAL AND VULVAR ULCERATION
Clinical Features
Aetiology
Genetic Factors
Allergy
Virus Infection
Hormonal Influences
Psychological Factors
Treatment
PELVIC ALLERGY
VICARIOUS MENSTRUATION
Clinical Features
Cause
Treatment
CYCLICAL HAEMOTHORAX AND PNEUMOTHORAX
Cyclical Haemothorax
Cyclical Pneumothorax
MENSTRUAL EPILEPSY
Clinical Features
Treatment
CHAPTER 41:
Hormone Therapy in Gynaecology
OESTROGENS
Natural Oestrogens
Synthetic Oestrogens
Potency
Actions
Therapeutic Applications
General Principles
Methods of Administration
Oral
Percutaneous
Implants and Depots
Injectable
Indications
Vulvovaginitis of Infancy
Secondary Sex Characters
To Decrease Excessive Growth
Menopausal Symptoms and Changes
To Improve Healing
Vulvar Epithelial Disorders
Disorders of Ovulation and Menstruation
Coitus and Conception
Breast Conditions
Conditions in the Male
Adverse Effects
Toxicity
Metabolic
Inhibition of the Hypothalamus, Pituitary, Ovaries and Testes
Genital Tract
Thromboembolism
Breasts
Skin
Libido
Cancer
Miscellaneous
Contraindications
ANTI-OESTROGENS
PROGESTOGENS
Types and Sources
Natural Progestogens
Synthetic Progestogens
Actions
Therapeutic Applications
General Principles
Methods of Administration
Indications
Disorders of Menstruation and Ovulation
Conception and Pregnancy
Endometriosis
Hormone Replacement Therapy
Pelvic Cancer
Breast Conditions
Adverse Effects
Toxicity
Uterus
Menstrual Disturbance
Breasts
Libido; Coitus
Virilism
Hypertension
Thromboembolism
Metabolism
ANTIPROGESTOGENS
ANDROGENS
Types and Sources
Natural Androgens
Synthetic Androgens
Biological Actions
Metabolic Effects in Both Sexes
Actions in the Male
Actions in the Female
Sex Organs
Secondary Sex Characters
Therapeutic Applications
Methods of Administration
Implants
Indications
Uterine Leiomyomas
In the Male
Adverse Effects in the Female
Toxicity
Fluid Retention
Epiphyseal Closure
Virilism
ANTIANDROGENS
TYPES OF GONADOTROPHINS
Pituitary Gonadotrophins
Chorionic Gonadotrophins
Recombinant Gonadotrophins
Therapeutic Applications
Methods of Administration
Indications
In the Male
Adverse Effects
Contraindications
ANTIGONADOTROPHINS
GnRH Antagonists
GnRH Agonists
Actions
Therapeutic Applications
General Principles
Methods of Administration
Indications
In the Female
In the Male
Adverse Effects
HYPOTHALAMIC HORMONES
Types and Sources
Actions
Diagnostic Applications
Thyrotrophin-Releasing Hormone
Gonadotrophin-Releasing Hormone
Corticotrophin-Releasing Hormone
CHAPTER 42:
Vaginal Discharge
GENERAL CONSIDERATIONS
TYPES AND CAUSES
Physiological Discharges
Composition
Amount
Pathological Discharges
Leucorrhoea
Inflammatory Discharge
Infections
Bacterial Vaginosis
Diagnosis
Treatment
Trichomonial Vaginitis
Clinical Features
Vulvovaginal Candidiasis (Moniliasis)
Diagnosis
Treatment
Inflammatory Vaginitis
Chronic Cervicitis
Neoplasms
Cervical Polyps
Prognosis
Urinary and Faeculent Discharges
Rarities
INVESTIGATION OF VAGINAL DISCHARGE
Clinical History
Examination
Treatment
SYNDROMIC APPROACH TO VAGINAL DISCHARGE
CHAPTER 43:
Pruritus Vulvae and Vulvodynia
DEFINITION AND INCIDENCE
NATURAL DEFENCE MECHANISMS
Causes
PRURITUS ASSOCIATED WITH VAGINAL DISCHARGE (LEUCORRHOEA)
Vaginal Discharge
Vaginal Yeast Infection
Trichomonas Infection
Bacterial Vaginosis
Chlamydia Trachomatis
Neisseria Gonorrhoeae
Why Should Reproductive Health Services Focus on STIs/RTIs?
Symptomatology of Vaginal Discharge
PRURITUS WITHOUT VAGINAL DISCHARGE
Generalised Pruritus
Skin Diseases Not Specific to the Vulva
Animal and Fungal Parasitic Infections
Diseases of the Anus and Rectum
Conditions of the Urinary Tract
Allergy and Drug Sensitivity
Deficiency States
Psychological Factors
Epithelial Disorders of the Vulva
Chronic Vascular Changes
Investigation
Treatment
Results
VULVODYNIA
Three Approaches to STI/RTI Diagnosis
The Clinical Approach
The Aetiological Approach
The Syndromic Approach
STI Risk Assessment for Women
Use of Risk Assessment in the Vaginal Discharge Algorithm
Classification by Syndromes
Treatment Guidelines
Bacterial Vaginosis
Advantages and Limitations of Syndromic Management
Advantages of Syndromic Management
Limitations and Concerns
When Should Syndromic Management Be Used?
Role of Syndromic Management inVaginal Discharge
Syndromic Approach
Prevalence and Effectiveness of Syndromic Approach
Operational Aspects
Vestibulitis
CHAPTER 44:
Low Backache and Chronic Pelvic Pain
GENERAL CONSIDERATIONS
CAUSES IN THE GENITAL TRACT
Prolapse and Retroversion
Chronic Cervicitis
Tumours
Pelvic Congestion; Pelvic Varicocele; Premenstrual Syndrome
Uterine Contractions
Gynaecological Operations
EXTRAGENITAL CAUSES
Muscular and Ligamentary Lesions
Bone and Joint Lesions
Diseases of the Kidney and the Ureter
Diseases of the Rectum
Psychological Factors
MANAGEMENT AND TREATMENT
Chronic Pelvic Pain
Evaluation
Management
CHAPTER 45:
Problems of Sex and Marriage
INTRODUCTION
PHYSICAL SEX—COITUS
The Art of Coitus
Consummation of Marriage
Frequency of Coitus
Coitus During Menstruation
Coitus During and After Pregnancy
Continence
The Annulment of Marriage
Rape
MASTURBATION
APAREUNIA AND DYSPAREUNIA
Definition
Male Causes
Impotence
Anatomical Defects of the Phallus
Extreme Obesity
Ignorance
Female Causes
Physiological
Inaccessibility of the Vulva
Obstruction at the Introitus
Large Tumours of the Vulva and Lower Vagina
Obstructions in the Vagina
Superficial Painful Lesions
Deep-seated Painful Lesions
Diagnosis
Treatment
FEMALE FRIGIDITY
True Frigidity—Absence of Libido
Aetiology
Physiological
Constitutional
Early Impressions
Lack of Deep Affection for Husband
Fear
Contraception
Infertility
Prolonged Separation from her Mate
Ill Health, Physical Fatigue and Other Interests
Systemic Disease
Treatment
Failure to Achieve Orgasm
Aetiology
Premature Orgasm
NYMPHOMANIA
Aetiology
Constitutional
Frustration and Orgasmal Incapacity
Psychoses and Neuroses
Menopause
Treatment
COITAL DIFFICULTIES IN THE MALE
Impotence and Male Frigidity
Clinical Types
Aetiology
Problems of Sex and Marriage
Other Problems of Coitus and Conception
Organic Causes
Drugs and Other Toxic Agents
Treatment
General Treatment
Specialist Psychiatric Treatment and Support
Hormone Therapy
Vasoactive Agents
Sex Aids
Artificial Insemination
Premature Ejaculation
Aetiology
Treatment
HOMOSEXUALITY
TRANSVESTISM AND TRANS-SEXUALITY
Definition and Clinical Features
Treatment
PREMARITAL CHASTITY AND FAITHFULNESS IN MARRIAGE
What to Tell the Partner in Marriage
The Unmarried Mother
CHAPTER 46:
Infertility and Assisted Reproductive Technology
INFERTILITY
FREQUENCY
A CONCEPT OF FERTILITY
CAUSES OF INFERTILITY
Failure to Produce Spermatozoa in Sufficient Numbers and with the Capacity to Fertilise
Bilateral Obstruction of the Epididymis, the Vas or the Ejaculatory Ducts
Failure to Deposit Spermatozoa in the Vagina
Abnormal Semen Quality (Table 46.1)
Female
Ovarian Factors
Peritoneal Factors
Tubal Factors
Uterine Factors
Cervical Factors
Vaginal Factors
Coital Errors
Apareunia and Dyspareunia
Frequency and Timing of Coitus
Lubricants
Other Factors
Orgasm
Effluvium Seminis
Anxiety and Apprehension
Familial Disposition; Genetic and Constitutional Factors
Occupation and Environment
Diet
Contraception
THE INVESTIGATION OF INFERTILITY
When Should Infertility be Investigated
Clinical Assessment of Both Partners
History
Examination
Assessment of Male Fertility
Clinical
Semen Analysis
Sperm Function Tests
Sperm Penetration Assay
In Vitro Sperm Penetration Tests
Other Tests
Sperm Antibodies
Hormonal Assessment
Testicular Biopsy
Varicocele Assessment and Significance
Other Tests
Assessment of Female Infertility
Importance of Body Mass Index (BMI) and Obesity
Significance of Basal Hormonal Evaluation
Estimation of the Time and Frequency of Ovulation
Ultrasonography
Baseline Transvaginal Ultrasound Scan
Hormone Assays
Endometrial Biopsy
Tubal Patency Tests
Hysterosalpingography (Figs 46.3 to 46.5)
Hysterocontrastsonography
Contraindications to Tubal Patency Tests
Hysteroscopy and Laparoscopy
The Postcoital Test
Screening for Chlamydia Trachomatis
TREATMENT
Both Partners
Reassurance
Correction of Coital Difficulties
Correction of General Ill Health
The Husband
Impotence and Premature Ejaculation
Defective Spermatogenesis
Azoospermia: Classification and Treatment
Prevention of Male Infertility
The Wife
Medical Treatment (Flow chart 46.5)
Bromocriptine
Operative Treatment
Correction of Uterine Position and Malformations
Laparoscopic Ovarian Diathermy
Prevention of Female Infertility
ASSISTED REPRODUCTIVE TECHNOLOGY
In Vitro Fertilisation and Embryo Transfer
Controlled Ovarian Hyperstimulation
Oocyte Retrieval
Insemination
Embryo Transfer
Factors Affecting Embryo Transfer
Outcome
Cryopreservation
Oocyte Donation (Fig. 46.14)
Embryo Donation
Surrogacy
Intrauterine Insemination
Semen Preparation
Donor Insemination
Other ART Methods
Intracytoplasmic Sperm Injection
Laser Assisted Hatching
Preimplantation Genetic Diagnosis
RESULTS OF TREATING INFERTILITY
DANGERS OF INVESTIGATING AND TREATING INFERTILITY
Complications of ART
Twins and Higher-order Multiple Gestation
Ovarian Hyperstimulation Syndrome
Severe OHSS Mandates Hospitalisation
ADOPTION
CHAPTER 47:
Instruments in Gynaecological Procedures
INSTRUMENTS
SOME OF THE INSTRUMENTS MENTIONED WARRANT SPECIAL COMMENTS
Scissors
Artery Forceps (Fig. 47.3)
Tissue Clamps
Uterine Sound (Fig. 47.5)
Blunt and Sharp Curette
Sims Double Bladed Posterior Vaginal Speculum (Fig. 47.7)
Cusco’s Bivalve Self-retaining Vaginal Speculum (Fig. 47.8)
Anterior Vaginal Wall Retractor (Fig. 47.9)
Cervical Dilators (Fig. 47.10)
Vulsellum (Fig. 47.11)
SPECIFIC INSTRUMENTS USED ONLY FOR GYNAECOLOGICAL OPERATIONS
SUTURE MATERIALS
GYNAECOLOGICAL PROCEDURES
Speculum Examination
Procedure
Instruments Used
Other Instruments that may be Used
Vaginal Examination
Dilatation of Cervix and Curettage
Instruments Used
Contraindications
Complications
Endometrial Biopsy
Cervical Punch Biopsy
Steps
Hysteroscopy
Indications
Technique
Complications
Colposcopy
Technique
Indications
Laparoscopy
CHAPTER 48:
Ultrasonography in Gynaecology
ULTRASONOGRAPHY
NORMAL FEMALE PELVIS
Uterus
Ovaries
Folliculogenesis
Fallopian Tubes
Pouch of Douglas
ULTRASOUND OF THE UTERUS
Uterine Size (Figs 48.13 to 48.15)
Uterine Shape
Diseases of the Myometrium
Benign Conditions
Benign Tumours
Malignant Tumour
Diseases of the Endometrium
Benign Condition
Benign Tumours
Malignant Tumour
Diseases of the Uterine Cavity
Adenomyosis
Ultrasonographic Appearance (Figs 48.23 to 48.25)
Myometritis
Myometrial Calcifications
Leiomyoma
Arteriovenous Malformation
Sarcomatous Change Within Leiomyoma
Endometritis
Endometrial Hyperplasia
Endometrial Polyp (Figs 48.33 and 48.34)
Endometrial Carcinoma
Endometrial Fluid
Intrauterine Contraceptive Devices (Figs 48.44A and B)
Synechiea (Asherman’s Syndrome)
Sonohysterography (Figs 48.33, 48.34, 48.38, 48.39)
Ultrasound and Puerperium
Ultrasound Findings
DISEASES OF THE CERVIX
VAGINA
OVARIAN SONOGRAPHY
Benign Cystic Lesion of Ovarian and Paraovarian Structures
Functional Cysts
Ovarian Vascular Lesions
Ovarian Neoplasms
Functional Cysts
Surface Epithelial Inclusion Cysts
Rete Cysts
Lutein Cyst
Ovarian Hyperstimulation Syndrome
Polycystic Ovarian Syndrome
Ovarian Remnant Syndrome
Paratubal, Paraovarian Cysts
Endometriosis
Pelvic Inflammatory Disease
Peritoneal Inclusion Cysts
Ovarian Vascular Lesions
Ovarian Torsion
Massive Ovarian Oedema
Ovarian Venous Thrombosis
Ovarian Neoplasms
Surface Epithelial Stromal Tumours
Germ Cell Tumours
Sex Cord—Stromal Tumours
Metastatic Tumours
Evaluation of an Ovarian Mass
GESTATIONAL TROPHOBLASTIC DISORDERS
Complete Hydatidiform Mole
Partial Hydatidiform Mole
Invasive Hydatidiform Mole
Placental Site Trophoblastic Tumour
Choriocarcinoma
Pelvic Kidney (Fig. 48.70)
SUMMARY
CONCLUSION
CHAPTER 49:
Endoscopic Surgeryin Gynaecology
INTRODUCTION
LAPAROSCOPY
Advantages
Disadvantages
Indications for Laparoscopy
Diagnostic Laparoscopy
Operative Laparoscopy
Contraindications to Laparoscopy
Absolute
Relative
Equipment for Laparoscopy
Ancillary Instruments
Techniques of Laparoscopy
Patient Position
Pneumoperitoneum
Secondary Trocar Insertions
Diagnostic Laparoscopy
Operative Laparoscopy
Complications of Laparoscopy
Anaesthetic Complications
Patient Positioning
Pneumoperitoneum
Vascular Injury
Bowel Injury
Bladder Injury
Ureteral Injury
Trocar Hernias
Incidence of Complications
HYSTEROSCOPY
Advantages
Disadvantages
Indications
Indications of Operative Hysteroscopy
Contraindications
Equipment for Hysteroscopy
Telescope and Sheath
Operative Hysteroscope
Resectoscope
Ancillary Equipment
Distension Media
Fluid Delivery Systems
Technique of Hysteroscopy
Diagnostic Hysteroscopy
Operative Hysteroscopy
Complications of Hysteroscopy
Anaesthetic Complications
Patient Position
Distension Media
Surgical Complications
Failure of Resolution of the Presenting Symptoms
Incidence of Complications
CHAPTER 50:
Contraception
GENERAL CONSIDERATION
EPIDEMIOLOGY
Impact of Contraception throughout World
EFFICACY OF CONTRACEPTION
Pearl Index
Life Table Analysis
INDICATIONS FOR CONTRACEPTION
CONTRACEPTIVE METHODS
NATURAL FAMILY PLANNING METHOD
Fertility Awareness Based Method or Traditional Methods
Lactational Amenorrhoea Method
Advantages of Natural Family Planning
Disadvantages
Coitus Interruptus (Withdrawal Method)
BARRIER METHODS
Condoms
Male Condoms
Female Condoms (Fig. 50.4B)
Diaphragm (Dutch Cap)
Cervical Cap (Fig. 50.7)
Fem Cap
Contraceptive Sponge or Today Sponge
Spermicides
INTRAUTERINE CONTRACEPTIVE DEVICES
History
Types of IUCDs (Figs 50.9 to 50.25)
Lippes Loop
Copper Releasing IUCDs
Hormone-releasing IUCDs
Future IUCDs
Mechanism of Action
Time of Insertion
Insertion Technique (Fig. 50.26)
Further Supervision and Management
Indications
Contraindications
Efficacy of IUCDs
Expulsion
Ectopic Pregnancy
Adverse Effects and Complications of IUCDs
Advantages
COMBINED HORMONAL CONTRACEPTION (FLOW CHART 50.1)
Combined Oral Contraceptive Pills
Formulations
Missing Pills
Mode of Action
Action of Oestrogen
Action of Progestogens
Technique
Efficacy
Advantages
Contraindications
Side Effects
Other Side Effects
Arterial Thrombosis
Myocardial Infarction
Stroke
Hypertension
Other Metabolic Effects
Risk of Cancer
Fertility and Oral Contraception
Breastfeeding
Amenorrhoea
Migraine Headaches
Drugs that Affect Efficacy
The Benefits of Low Dose Oral Contraceptive Pills
Other Uses
Technique
Contraceptive Patch (EVRA)
Use
Missed Patch Changes
Efficacy
Combined Contraceptive Vaginal Ring (Fig. 50.57)
Combined Injectable Contraceptive (LUNELLE)
Progestogen Only Contraception
Indications
Contraindications
Progestogen Only Pills (Minipill)
Mode of Action
Pill Taking
Side Effects
Progesterone Only Injectables
Mechanism of Action
Indications
Contraindications
Efficacy
Side Effects
Other Side Effects
Progestogen Only Implants (Norplant)
Mechanisms of Action
Insertion
Efficacy
Advantages
Disadvantages
Indications
Contraindications
Side Effects
LNG Rod
Implanon (Fig. 50.59)
Mechanism of Action
Uniplant
Biodegradable Implant Contraception
Capronor
Norethindrone Pellet or Anuelle
Progestogen Intrauterine System (Mirena)
Structure
Mechanism of Action
Time of Insertion
Efficacy
Indications
Adverse Effects
Changes in Bleeding Pattern
Risk of Pelvic Inflammatory Disease
Risk of Ectopic Pregnancy
Return to Fertility
Expulsion
Perforation
Lost Threads
Delayed Follicular Atresia
Insertion and Removal
EMERGENCY POSTCOITAL CONTRACEPTION (MORNING AFTER PILLS)
Indication
Advantages
Hormonal Emergency Contraception
Combined Oestrogen and Progestogen Pills
Levonorgestrel Only Pills
Newer Emergency Contraceptives
Mechanical Emergency Contraception
Indication
Advantages
Disadvantages
Mechanism of Action
Efficacy
Others
OTHER METHODS OF CONTRACEPTION
Immunological Method
Male Contraceptive Pill
Choice of Contraception
Postpartum Choice of Contraception
The Rule of 3’s
Oral Contraception
Postpartum Intrauterine Contraceptive Device
Adolescent’s Choice of Contraception
Choice of Methods
Contraception Choice for Older Women
CONTRACEPTION AND LITIGATION
CHAPTER 51:
Sterilisation and Termination of Pregnancy
STERILISATION
Definition
Legal Position
Indications
Permanent Ill Health of the Potential Mother
Permanent Ill Health of the Potential Father
Diseases and Genetic Faults Transmissible to the Foetus
Previous Obstetrical Complications and Operations
Family Limitation
Population Control
FEMALE STERILISATION
Techniques
Laparoscopic Sterilisation
Obstructing the Tubes via the Uterus
Contraindications
Reliability
Adverse Effects of Tubal Resection
Immediate
Remote
MALE STERILISATION
Techniques
Vasectomy
Contraindications
Reliability of Vasectomy
Adverse Effects of Vasectomy
No-scalpel Vasectomy
Other Methods
COMPULSORY STERILISATION
TERMINATION OF PREGNANCY
Ethical and Legal Considerations
Indications for Therapeutic Abortion
Pre-existing Maternal Disease
Heart Disease
Severe Degrees of Chronic Hypertension
Kidney Disease
Pulmonary Disease
iseases of the Alimentary Tract
Diseases of the Central Nervous System
Psychiatric Disorders
Malignant Disease
Diseases of Pregnancy
Foetal Disease and Malformation
Methods of Terminating Pregnancy
First Trimester Termination
Suction Curettage
Mid-trimester Abortion
Prostaglandins
Ethacridine Lactate
Surgical Methods
Hysterotomy
Hysterectomy
Dangers and Complications
Mortality
Morbidity
Remote Psychological
Remote Physical
ABORTION AS A MEANS OF CONTRACEPTION
“Lunchtime” Abortions
Menstrual Regulation
CHAPTER 52:
Urinary Problems
BLADDER DYSFUNCTION
Bladder Irritability and Instability
Causes of Bladder Dysfunction
Polyuria
Mechanical Factors
Displacement of the Bladder
Pelvic and Lower Abdominal Tumours
Adhesions and Bands in the Uterovesical Pouch
Incomplete Emptying of the Bladder
Diseases of Organs Adjacent to the Trigone
Diseases of the Renal Pelvis and Ureter
Diseases of the Bladder
Trigonitis
Diseases of the Urethra
Urethral Prolapse
Diseases of the Vulva and Vagina
Diseases of the Central Nervous System
Functional: The Psychogenic Bladder
Hypotonic Bladder
URETHRAL SPHINCTER DYSFUNCTION
Stress Urinary Incontinence
Anatomical Classification (Blaivis and Olsson, 1998)
Grading of Stress Urinary Incontinence
The Urethral Sphincter
The Urethral Length
The Pelvic Floor
Detrusor Sphincter Dyssynergia
INVESTIGATION OF URINARY PROBLEMS
History and Examination
Examination of the Urine
Uroflowmetry
Cystometry
Urethral Profilometry
Electromyography
Cystourethroscopy
Radiological Studies
Ultrasound
TREATMENT OF URINARY PROBLEMS
Infection
Detrusor Dysfunction
Sphincter Dysfunction
INCONTINENCE OF URINE
Continual Incontinence
Overflow Incontinence
Urge Incontinence
Stress Incontinence
Definition and Clinical Features
Demonstration of Stress Incontinence
Investigation of Urinary Incontinence
Diagnosis of GSI
Medical Management
Mechanical Devices
The Surgical Management of Stress Incontinence
Abdominal and Combined Abdominal-vaginal Approach
Tension-free Vaginal Tape (Table 52.4)
Postoperative Management
Pregnancy after Cure of Stress Incontinence
ENURESIS
Aetiology
Natural Variability in Age
Organic Disease
Psychological Disturbances
Subnormal Bladder Capacity
Management and Treatment
URINARY RETENTION AND DIFFICULTY IN MICTURITION
Causes and Mechanisms of Retention
The Bladder Detrusor Muscle may Fail to Contract and thus to Open the Upper Urethra
Interference with the Opening of the Internal Sphincter
Spasm of the Voluntary External Urethral Sphincter
Obstruction of the Urethra
Treatment
URINARY TRACT INFECTIONS IN WOMEN
Incidence
Definitions
Aetiopathogenesis
Host Risk Factors
Bacterial Factors
Diagnosis
History of Symptoms
Investigation
Treatment
Common Antibacterials
Common Treatment Regimens
Single-dose Treatment
Three Days Course
Other Regimens
Aminoglycocides (Injectable)
General Treatment Measures
Special Conditions
Recurrent UTIs/Recurrent Cystitis
Acute Cystitis
Acute Pyelonephritis
CHAPTER 53:
Menopause
INTRODUCTION
HISTORY
DEFINITIONS AND STAGING OF MENOPAUSE
The Menopausal Transition
Postmenopause
As Defined by WHO
Early Postmenopause
Senescence
Another Menopause Staging was First Published by Dr Behram Anklesaria in 1997 (Fig. 53.1)
Factors Influencing Age of Menopause
PHYSIOLOGY OF MENOPAUSE
Hormonal Changes
Final Hormonal Changes with Established Menopause
PROBLEMS ASSOCIATED WITH MENOPAUSE
EFFECT OF OESTROGEN DEFICIENCY
Brain and Central Nervous System
Hot Flushes
Physiology of Hot Flushes
Diagnostic or Metabolic Workup for Differential Diagnosis of Hot Flushes
Management
Mood Changes and Cognitive Function
Migraines
Vision
Collagen
Urogenital Atrophy
Urinary Symptoms at Menopause
Recommendation
Treatment Includes
Weight Gain and Loss of Muscle Mass or Sarcopaenia
Changes in Fat Distribution
Causative Factors for These Changes
Prevention of Weight Gain
Bone Loss (Osteoporosis) and Fracture Risk
Risk Factor Assessment
Role of Oestrogen in Osteoporosis
Biochemical Markers of Bone Turnover
Spinal Complications of Osteoporosis
Back Exercises for Kyphosis
Prevention and Management of Osteoporosis
Recommendations for Pharmacological Treatment
Cardiovascular Effects
Present Recommendations
MENSTRUAL PROBLEMS
Management of Bleeding on Postmenopausal Hormone Therapy
CANCER SCREENING IN MENOPAUSE
Recommendations for Screening for Breast Cancer
Management of Menopause
Creating Awareness
Lifestyle Modifications
Prescription of Exercise
Informed Consent for Hormone Therapy
Advantages of Hormone Therapy
VARIOUS TYPES OF HORMONAL AND NON-HORMONAL PHARMACOLOGICAL AGENTS AVAILABLE
Natural Oestrogens
Semisynthetic Oestrogens
Synthetic Oestrogens
Hormone Delivery System
Transvaginal Route
USE OF PROGESTERONE FOR HRT
Present Scenario of HT Risks and Contraindications
Key Points
HT IN SPECIAL CIRCUMSTANCES
Contraindications to HT
Gonadomimetic Agents
Temporal Implications of HRT Use
ANDROGENS IN MENOPAUSE
CHAPTER 54:
Hysterectomy and its Aftermath
INDICATIONS FOR HYSTERECTOMY
TYPES OF HYSTERECTOMY
Total Hysterectomy
Subtotal Hysterectomy
Advantages Over Total Hysterectomy
Disadvantages Compared to Total Hysterectomy
Panhysterectomy
Radical Hysterectomy
Schauta’s Operation (Radical Vaginal Hysterectomy)
ROUTES OF HYSTERECTOMY
Abdominal Hysterectomy
Vaginal Hysterectomy
Advantages Over Abdominal Hysterectomy
Disadvantages Compared to Abdominal Hysterectomy
Laparoscopy-assisted Vaginal Hysterectomy
Laparoscopic Supracervical Hysterectomy
Laparoscopic Doderlein Hysterectomy
SHOULD THE OVARIES BE REMOVED?
SHOULD THE UTERUS BE REMOVED AT THE TIME OF BILATERAL OOPHORECTOMY?
THE AFTERMATH OF HYSTERECTOMY
CHAPTER 55:
Conditions of the Lower Intestinal Tract
RECTAL PROLAPSE
Rectal Prolapse in Childhood
Rectal Prolapse in the Adult
Causes
Treatment
Surgical
Palliative
INCONTINENCE OF FAECES AND FLATUS
Causes
Neurological Conditions Affecting the Nervous Control of the Sphincters
Fistulas
Congenital Malformations
Descending Perineum Syndrome
Treatment
DIARRHOEA
DIFFICULT EVACUATION
Causes
Constipation
Pregnancy and Puerperium
Rectocele
Constriction of the Rectum and Anus
Malformations
Stricture Following Infection
Stricture Following Operation or Radiotherapy
Pelvic Tumours
Endometriosis
Carcinoma of the Rectum
Faulty Powers of Expulsion
Treatment
IRRITABLE BOWEL SYNDROME
Causes
Diagnosis
Treatment
Results
PRURITUS ANI
Causes
Threadworms
Fungus and Other Infections
Drugs; Allergy
Haemorrhoids, Fissure in Ano
Treatment
RECTAL AND ANAL PAIN
Fissure in Ano
Pathology
Symptoms
Signs
Treatment
Haemorrhoids
Pathology
Treatment
Treatment of Strangulated Haemorrhoids
Treatment Between Attacks
Infections
Radiation Proctitis
Proctitis
Endometriosis
Malignant Disease
Rectal Spasm; Proctalgia Fugax
Vaginal Neuralgia; Vaginal Myalgia
CHAPTER 56:
Preoperative and Postoperative Management: Postoperative Complications
INTRODUCTION
FLUID AND ELECTROLYTES
PREOPERATIVE MANAGEMENT
Preoperative Counselling
Routine Investigation
Surgery and Menstruation
Prophylactic Antibiotics
Preparation of the Bowel
Preparation of the Vagina
Preparation of the Bladder
Preparation of the Abdomen
Universal Precautions
POSTOPERATIVE MANAGEMENT
General
Analgesics and Hypnotics
Epigastric and Shoulder Pain
Fluid Replacement—Diet
Bowel Action
Attention to Bladder—Urinary Retention
POSTOPERATIVE EXAMINATION
POSTOPERATIVE COMPLICATIONS
Shock
Causes
Intravascular Volume Depletion
Mixed Aetiology
Treatment
Haemorrhage
Vaginal Site
Intrapelvic Site
Pyrexia
Retention of Urine
Anuria
Incontinence of Urine
Cystitis, Urethritis, Pyelonephritis
Causes
Clinical Features
Treatment
Results
Postoperative Vomiting
Causes
Treatment
Intestinal Distension and Colic
Paralytic Ileus
Clinical Features
Causes
Treatment
Intestinal Obstruction
Peritonitis
Types
Causes
Treatment
Wound Infection; Wound Disruption
Causes
Diagnosis
Treatment
Suppurative Thrombophlebitis
Superficial Venous Thrombosis
Deep Venous Thrombosis
Incidence and Site
Causes
Treatment
Pulmonary Embolism
Aetiology
Pathology
Clinical Features
Diagnostic Aids
Treatment
General
Anticoagulants
Embolectomy
Thrombolysins
Vena Cava Interruption
Pulmonary Complications
Adult Respiratory Distress Syndrome
Vaginal Discharge after Operations
Healing of Vaginal Incisions by Secondary Intention
Granulation Tissue
Cellulitis
Retained Foreign Body
Vaginitis
Cervical Discharge
Urinary and Faecal Fistulas
Rare Causes
CHAPTER 57:
Nutrition in Women from Adolescence to Menopause
INTRODUCTION
NUTRITION BASICS
PROTEINS
Sources of Proteins
Biological Values of Proteins
FATS
Background
Sources of Fats
Saturated Fatty Acids
Trans Fatty Acids
Monounsaturated Fats
Polyunsaturated Fats
Omega-6s (n-6)
Omega-3s (n-3)
Limit Omega-6 Fats
CARBOHYDRATES
Definition and Composition
Classification
What is the Glycaemic Index?
Glycaemic Index of Foods
Fibres
Sources of Fibres
Recommended Dietary Allowance
ENERGY
Physical Activity
Dietary Reference Intakes
Recommended Dietary Allowance
Adequate Intake
Tolerable Upper Intake Level
Estimated Average Requirement
ADOLESCENTS NUTRITION
Definition of Adolescents
Obesity in Adolescents
Obesity is Epidemic!
Parameters of Obesity
Aetiology of Obesity
Other Factors
Environmental Influences on Obesity
Prevention of Obesity in Adolescents
Anaemia in Adolescent Girls
Definition
Incidence
Diagnosis
Sources of Iron in Diet
Bioavailability or Iron Absorption
Folic Acid
Iodine Deficiency Disorders
Prevention and Control
Vitamin A Deficiency
Sources of Vitamin A
Clinical Signs of Deficiency
Prevention
Undernutrition or Stunting in Adolescents
Calcium Requirements in Adolescents
NUTRITION IN PREGNANCY
Causes of Maternal Mortality
What is Adequate Nutrition for a Childbearing Woman?
Macronutrients
Nutrition during Pregnancy
Physiological Changes in Pregnancy
Recommended Weight Gain by BMI (Weight in Kg/Ht in Sqm) (Table 57.11)
Energy Requirements during Pregnancy
Energy Requirement during Lactation
Iron
Calcium
Zinc
Iodine
Essential Fatty Acids
NUTRITION IN ELDERLY
Nutritional Requirements of Elderly
Energy
Protein
Carbohydrate
Fats
Minerals
Vitamins
Water
CONCLUSION
CHAPTER 58:
Exercise and Physiotherapy in Gynaecology
ACTIVE MUSCLE EXERCISES
Postnatal Exercises
Pelvic Floor Exercises
Preoperative Physiotherapy
Postoperative Exercises
ELECTRICAL STIMULATION OF PELVIC MUSCLES
SUPPORTING PESSARIES
Ring Pessaries
Hodge Pessary
Insertion and Management
Indications
Prolapse
Retroversion
Complications
Constipation
Urinary Incontinence
Vaginitis, Cervicitis, Ulceration of Vaginal Wall
Carcinoma of the Vaginal Wall
Impaction of the Pessary
Strangulation of Prolapsed Tissue
VAGINAL PACKING: TAMPONADE
Indications
Method
DOUCHING
Types of Douches
Cleansing
Antiseptic
Methods
Douche Can
Syringe or Whirling Spray
SHORT-WAVE THERAPY
Indications
Techniques
Results
INFRARED RADIATION
TRANSCUTANEOUS ELECTRIC NERVE STIMULATION
Indications
Technique
Results
ULTRASOUND
CHAPTER 59:
Applications of Laser in Gynaecology
INTRODUCTION
LASER SURGERY FOR CERVIX
Vaporisation Conisation
Excision Laser Conisation of the Cervix
LASER SURGERY OF THE VULVA
Condyloma Acuminata
Vulvar Intraepithelial Neoplasia
LASER SURGERY OF THE VAGINA
INTRA-ABDOMINAL LASER SURGERY
Gynaecologic Laser Laparoscopy
HYSTEROSCOPIC LASER SURGERY
CHAPTER 60:
Robotics Surgery
INTRODUCTION
da Vinci® Surgical System
FDA Approval
FEATURES OF ROBOTIC SURGERY (FIG. 60.1)
High-Definition 3D Vision
Precise, Collision-Free Movements
Ergonomic Comfort
Intuitive Motion
OVERVIEW
Set Up of the Operating Room
ADVANTAGES OF ROBOTIC SURGERY
Advantages of Robotic Surgery for the Surgeon
Advantages of Robotic Surgery for the Patient
RISKS OF ROBOTIC SURGERY
INNOVATIONS USED IN ROBOTIC SURGERY
EndoWrist® One Vessel Sealer
Features of EndoWrist® One Vessel Sealer (Fig. 60.6)
EndoWrist® One Suction/Irrigator for Da Vinci® Myomectomy
Potential Benefits(Table 60.1)
Fluorescence Imaging
Features
Potential Benefits
INDICATIONS FOR USE OF ROBOTIC SURGERY IN GYNAECOLOGY
ENDOMETRIOSIS
Endometriotic Resection Using the Robotic System
Adhesiolysis
Excision of Ovarian Endometrioma
Ureterolysis
Resection of Rectovaginal Nodules
Surgeon Benefits
MYOMECTOMY
Surgeon Benefits
Potential Patient Benefits
Potential Patient Risks
Myomectomy Using the Robotic System
Hysterotomy
Multilayered Suture Closure of Defect—Deep Layers
Enucleation
Multilayered Suture Closure of Defect—Superficial Layer
CRITICISM AND CONTROVERSIES
INDEX
TOC
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