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RWAMAGANA SCHOOL OF NURSING AND MIDWIFERY PO.

BOX 2 RWAMAGANA

COURSE OF GYNECOLOGY

2nd year nursing &midwifery

FACILITATOR: MUSENGIMANA

INFORMATIONS RELATED TO THE COURSE 1. COURSE DESCRIPTION Throughout this course different variations of structure and functions of female reproductive system will be discussed, it is important for a nurse and midwife to be familiar with various terminologies used in gynecology. Common problems encountered in gynecology will be discussed in detail in terms of prevention of risk and treatment.

2. BACKGROUND & PURPOSE OF COURSE The course aim is to enable the learner to understand and manage problems which can occur in female. 3. Course objectives At the end of this course, student will be able to: To define gynecological conditions and diseases To identify their etiologies To explain their pathogenesis To enumerate principal signs and symptoms of gynecological problems To diagnose gynecology diseases To manage client with gynecological diseases

4. TEACHING/LEARNING METHODS Lecturing Group discussions Presentations Case studies 5. REFERENCES Coad. (2008), Anatomy and physiology for midwives, 2nd edition, Churchill Livingstone,

London, U.K Dictionary of nursing (2007), 2nd edition, Black publisher ltd, London Elisabeth A Gangar (2001) Gynecological nursing, a practical guide, Churchill Livingstone, London, U.K Ellis Q. Y .Marcia S.D (2004) Womens health, a primary care clinical guide, 3rd edition. Pearson Education, Inc. Fraser D& Cooper M. (2003).Myles textbook for midwives, Churchill Livingstone, London, U.K Kerri D S and Frances E.L (2006) Womens gynecologic health, Jones and Bartlett, USA

UNIT I. INTRODUCTION

I.0.DEFINITION 1. Gynecology The branch of medicine particularly concerned with the health of the female organs of reproduction and diseases thereof. The word "gynecology" comes from the Greek gyno, gynaikos meaning woman + logia meaning study, so gynecology literally is the study of women. However, these days gynecology does not address all of women's medicine but focuses on disorders of the female reproductive organs. 2. REVIEW OF FEMALE REPRODUCTIVE ORGANS Areas of special concentration for gynecologists include disorders of the uterus, or womb: the organ where an unborn fetus develops; ovaries: the organs that produce ova, or eggs, which are the female sex cells; fallopian tubes: the channels connecting the uterus and ovaries; cervix: the organ that connects the vagina and uterus; vagina: the canal between the cervix and vulva, or external female organs; and breasts. It is very necessary to know that gynecology study the woman in her four periods of genital life: Pre-puberty Puberty : The stage in a person's life when they develop from a child into an adult because of changes in their body that make them able to have children: At puberty, pubic hair develops and girls begin Reproduction
Menopause : The time in a woman's life when she gradually stops having periods(mostly

between the ages of 40 and 50 )

Midwifes role in gynecological consultation

- Welcoming the client - Screening and orientation - Make clients file available - Empty the bladder and anus before any gynecological exam - Install the client. I.1.Investigations in gynecology
PHYSICAL EXAM

It starts by taking a history: because you cant examine a person to whom you dont have his history (personal, or of his disease).Taking history and physical examination go together and they are parts of clinical examination.
Personal data: name, age, marital status, social status, address Symptoms: complaint and duration, Obstetric history: number of pregnancy, antenatal care, premature birth, stillbirth,

abortion,
Gynaecological history: menstruation: age of onset, length of cycle, amount of

blood loss, pain


Vaginal discharge: character, color, purulent, quantity. Bowels: constipation, pain, difficulty on defecation Sexual history: dyspareunia, post-coital bleeding Past medical and surgical history: ask for a written report of treatment received

from other hospital


Social history: home condition, work condition. Family history: hereditary diseases, health. Current treatment: note this in detail for it may affect the course of management

of the condition
Summary: allow the patient to explain her symptoms freely; in this way it is

possible to assess her character and whether she tends to exaggerate or underrate her complaints.
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General

While some physicians perform each of these evaluations at every routine gynecologic visit, some perform only those which focus on specific issues for the specific patient. 1. Weight the patient Make an assessment of how her weight fits with standards for good health. Too much and too little weight is both problems. Compare the weight with previous weights to assess the trend. Make an assessment of how her weight fits with standards for good health. Too much and too little weight is both problems. Compare the weight with previous weights to assess the trend. 2. Blood Pressure Measure the blood pressure and the other vital signs, particularly among older women, elevated blood pressure is a common problem and one that may be effectively controlled or treated. Uncontrolled hypertension is associated with a number of serious medical consequences. A single elevation of blood pressure is usually not significant, particularly if the patient has some anxiety about being seen and examined. Blood pressure that is persistently 140 (systolic)or 90 (diastolic) is considered elevated. About 90% of hypertension is "primary" or "essential" hypertension. 5-10% is caused by chronic renal disease, and only 1-2% is caused by a curable condition. If hypertension is found, a basic laboratory workup to identify underlying illness might include: Urinalysis Creatinine Potassium Sodium Glucose Lipoproteins(Total cholesterol) 3. Inspection Look in their hair, eyes, Face.
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Check distribution of body hair, anaemia, oedema, Watch they eyes for symmetry, focus, and movement. Look for any facial muscle weakness appearing as a droop or asymmetry. Eye movements should be coordinated. The ability to read a sentence with each eye suggests intact ophthalmic, neurologic and higher brain function. Facial muscles should have symmetry. If she can read text off a page, you have confirmed the essential elements of neurologic function related to vision. Look in their ears While not always necessary, a quick look in the ears will confirm pearly-white drums, the absence of fluid behind the drum, clean canals and the absence of pain while pulling on the external ear to straighten the canal. Note any redness, drainage, or tenderness. She should be able to hear your whispering voice or the ticking of your watch. Inspect from the head to foot: the state of the mouth, axillaries adenopathy, chest (asymmetry), abdomen (ballonement,ligne blanche,..),varices and oedma (legs) 4. Palpation Feel the thyroid Checks the thyroid gland, many gynecologists routinely feel the thyroid for enlargement, tenderness or lumps which might suggest a thyroid nodule. Thyroid disease is more common among women than men, and increases in incidence with advancing age. Some menstrual abnormalities are associated with thyroid dysfunction and many hypothyroid patients, for example, have infrequent menstrual periods in addition to their fatigue and cold intolerance. Hyperthyroid patients are more likely to have heavy, frequent menstrual cycles. 5. Auscultate Listen to the lungs Listen for wheezes suggesting asthma, diminished breath sounds, or fine crackles, suggesting pneumonia or heart failure. Some apparently abnormal sounds will clear if the patient coughs.

Listen alternately in mirror image areas from one side of the chest to the other. Asymmetry in breath sounds will attract your attention. Listen to the heart Heart Note the regularity of the rhythm. Listen over the aortic, pulmonic, tricuspid and mitral valve areas for abnormal sounds such as clicks or murmurs. Any hyper dynamic state, such as pregnancy, leads to increased flow across the heart valves and leads, in many patients, to soft flow murmurs that are not ordinarily heard. The commonness with which these murmurs are heard during pregnancy should not lull the examiner into assuming all murmurs heard during pregnancy are innocent. GYNECOLOGICAL EXAM a) Breast examination Inspect and palpate for lumps, masses, tenderness, nipple discharge, or skin changes such as dimpling, retraction or crusting, dominant masses need further evaluation, sometimes with mammography, ultrasound and/or fine needle aspiration, bilateral nipple discharge may indicate hyperprolactinemia, unilateral nipple discharge, if bloody, may be the presenting finding with an intraductal papilloma. Most breasts can demonstrate a drop or two of clear to white or greenish fluid if the ducts are stripped. b) Abdomen Inspection, Palpation, percussion and auscultation of the abdomen. On abdomen it is not only to palpate, you inspect, palpate, precut and auscultate, ask to empty her bladder before examination of her abdomen and pelvis, it should be soft, and non-tender, with no masses. The liver may be just barely palpable below the rib cage and should not be tender. Have the patient take a deep breath while you press your examining hand down beneath the ribs on her right side. While she exhales, keep pressure on your hand. With her next deep breath, you will feel the liver edge descend down to or just past the costal margin. If it is tender, that suggests

swelling or inflammation of the liver. The gall bladder is normally not tender, but if diseased, it may be. c) Pelvic Evaluate the pelvis systematically, position the patient at the very edge of the exam table, with her feet in stirrups, knees bent and relaxed out to the side. If she is not down far enough, the exam will be more difficult for you and more uncomfortable for her. Pad the stirrups to avoid the stirrups digging into her feet. Kitchen pot-holders work well for this, but almost any soft material can be used. Use a bright light to visually inspect the vulva, vagina and cervix. Most examiners find it easiest to look just over the light to get the best view. Inspect the vulva Separate the labia with your gloved fingers to look for any surface lesions, redness, or swellings. Look within the pubic hair for the tiny movement of pubic lice or nits. Look on the labia for the Cauliflower-like bumps that are known as venereal warts. Using magnification (Magnifying lenses or colposcope) is very useful when the patient has vulvar complaints and the diagnosis is not obvious. Look between the folds of skin for ulcerative lesions that can indicate an active herpes infection. Gently retract the clitoral hood back, exposing the clitoris while looking for peri-clitoral lesions. Look for the hymen or remnants of the hymen and identify any redness just exterior to the hymen that can indicate vulvar vestibulitis. The periurethral glands (Skene's glands) have tiny ducts that open onto the surface. Look for them next to the urethra. While looking at the urethra, note any discharge coming from the urethral opening that might suggest gonorrhea or chlamydia. Palpate the upper labia majora for masses related to hernias extending through the Canal of Nuck. Palpate the middle and lower portion of the labia majora for masses suggesting a Bartholin duct Cyst. Warm and lubrificate the speculum with warm water

After warming a vaginal speculum with warm water, separate the labia with one hand while gently inserting the speculum with the other hand. It is frequently more comfortable for the patient if you insert the speculum rotated about 45 degrees (so the blades are not horizontal but are oblique). Once past the introitus, rotate the speculum back to its normal position. Separating the labia with one hand, insert a warmed, water lubrificate speculum with the other hand. The labia, particularly the labia minora, are very sensitive to stretching or pinching, so try not to catch the labia minora in the speculum while inserting it. Some gynecologists ask their patients to "bear down" while they are inserting the speculum and feel that this assists with insertion. Others find this instruction to be confusing and don't use it. Obtain a pap smear or cervical cultures, if indicated. Obtain specimens for a Pap smear and any cultures that may be indicated. Then feel the pelvis by application of a "bimanual exam." For a normal examination: External genitalia are of normal appearance. There is no enlargement of the Bartholin or Skene glands, Urethra and bladder are non-tender. Vagina is clean, without lesions or discharge Cervix is smooth, without lesions. Motion of the cervix causes no pain. Uterus is normal size, shape, and contour. It is non-tender. The adnexa (tubes and ovaries) are neither tender nor enlarged. Vaginal examination: Bimanual examination Feel for masses or tenderness. During the bimanual exam, you may use one finger or two fingers inside the vagina. Two fingers allow for deeper penetration and more control of the pelvic structures, but one finger is more comfortable for the patient. You should individualize your exam for the specific patient. Turning your hand palm up, compress the urethra against the underside of the pubic bone. Normally, this doesn't hurt. If it causes discomfort for the patient, it is likely that at least some degree of urethritis is present. Then insert your fingers deeper into the pelvis. Keeping your palm up, curl your vaginal finger(s) up, compressing the bladder against the back of the pubic bone. Normally, this pressure creates the sensation that the patient needs to urinate, but is not painful. If it is painful, this is good clinical evidence of cystitis (urinary tract infection), or (less likely) endometriosis. In some patients,

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particularly those with difficult to feel pelvic masses, a combined rectovaginal exam is useful. Change gloves, lubricate the rectum, and then gently insert your index finger into the vagina and your middle finger into the rectum. The rectovaginal exam is helpful in feeling the uterosacral ligaments, a common site of endometriosis involvement. On completion of the rectal exam, stool can be checked for the presence of occult blood. If the hymen is intact, it may still be possible to perform a comfortable and complete exam, but if the exam is causing too much pain, stop the exam and consider these alternatives: Rectal exam with your index finger can often provide all the information you need at that time. Exam under anesthesia will provide full access without causing pain to the patient. Ultrasound scan, abdominally and trans-perineal, can sometimes provide you with the information you need. PARA CLINIC EXAM -Urine exam: for urine analysis
-Colposcopy:is a lower-powered microscopy used for examining the vaginal aspect of the

cervix. It is of great value in detecting area of dysplasia,preinvasive and invasive carcinoma.


-Endometrial biopsy:for diagnosis of functional disorders of menstruation,tuberculosis or

carcinoma.
-Hysteroscopy:for inspect the uterine cavity;identification of endometrial polyps or

carcinoma,uterine septa,and submucus fibroids.

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-Laparoscopy: inspection of pelvic organs through an endoscope is performed by the

insertion of an endoscope through with a fibreoptic light cable and a small telescope through the anterior abdomen wall: allowing many diagnosis procedures to take place principally on the fallopian tubes and the ovaries.
-Ultrasound examination: the most useful diagnostic gynecological technique. The

examination may either be performed transabdominally (through a full bladder), or transvaginally (bladder could be empty); the uterus and ovaries can be identified, and any tumour located and measured. It is particularly useful in differentiating solid from cyst tumours.
-Radiological investigations: plain X-ray of the pelvic is sometimes helpful to locate an

intrauterine device or to look for calcification in a pelvic tumor.


Intravenous urography is useful to diagnose displacement or obstruction to the ureters or

bladder.
Computerized tomography and magnetic resonance imaging are becoming useful in the

investigation of abdominal and pelvic tumors, and to assess their response to treatment.
Lymphography: prior to computerized tomography, was only way to assess enlarged

retroperitoneal lymph nodes radiologically. It is still sometimes performed in patients with carcinoma of the cervix.
Hysterosalpingography: is used in patients presenting with infertility in order to assess

the patency of the fallopian tubes and the contour of the uterine cavity. Occasionally cervical incompetence may be diagnosed.

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UNIT.II. SIGNS AND SYMPTOMS IN GYNECOLOGY II.1. PAIN Most women experience pelvic pain at some time during their lives. Many times pelvic pain is just the normal functioning of the reproductive or other organs. Other times pelvic pain may indicate a serious problem that needs urgent treatment. Here we look at the causes of pelvic pain, and how the cause of pelvic pain is determined. But, the uterus, cervix, and adnexa share the same visceral innervation as the lower ileum, sigmoid colon, and rectum. Signals travel via the sympathetic nerves to spinal cord segments T10 through L1. Because of this shared pathway, distinguishing between pain of gynecologic and gastrointestinal origin is often difficult. ACUTE PAIN Acute pain due to ischemia or injury to a viscous is accompanied by autonomic reflex responses such as nausea, vomiting, restlessness, and sweating. The following is a discussion of some of the important gynecologic causes of acute abdominal pain. Gynecological acute pain is a medical condition which come from another medical condition or a pathology. The degree of the pain depends on the patient emotion or its etiology. Acute pain is resolved quickly due to its etiology and treatment. Many times pelvic pain is just the normal functioning of the reproductive or other times pelvic pain may indicate a serious problem that needs urgent treatment. Some of the causes of gynecological acute pain a) Ectopic pregnancy An unruptured ectopic pregnancy produces localized pain due to dilatation of the fallopian tube. Once the ectopic pregnancy is ruptured, the pain tends to be generalized due to peritoneal irritation. Symptoms of rectal urgency due to a mass in the pouch of Douglas may also be present. Syncope, dizziness, and orthostatic changes in blood pressure are sensitive signs of hypovolemia in these patients.

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Abdominal examination findings include tenderness and guarding in the lower quadrants. Once hemoperitoneum has occurred, distension, rebound tenderness, and sluggish bowel sounds may develop. Pelvic examination may reveal cervical motion tenderness that is exaggerated on the side of the tubal ectopia. Initially, a sensitive serum or urine pregnancy test should be performed. Transvaginal ultrasonography should be performed. If an intrauterine gestational sac with a fetal pole is identified, the chances of a coexisting ectopic pregnancy are remote. Such a heterotopic gestation should be considered in patients taking ovulation-inducing drugs. Serial serum beta-human chorionic gonadotropin (hCG) estimations are often helpful in making the diagnosis. In early intrauterine gestation, the doubling time for HCG is usually 48 hours. Only 15% of cases are exceptions to this rule. In the absence of the availability of ultrasonography or in an emergency setting, culdocentesis can be of value to detect unclotted blood. A hematocrit of less than 16% (in the peritoneal blood) excludes hemoperitoneum. Laparoscopy should be attempted if the patient is hemodynamically stable, a high index of suspicion remains, or the patient complains of increasing pain despite adequate analgesia. Treatment options for an unruptured ectopic pregnancy include salpingostomy and salpingectomy. These may be performed laparoscopically or by open procedure. Methotrexate, a folic acid antagonist, is also used for the treatment of unruptured ectopic pregnancy. A ruptured ectopic pregnancy requires a laparotomy with removal of blood clots. b) Adnexal masses Corpus luteum hematoma This condition develops in the luteal phase of the menstrual cycle. Slow leakage produces minimal pain. Frank hemorrhage can lead to hemoperitoneum and hypovolemic shock. Generalized abdominal pain and syncope are features of such a presentation. Treatment includes laparoscopy or laparotomy, evacuation of clots, and control of ovarian bleeding.

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Ruptured ovarian cyst The most common causes are dermoid cyst, cystadenoma, and endometrioma. Because the amount of blood loss is minimal, hypovolemia does not supervene. Peritoneal irritation due to leakage of cyst fluid can lead to significant tenderness, rebound tenderness, abdominal distension, and hypo peristalsis. Treatment involves cyst removal. Ovarian torsion Changes in ovarian axial morphology, which are typically secondary to ovarian cysts (most commonly dermoids), can undergo torsion around the pedicle. Frequently, torsion resolves spontaneously, and the only presenting symptom is lower abdominal pain. Persistent torsion progresses to occlusion of the venous drainage of the ovary, which leads to congestion, ovarian enlargement, thickening of the ovarian capsule, and subsequent infarction. Pain eventually becomes severe and is accompanied by nausea, vomiting, and restlessness. Infarction also leads to fever and mild leukocytosis. If the ovary appears viable based on laparoscopic examination findings, the pedicle may be untwisted and the cyst removed. An infracted ovary must be removed. Acute pelvic inflammatory disease Acute Salpingo-oophoritis is a polymicrobial infection that is transmitted sexually. Neisseria gonorrheae and Chlamydia trachomatis are usually identified in patients with PID, and both organisms often coexist in the same patient. Gonococcal disease tends to have a rapid onset, while chlamydia infection has a more insidious onset. The strict diagnostic and management guidelines for the treatment of PID are recommended in an effort to reduce serious preventable sequel such as adhesions and infertility.

Diagnostic criteria for PID All of the following criteria must be present:

Lower abdominal tenderness

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Cervical motion tenderness Adnexal tenderness

Diagnosis may also be supported by any of the following criteria:


Temperature greater than (38.3C) Abnormal cervical or vaginal discharge Laboratory evidence of C trachomatis or N gonorrheae Elevated erythrocyte sedimentation rate or elevated C-reactive protein value

Definitive criteria for diagnosis include the following:

Positive findings on Transvaginal ultrasound or other imaging technique demonstrating thickened fluid-filled tubes with or without tubo-ovarian abscess or free pelvic fluid Positive endometrial biopsy findings Positive laparoscopy findings Tubo-ovarian abscess A ruptured abscess can lead to gram-negative endotoxic shock; therefore, this condition is a surgical emergency. The most common presentation is bilateral, palpable, fixed, tender masses. Patients often present with generalized abdominal pain and rebound tenderness caused by peritoneal inflammation. In such cases, the infected tissue must be surgically removed under broad-spectrum antibiotic coverage. Preoperative antibiotic coverage for 24-48 hours is recommended if the patient is stable.

Degenerating fibroid This may occur during pregnancy when rapid growth of the tumor outstrips its blood supply. This condition is conservatively managed as much as possible. Twisted subserous fibroid

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A pedunculated subserous fibroid may twist and undergo necrosis, causing acute abd ominal pain. It may be removed by laparoscopy or an open procedure. Submucous fibroid A pedunculated submucous fibroid may present with cramping pain and vaginal bleeding. Hysteroscopy resection is the treatment. RECURRENT PELVIC PAIN Mittelschmerz Mittelschmerz is midcycle abdominal pain due to leakage of prostaglandin-containing follicular fluid at the time of ovulation. It is self-limited, and a theoretical concern is treatment of pain with prostaglandin synthetase inhibitors, which could prevent ovulation. Endometriosis Pain associated with endometriosis may worsen premenstrual or during menses. Patients experience generalized lower abdominal tenderness, and associated complaints include dysmenorrhea, dyschezia, and dyspareunia. Endometriosis deposits in both the uterosacral ligaments and rectovaginal septum contribute to pain during intercourse. Painful defecation is due to infiltration of the bowel wall by endometriosis deposits. Importantly, remember that the pain associated with endometriosis is not correlated with the presence or amount of visible endometriosis tissue. In fact, prevalence of endometriosis is the same in women with and without pain. Rather, pain is related to the chemical mediators of inflammation and neural infiltration. Primary dysmenorrhea By definition, primary dysmenorrhea is menstrual pain associated with ovulatory cycles in the absence of structural pathology. It usually manifests in younger women, and a recent study on the natural course of dysmenorrhea found that most women are affected throughout the menstrual years. Improvement is more likely in women who bear children. Patients experience suprapubic cramping pain that may radiate to the anterior thigh or sacral region. Pain may be accompanied by autonomic symptoms such as nausea, vomiting, and syncope. The onset of primary dysmenorrhea is a few hours prior to the onset of menses, and pain usually lasts up to 72 hours. More than 80%
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of patients have an excellent response to treatment with prostaglandin synthetase inhibitors. Oral contraceptives may be used with equal effectiveness in patients who desire simultaneous fertility control. Smoking was associated with a higher relative risk of severe dysmenorrhea. In a systematic review, naproxen, ibuprofen, and mefenamic acid were more effective for pain relief compared to placebo. Secondary dysmenorrhea Secondary dysmenorrhea is cyclic menstrual pain associated with structural pathology. The most common causes are endometriosis, adenomyosis, and the presence of an intrauterine device. Pain starts 1-2 weeks prior to the onset of menses and persists for a few days after cessation of flow. Hypertonic uterine activity coupled with an excess of prostaglandins is postulated to be the cause of secondary dysmenorrhea. Patients are somewhat less responsive to nonsteroidal antiinflammatory drugs (NSAIDs) and combination oral contraceptives compared with patients with primary dysmenorrhea. Presacral neurectomy (PSN) has been shown in a single randomized trial to improve severe dysmenorrhea due to endometriosis. Adenomyosis Adenomyosis typically manifests in women in their 40s and is essentially a clinical diagnosis. It coexists with endometriosis and fibroids, and a recent study found that prior uterine surgery was significantly associated with increased risk of adenomyosis. Dysmenorrhea is associated with dyspareunia, dyschezia, and acyclical uterine bleeding. The uterus is soft and tender, especially around the time of menstruation. Magnetic resonance imaging shows an enlarged junctional zone and myometrial cysts, whereas ultrasonography shows heterogeneous abnormal myometrial echogenicity in patients with adenomyosis. Histopathologic correlation with the clinical diagnosis can be found in only half the cases. For reproductive-aged women, treatment includes NSAIDs, combination oral contraceptives, progesterone-only pills, and GnRH agonists. Hysterectomy is a last resort.

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CHRONIC PELVIC PAIN Chronic pelvic pain is defined as continuous or intermittent pelvic pain of longer than 6 months duration. No symptoms uniquely identify genitourinary structures as a source of pelvic pain. Even the relationship of recurrent pain to menstruation or the presence of dyspareunia is only suggestive. Important non gynecologic causes that must be considered in the differential diagnosis include irritable bowel syndrome (IBS), interstitial cystitis (IC), and pelvic floor myofascial syndrome. Importantly, rule out abdominal wall etiologies that are aggravated by rising of the head or rising of straightened legs while supine. Dyspareunia as a significant factor Patients with deep, internal, or thrust dyspareunia often express a feeling that some sort of internal collision is occurring during sexual activity. Any pelvic pathology may be responsible for this discomfort, but abnormalities such as endometriosis, pelvic adhesions, pelvic relaxation, malposition (retroversion), adnexal pathology or prolapse, and uterine fibroids are the most likely causes. IC may cause dyspareunia before it proceeds to chronic unremitting pain. IBS may also cause dyspareunia and pain at the apex of the vagina. Adhesions A recent study using conscious pain mapping during laparoscopy found that peritoneal adhesions and filmy adhesions that allowed for movement between 2 structures had the highest pain scores, while dense, fixed adhesions caused less pain. Pain is a cyclical and not accompanied by vaginal bleeding. Dyspareunia and symptoms suggestive of intermittent subacute bowel obstruction may be associated with adhesions. Adhesiolysis should be recommended with realistic expectations, and a multidisciplinary approach in a pain clinic may be worthwhile prior to attempting surgery. In one study, cure or improvement was reported in two thirds of patients with chronic pelvic pain and nearly half of those with dysmenorrhea. In a randomized study, patients with severe adhesions involving the intestinal tract were shown to benefit from Adhesiolysis. A recent study found adhesions deflecting the sigmoid colon to the pelvic sidewall in 38% of patients with chronic pelvic pain. Among patients without detectable endometriosis, 80% had a significant reduction in symptoms after Adhesiolysis on an 18-month follow-up. Various agents have been reported to

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reduce adhesion formation, but none have gained universal acceptance. A recent small randomized study of 25 patients found a significant improvement in right-sided pain in women who underwent paracolic Adhesiolysis. Chronic pelvic inflammatory disease Pain is thought to be due to infection or adhesions that exacerbate the baseline condition. However, a recent animal study failed to show adhesions following direct bacterial inoculation. Infection may be accompanied by fever, leukocytosis, and gonococcal or chlamydial infection. Laparoscopy and peritoneal fluid cultures help confirm the diagnosis in most cases. Empiric treatment with antibiotics should be commenced prior to laparoscopy. Ovarian remnant syndrome Following a total abdominal hysterectomy and bilateral salpingo-oophorectomy, the ovarian remnant can undergo cystic changes that cause pain. Hormonal suppression with danazol, combined oral contraceptive pills, high-dose progestins, and GnRH agonists are possible treatment options. Diagnosis may be aided by ultrasonography. Laparoscopy is often fruitless because of the density of adhesions, and a laparotomy is the surgical procedure of choice for tissue removal. Finding the ovarian tissue may be challenging. Urethral syndrome Patients with urethral syndrome present with classic symptoms of urinary tract infection, but urinary culture results are negative for infection. Symptoms include frequency, urgency, and pressure in the absence of nocturia. Physical examination reveals a tender ropelike urethra. The clinical course is marked by remissions and exacerbations. Causes include chlamydia, mycoplasmas, herpes simplex, urethral trauma, atrophy, stenosis, and functional obstruction. Female prostatitis is believed to be due to inflammation of the paraurethral glands and is believed to be a frequent cause of urethral syndrome. Clinical examination reveals localization of tenderness to these glands. Treatment of urethral syndrome should be tailored to the individual cause. Patients with sterile pyuria respond to a 2- to 3-week course of doxycycline or erythromycin. All postmenopausal women should also receive a trial of local estrogen therapy. Urethral dilatation and biofeedback have been used for resistant cases.

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Post hysterectomy syndrome Post hysterectomy syndrome is pain due to a low-grade cuff cellulitis, stroma or hematoma of the cuff, or neuralgia related to transection of the nerve tissue. Resection of a portion of the vaginal cuff occasionally helps relieve the pain. Hysterectomy for chronic pelvic pain Long-term studies have shown that success with hysterectomy is disappointing when the only indication is pain (Garcia, 1977). If the pain has persisted for more than 6 months, has not responded to analgesics, and is causing significant distress and impairment, then hysterectomy may be considered an option after counseling the patient that the pain may persist after surgery.
Idiopathic pain

Newer treatment modalities like percutaneous tibial nerve stimulation have shown initial promise. Because of their noninvasive nature, they are likely to be tried in women with unexplained pelvic pain. VULVA PAIN Vulvo vaginitis may be due to allergic reaction (eg, contact vaginitis), infection (eg, bacterial, parasitic, fungal), or hypoestrogenism (ie, atrophic). Symptoms include burning, discomfort, dyspareunia, and abdominal vaginal discharge. Localizing the pain is important in order to determine the diagnosis. Contact vulvitis The patient usually complains of itching or burning that involves the vulva but not the vagina. Elimination of the possible agent and administration of topical steroids for 7-10 days usually result in resolution of symptoms. Atrophic vaginitis Primary complaints include burning, dyspareunia, and vaginal spotting. The patient may also experience burning during mucturition, urinary urgency, and urinary frequency. Topical estrogen cream is the first-line treatment. Incidence of systemic absorption is low with low-dose topical
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estrogens. Estradiol-releasing vaginal rings have the highest continuance and efficacy rates among all topical preparations. Microbial vaginitis The usual complaints are accompanied by vaginal discharge. Appropriate treatment results in resolution of symptoms. Vulvodynia (idiopathic) Vulvodynia is defined as chronic vulva burning and/or pain without clear medical findings. Specific treatable causes, such as dermatoses or group B streptococci infection, should be ruled out in the first instance. Essential (dysesthetic) vulvodynia is a diffuse unremitting vulval burning that may radiate to the inner thigh, buttocks, and perineum. Associated complaints include urethral and rectal burning or discomfort. This condition is commonly found in postmenopausal women. Physical examination reveals findings of hyperalgesia in the affected areas. Pudendal nerve damage or compression is a possible contributory factor. Urinary frequency, urgency, and incontinence may develop as a consequence, and chronic constipation may also develop. Vulvar vestibulitis (provoked vulvodynia) is severe pain upon vestibular touch or attempted vaginal entry during coitus, tenderness to pressure localized within the vulvar vestibule, and physical examination findings limited to vestibular erythema of various degrees. Because both the vestibule of the vulva and the bladder are derived from the urogenital sinus, a common etiology has been suggested for these conditions. Standard therapy for vulvodynia includes amitriptyline and, more recently, gabapentin. Additional therapies include estrogen cream, nitroglycerin cream (0.2%), interferon-alpha, and pelvic floor rehabilitation with surface electromyography (EMG) biofeedback. Vestibulodynia is an entity that may be a combination of vestibulitis and constant spontaneous vulvodynia. Patients have a higher incidence of dysuria, and even the contact of urine on the vestibular skin evokes a sensation of pain. Perineoplasty is associated with a higher failure rate in these patients. Further, a higher frequency of human papilloma virus is found in tissue samples of patients with vestibulodynia.

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PAIN DUE TO COMPLICATIONS OF GYNECOLOGICAL SURGERY Thermal bowel injury is a serious complication of surgery. It occurs in 0.5-3.2 per 1000 cases, and symptoms may not develop for days or weeks. Patient presentation includes bilateral lower quadrant pain, tenderness, fever, leukocytosis, and peritonitis. Ileus or free gas under the diaphragm may be noted on a plain abdominal radiograph. Peritonitis may occur as a consequence of undetected bowel perforations. Other complications include abscess, enterocutaneous fistula, and septic shock. Thermal injury to the bladder or urethra may manifest up to 14 days postoperatively with abdominal or flank pain, fever, and peritonitis. Findings from an intravenous pyelogram demonstrate extravasations of urine or urinoma. Patients with mechanical obstruction may present in 1 week with a similar clinical picture. Incisional hernia rarely becomes incarcerated. Patients present with abdominal pain and signs of bowel obstruction or perforation. Hysteroscopy commonly leads to uterine perforation, which may involve the bowel. Such a possibility should be kept in mind when evaluating a patient. Following a vaginal hysterectomy, patients may present with pelvic pain due to vaginal cuff hematoma, cellulitis, or ovarian abscess. Wound complications such as dehiscence, renal angle pain due to ureteric injury, and retention should be considered. Osteitis pubis is a possibility in patients who undergo with operations for vaginal vault prolapse.

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Summary of causes of gynecological pain Acute pelvic pain Complications of pregnancy

Chronic pelvic pain Gynecologic ruptured or

Ectopic unruptured

pregnancy,

Extrauterine
o o o

Adhesions Chronic ectopic pregnancy Chronic pelvic inflammatory disease Endometriosis Ovarian remnant syndrome Adenomyosis Chronic endometritis Fibroids Intrauterine device Pelvic congestion Pelvic support defects Polyps

Abortion (Threatened Abortion and Abortion, Incomplete) Degenerating fibroid

Acute infection

o o

Endometritis Acute pelvic inflammatory disease Tubo-ovarian abscess Pelvic thrombophlebitis Ovarian vein thrombosis

Uterine
o o o o o

Adnexal mass

o o

Corpus luteum hematoma Ovarian torsion Ruptured ovarian cyst Paratubal cyst Endometriosis hyperstimulation syndrome Ovarian Urologic

Chronic urinary tract infection Overactive bladder Interstitial cystitis Bladder stones

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Suburethral diverticulitis Urethral syndrome Trigonitis

Gastrointestinal

Constipation

(very

common

in

elderly persons)

Diverticular disease Inflammatory bowel disease Enterocolitis Irritable bowel syndrome Neoplasia Chronic appendicitis Cholelithiasis

Musculoskeletal

Coccydynia Disk problems Degenerative joint disease Fibromyositis Hernia Herpes zoster Lower back pain Levator ani syndrome (pelvic floor spasm) Myofascial pain Nerve entrapment syndromes Osteoporosis Posture-related pain Scoliosis , lordosis, kyphosis

25

Strains, sprains

Other

Physical or sexual abuse, prior or current Lead or mercury toxicity Hyperparathyroidism Porphyria Somatization disorders Substance abuse, ie, cocaine Sickle cell disease Sympathetic dystrophy Tabes dorsalis

II.2. LEUCCORRHEA Leucorrhea (US) or leucorrhoea (Commonwealth) is a medical term that denotes a thick, whitish vaginal discharge. It is a natural defense mechanism the vagina uses to maintain its chemical balance, as well as to preserve the flexibility of the vaginal tissue. It may also result from inflammation or congestion of the vaginal mucosa. In cases where it is yellowish or gives off an odor, a doctor should be consulted since it could be a sign of an STD TYPES OF LEUCORRHEA

Physiologic leucorrhea

Physiologic leucorrhea are vaginal desquamation which is responsible of white leucorrhea low amount their amount increase in premenstrual period, they are also the cervical mucus secreted by cylindrical cells into the cervix which increase on 8th day to 15th day of menstrual
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cycle ,those discharge do not cause vaginal irritation, no bad smell and not contain the polynucleaire . Pathologic leucorrhea

Pathologic leucorrhea are vaginal discharge characterized by bad smell, abundance, their color, their aspect depend on their pathology. Causes There are many causes of leucorrhea, the usual one being estrogen imbalance i.e. increase or decrease in levels of. The amount of discharge may increase due to vaginal infection or STDs, in which case it becomes more yellow and foul-smelling; it is usually a non-pathological symptom secondary to inflammatory conditions of vagina or cervix. Vaginal discharge is normal for a woman, and all women are different. Causes of change in discharge include infection, malignancy, and hormonal changes. It sometimes occurs before a girl has her first period, and is considered a sign of puberty. The amount of discharge increases slightly during mid-cycle and during sexual arousal. Leucorrhea may occur normally during pregnancy. This is caused by increased blood flow to the vagina due to increased estrogen. Female infants may have leucorrhea for a short time after birth due to their in-uterine exposure to estrogen. After delivery, leucorrhea accompanied by backache and foul-smelling lochia (post-partum vaginal discharge, containing blood, mucus, and placental tissue) may suggest the failure of involution (the uterus returning to pre-pregnant size) due to infection. Investigations: wet smear, gram stain, culture, Pap smear and biopsy. Leucorrhea general observation on the volume, color, consistency, smelling and accompanying symptoms. Summary of types of leucorrhea/discharge and possible pathological causes White and looking like curdled milk:

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Candidial/ monomial vaginitis (there is much itching) Purulent/ yellow or yellow-green thin: Trichomoniasis vaginitis Gonorrhea Foreign body in the vagina, senile vaginitis, Puerperal or post-abortion sepsis Vaginitis through the trichomonas is essential sexual intercourse (venereal) contamination, the leucorrhea are grayish, large amount with bad smell (plate frais) By speculum insertion the vagina is red and the cervix is raspberry in color, burn sensation during sexual intercourse and urination, itching varies according to intensity To diagnose and treat it, they do urinary analysis or vaginal swab to confirm the disease. Treatment concerns two partners/couple Unique dose 2grof Metronidazole (Flagyl) Treatment during 10 days 500mg twice day of Metronidazole or during 15 days 500mg Flagyl ovule for local treatment, it can be renewed to one month. Mucoid: Chronic cervicitis, cervical erosion, cervical polyp The essential symptom is itching, often intolerable lead to dysuria (painful miction) and pollakiuria (frequently and small amount urination). Speculum insertion the leucorrhea is white in color like that of yoghourt, they appear out of the vagin, and vulva is dry edematous with frequent scratching lesions, redness of the vagina with continuous whitish discharge. To diagnose and treat it, they do vaginal swab analysis to see the filament of Candida albicans which is causative germs.

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The treatment prescription of anti mycosis such as: Econazole(Gynopevaryll),Fenticonazole(Lomexin),Mconazole(Gynodaktarin),Butoconazole(Gyno myk) or Isoconazole(Fazol) in gynecological ovule or cream. Comfort treatment use thickening solution such as Gyn-hydralin, Sforell or Opalgine. Local hygiene regulation, medical soap is used on intimate toilet, use of non stick underwear The treatment of partner is done with local antimycosal ointment in 10 days. In case of renew: search the factors which can influence the leucorrhea like antibiotherapy, diabetics or pregnancy. Blood- stained: Carcinoma of the cervix of uterus Hydatiform mole, threatened abortion, and malignant uterine tumors (such as cervical cancer, endometrial cancer, chorion carcinoma, etc.).

Watery /egg white or white-water samples Leucorrhea When Leucorrhea of many, often prompted to cervical erosion, ovarian dysfunction. Sometimes oral contraceptives and other hormone drugs, such cases will arise. In addition, all can and pelvic congestion of the uterus, such as the uterus after the dumping, pelvic tumor, and certain systemic diseases such as heart failure, tuberculosis, anemia, diabetes, or frail women can also increase this Leucorrhea. Meat, also known as wash water samples Leucorrhea, bad smell, a lot of volume. As is often the lesions caused by necrosis or degeneration, and often occurred in sub mucosal uterine fibroids vaginal prolapsed co-infection, or advanced cervical cancer, endometrial cancer, cervical pyonephrosis are. A few may also be caused by the fallopian tube cancer. The four most common causes of vaginal discharge seen in daily practice are

29

Trichomoniasis, Candidiasis, Gonorrhea, Chronic cervicitis and cervical erosion II.3. HAEMORRAGE Gynecologic haemorrhage represents excessive bleeding of the
female

reproductive system. Such

bleeding could be visible or external, namely bleeding from the vagina, or it could be internal into the pelvic cavity or form a hematoma (uterus). Normal menstruation is not considered a gynecologic hemorrhage, as it is not excessive. Hemorrhage associated with a pregnant state or during delivery is an obstetrical haemorrhage. Causes of gynecologic bleeding include Hormonal An ovulation is a common cause of gynecological haemorrhage. Under the influence of estrogen the endometrium (uterine lining) is stimulated and eventually such lining will be shed off (estrogen breakthrough bleeding). An ovulation chapter discusses its multiple possible causes. Longstanding an ovulation can also lead to endometrial hyperplasia and facilitate the development of endometrial cancer. Neoplasm 1. Cancer of the uterus is always a concern, specifically when the bleeding occurs after menopause. Other types of cancer include cervical cancer; bleeding in that case can sometimes be triggered by intercourse and is termed postcoital bleeding. Cancers of the vagina or fallopian tubes are rare causes of hemorrhage. 2. Uterine fibroids represent a common, benign condition that may lead to bleeding, specifically if the lesion affects the uterine cavity. 3. Polyps of the uterine lining are a common cause of bleeding, but such bleeding tends to be light. Trauma 1. Sexual assault and rape can lead to injury and gynecological hemorrhage.

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2.

Accidents to the lower abdomen may lead to internal or external bleeding.

Bleeding disorder Women with a bleeding disorder may be prone to more excessive bleeding. A hematologic workup should discover the cause. Other On occasion an ovarian cyst can rupture and give rise to internal hemorrhage. This may occur during ovulation or as a result of endometriosis. If the is positive, consider pregnancy related bleeding (see miscarriage and ectopic pregnancy. Diagnosis A history will establish if the condition is acute or chronic, and if external circumstances are involved. A gynecologic examination is usually complemented by a
gynecologic ultrasonography. obstetrical

haemorrage), including

blood count determines the degree of anemia and may point out bleeding problems. The pregnancy test is important, particularly as bleeding in early pregnancy presents as gynecological hemorrhage and ectopic pregnancy can be fatal. NB: To know a source (origin) of the hemorrhage is very crucial. Prevention Generally gynecologic hemorrhage does not arise out of nowhere. Regular gynecologic examinations, cancer screening, and contraceptive measures go a long way in preventing and forestalling unsuspected acute bleeding events. First aid Gynecologic hemorrhage needs to be evaluated as soon as possible by a physician. The amount and duration of bleeding will dictate whether a bleeding event is an emergency event.

31

Clinical treatment Treatment depends on diagnosis and may include hormonal therapy, IV fluids, blood transfusion, and/or a dilation and curettage. Internal bleeding requires laparoscopy or abdominal surgery. II.4.MODIFICATIONS OF MENSTRUATION CYCLE
Physiology

The periodic series of changes associated with menstruation and the intermenstrual cycle; menstrual bleeding indicates onset of the cycle. Throughout a woman's reproductive life from puberty to the menopause the ovaries are programmed to produce a mature egg (ovum) approximately every 28 days and to prepare the uterus (womb) for implantation of an embryo if the egg becomes fertilized. To achieve this reproductive competence the ovaries must receive the correct hormonal signals from the brain and the pituitary gland. These signals stimulate the production of female sex hormones and the cyclical changes which occur in the ovary during each normal menstrual cycle. In turn the sex steroids released by the ovary induce changes in the lining of the womb and other parts of the female reproductive tract. The system is subtly regulated and fine-tuned by feedback effects of the ovarian steroid hormones on hormone secretions from the hypothalamus and pituitary gland, so there is a complex interplay of hormones and feedback signals which ultimately controls female fertility. Collectively these events constitute the menstrual cycle. The first day of the menstrual cycle is defined as the first day of menstrual blood loss. This is when the uterus begins to shed its lining and bleeding occurs. At this time the secretion of hormones (estrogen and progesterone) from the ovaries is at a minimum. This diminishes the braking effect that circulating ovarian hormones have on the secretion of the gonadotrophic hormones from the pituitary gland, namely luteinizing hormone (LH) and follicle stimulating hormone (FSH). As a consequence these pituitary secretions increase and stimulate a new wave of activity in the ovaries. Early in the cycle, FSH stimulates growth of a few follicles (egg-containing sacs) in each ovary. By about day 10 the ovaries contain several follicles with a diameter of 14-21 mm. As mid cycle approaches, all but one of these degenerate, and only the dominant follicle becomes fully mature,
32

with a diameter of 20-25 mm. What determines which follicle becomes the dominant one, and in which ovary, remains speculative. Local hormones or other factors acting within the ovaries may play an important role. This first half of the ovarian cycle is known as the follicular phase and is characterized by increasing secretions of estrogen from the developing follicles; this is released into the bloodstream, reaches the uterus, and causes its lining to thicken: the glands enlarge and it becomes richly supplied with blood vessels: the proliferative phase of the uterine cycle. In most normal human menstrual cycles only one follicle reaches full maturity, to be released at ovulation, on about day 14. The occasional release of two accounts for non-identical twins, and fertility drugs can increase the number of follicles reaching maturity at mid cycle. These drugs are either pituitary gonadotrophins, or synthetic chemicals which interfere with the negative feedback loop in such a way as to promote an increase in the release of these hormones from the pituitary gland itself. In both cases the ovaries receive an increased drive for follicular development, and thus several follicles will mature. Such drugs are used for treating certain types of infertility, and are given to women undergoing in vitro fertilization (IVF) treatment. If the result is multiple ovulations, the chances of fertilization are increased or, in the case of IVF, more than one mature egg can be recovered for external fertilization and subsequent implantation. At mid cycle there is a dramatic change of events. There is a high blood concentration of estrogen, but this ceases to have a braking (negative feedback) effect on the pituitary hormones. About 24-48 hours after the peak of estrogen production a surge of the gonadotrophins occurs especially of luteinizing hormone. This is one of the rare biological examples of a positive feedback action. The surge causes the mature dominant follicle to rupture and release its egg within 9-12 hours. Indeed, one way of predicting ovulation is by the detection of the increase in luteinizing hormone in the blood, which is reflected in the urine. This is the scientific basis for the kits which are commercially available to identify the most likely time for conception.

33

Changes of hormone concentrations in the blood during a 28-day menstrual cycle, and the associated changes in follicular development and ovulation (follicular phase), formation and degeneration of the corpus luteum (luteal phase), cyclical growth and degeneration of the endometrium of the womb, and changes in basal body temperature. At the time of ovulation there is a small rise in body temperature. This is thought to be due to the action of rising progesterone in the blood, resetting in some way the thermostat in the brain which controls our body temperature. This small rise can be used to indicate when ovulation occurs, but obtaining reliable temperature measurements is difficult, making the method often unsatisfactory. Some women feel mild pain in the abdomen around the time of ovulation, lasting from a few minutes to a couple of hours. Known as Mittelschmerz (German for

34

midpain), it is probably caused by irritation of the abdominal wall due to blood and fluid escaping from the ruptured follicle. Changes in the cervical mucus also occur about the time of ovulation. After ovulation the empty follicle left behind in the ovary is remodeled, and it plays an important role in the second half of the menstrual cycle, known as the luteal phase of the ovarian cycle. The cells remaining in the ruptured follicle proliferate rapidly and form the corpus luteum. This yellow body produces increasing amounts of progesterone and some estrogen, and these hormones act on the lining of the womb it becomes thick and spongy and its glands secrete nutrients that can be used by the embryo if fertilization has occurred: this is the secretory phase of the uterine cycle. The high progesterone level in the blood, together with estrogen, also exerts negative feedback effects, which decrease the secretion of the gonadotrophin-promoting secretion by which the hypothalamus influences the pituitary. Small amounts of gonadotrophins nevertheless continue to maintain the function of the corpus luteum but if fertilization does not occur, towards the end of the cycle this support fails and the corpus luteum breaks down. The precise mechanisms which induce this degeneration are unknown, but the consequences are that progesterone and estrogen secretions decline, the hormonal support of the uterine lining is lost, the spiral arteries contract, and the lining cells, starved of their blood supply, break away. Menstrual bleeding ensues. A new cycle begins. While the average time for each menstrual cycle is typically depicted as 28 days, cycles do vary considerably in length, ranging from 25 days to 35 days. It is usually the length of the first (follicular) phase of the cycle that accounts for most of the variation. The luteal phase is more likely to last the typical 14 days, with ovulation occurring two weeks before rather than after the onset of menstruation, so it is unpredictable. Furthermore, the luteal phase in some women can also vary. This variability clearly makes safe period birth control unreliable. A recurring cycle of change in the endometrium during which the decidual layer of the endometrium is shed, and then regrows, proliferates, is maintained for several days, and is shed again at menstruation. The average length of the cycle is 28 days. The menstrual cycle encompasses approximately four weeks framed by two menstrual flows (called "periods"). Though few population-based, hormonally valid prospective studies of menstrual cycle intervals and ovulation are available, normal menstrual cycles are twenty-one to
35

thirty-five days long with flow lasting three to five days. The menstrual cycle occurs during approximately thirty to forty-five years of a woman's life beginning with menarche (the first flow) at ages ten to sixteen. The menstrual cycles permanently end with menopause (one year following the final menstrual period), which occurs between ages forty and fifty-eight. Within each normal menstrual cycle a complex, highly coordinated series of hormonal, physiological and physical changes occur in a predictable fashion. The cycle is divided by ovulation into two phases called follicular and the luteal phase. The start of flow is cycle day 1. The follicular phase leads to increased sexual interest at midcycle, slippery (like egg white) cervical mucous, and release of an egg (ovulation). Ovulation marks the end of the follicular and start of the luteal phase that itself ends with flow. Luteal phase length is ten to sixteen days, during which changes occur in the endometrium (lining of the uterus), breasts, fluid balance, exercise physiology, metabolism, and women's experiences (molimina). If fertilization does not occur, the thickened endometrium starts to shed and a new cycle begins. The normal menstrual flow entails approximately 43 2.3 (median 32) milliliters of blood loss and will soak two to eight regular-sized pads or tampons. Menstrual interval and ovulatory disturbances are most common in adolescence (young gynecological age) and in the years prior to menopause (perimenopause). In general, they are reversible and treatable and thus represent disturbances of physiology. Disturbances of Menstrual Flow Menorrhagia, abnormally heavy flow, occurs at the extremes of menstrual life when ovulation disturbances are also common. Women older than forty-five or fifty tend to have greater blood loss with more variability than women of other ages. The cause of menorrhagia is often unclear but it entails soaking over eleven to sixteen pads or tampons and is associated with clots, cramping (dysmenorrhea), and anemia. Disturbances of Cycle Interval

36

Amenorrhea, no vaginal bleeding for six or more months, indicates a rare anatomical abnormality (of uterus or vagina), very low or noncyclical, normal estrogen production. Primary amenorrhea means delay of menarche beyond fifteen years of age in 6.4 percent of the population. Secondary amenorrhea, after menarche, is rareit occurs in about 1 to 2 percent of the population. The most common causes are (undiagnosed) pregnancy, lactation, young gynecological age (years after menarche), under nutrition or weight loss, and emotional stress (including depression, anxiety, and eating disorders [anorexia and bulimia]). Although amenorrhea is attributed to exercise, it is more likely related to coexistent emotional stress, nutritional deficiencies, and young age. Oligomenorrhea, flow at intervals longer than thirty-six (but less than 180) days, is more common than amenorrhea and also occurs at the extremes of reproductive life. There is a decrease of menstruation frequency (infrequent periods). The most common cause of infrequent periods is a condition called polycystic ovaries. This is a common condition affecting as many as 10 per cent of women, in which a large number of very small (less than 1cm) cysts on the ovaries appear in association with a hormone imbalance. This condition results in irregular ovulation and thus periods are usually infrequent. The diagnosis of polycystic ovaries is made on the basis of one or more blood tests to measure hormones; a pelvic ultrasound scan of the ovaries is often taken as an additional test. Polymenorrhoea, (short cycles) are under twenty-one days in length, are common at extremes of reproductive life, and imply higher estrogen production. Short cycles are commonly abnormal in ovulatory characteristics and often have increased in flow. Disturbances of Ovulation Ovulatory disturbances are of two main types: low hypothalamic/pituitary stimulation, called "hypothalamic" or high pituitary stimulation called "anovulatory androgen excess." Ovulatory disturbances of either type include anovulation and cycles with ovulation but short luteal phase length. Anovulation (lack of egg release) universally causes ovarian cysts.

37

Hypothalamic ovulatory disturbances are common but not often detected because they occur in "regular" cycles of normal interval and flow. Hypothalamic ovulatory disturbances explain approximately 25 percent of infertility and 20 percent of prospectively documented cancellous bone loss. Seventy-five percent of normal weight, healthy premenopausal women experienced at least one cycle with ovulatory disturbance during one-year prospective monitoring, thus this may be an unrecognized cause for osteoporosis. Although not all investigators agree, no other prospective one-year study has simultaneously and continuously documented both ovulation and bone loss. Hypothalamic ovulatory disturbances are related to cortisol excess caused by physical or psychological stress including cognitive dietary restraint in normal weight women. Ovulatory disturbances may also be associated with menorrhagia and increased risk for anemia, endometrial cancer, breast swelling, nodularity and/or pain (fibrocystic) problems, troublesome premenstrual symptoms, and breast cancer. Anovulatory androgen excess (commonly called "polycystic ovarian disease") occurs in approximately 5 percent of reproductive-age women. This may cause cycle or flow disturbances, acne, or unwanted male-pattern hair changes (increased facial and body hair and head hair loss). This type of anovulation may be related to insulin excess/resistance, gynecological age, and heredity. Health outcomes related to prolonged anovulatory androgen excess include increased risks of endometrial and breast cancers and probable cardiovascular disease (abnormal lipids, central obesity, increased waist/hip/ratio, and insulin resistance) but protection from osteoporosis. Overview of Menstrual Cycle and Ovulatory Disturbances Cycle interval and ovulatory disturbances are common in adolescence and perimenopause. The majority are reversible (except in perimenopause). Treatment with cyclic progesterone is physiological and increases bone mineral and thus minimizes osteoporosis. Population-based, X\prospective studies of menstrual cycles, ovulatory characteristics, and health parameters are needed.

38

II.5. VAGINISMUS What is Vaginismus? Vaginismus is an involuntary spasm of the muscles surrounding the vagina. The spasms close the vagina. Vaginismus is a condition in which an attempt to insert something into a woman's vagina causes the muscles surrounding the vagina to tighten, and to clamp shut, making penetration painful or impossible. Vaginismus can affect sexual intercourse as well as gynecological examinations and even the use of tampons. Vaginismus is involuntary, and can be compared to any other reflex action where the body closes up as a reflex, like when the eye blinks if something approaches it. In vaginismus, although the closing of the vagina is involuntary, it is often due to a learned response to pain, that is to say, the woman expects pain, or remembers previous painful experiences, or simply imagines that penetration will be painful, and the vaginismus reflex occurs. Vaginism can be helped very successfully. Primary Vaginismus

Primary vaginismus is the name given to the condition when the woman has never been able to have sexual intercourse. Primary vaginismus is often discovered in the teenage years, when the girl tries to use tampons, or goes for an internal examination and finds it to be extremely uncomfortable. This fear of pain then causes an anxiety which will bring with it the conditioned reflex response of closing up whenever the woman then subsequently attempt intercourse. Secondary Vaginismus Secondary vaginismus is the name given to the condition where the woman has been able to achieve penetration in the past, but develops vaginism after some time.

39

For the woman, being trapped within herself with the painful symptoms of vaginismus brings about the feelings of panic and anxiety, of being "stuck with it forever", of feeling inadequate and "the only one who suffers from this" Partners suffer as well, feeling frustrated, helpless, rejected and inadequate. Inaccurate sexual information and the lack of understanding of the woman's body will worsen the crisis, often leading to alienation and even break-ups. Diagnosis Diagnosing vaginismus is quite simple. It requires identifying an inability, or great difficulty, with one or more of the following Five Penetrations of Life

Finger Tampon Applicator Intercourse (or use of penis-size dildo) Gynecologic exam

Typically, intercourse will not be possible even if she can have the other penetrations. In other words, a woman may not be able to have any of the five penetrations; or she may be able to have four of those five penetrations, with intercourse being the missing one; or she may have any combination in between.

Treatment

Women with primary vaginismus fall into two categories:

Those who can self-treat with education, encouragement, and/or self-help home (dilator) kits obtained from their doctors, counselors, the Internet, sex shops, etc. Those who cannot cure their vaginismus on their own and need further intervention in the form of individualized treatment by clinicians with knowledge and expertise in treating vaginismus.

40

Treatment for vaginismus is often easier for women with secondary vaginismus than it is for women with primary vaginismus, simply because the woman is aware that penetration without pain is possible. II.6. FRIGIDITY What is Frigidity? Frigidity is broadly used to refer to a low libido (sex drive) in women. This term is often used incorrectly to describe a woman who is emotionally cold or does not respond to her partners sexual advances. A lack of sexual desire can be psychologically embedded in a persons subconscious and linked to greater issues that should be addressed or discussed. In some cases women may experience low libido and refuse or avoid sexual intimacy or they may endure it without being able to reach orgasm, finding little pleasure in the act. In other cases, women may have difficulty being aroused or sex may even cause considerable pain or discomfort. But whether the root cause is emotional or physical, frigidity can result in conflict and strain in even the most secure relationships. Causes of Frigidity Emotional Causes of Frigidity

Past traumatic sexual experience such as rape, incest, or sexual assault Feeling emotional distance from a partner Communication problems, an argument or an unresolved emotional issue between partners Intimacy inhibitions linked to religious or personal taboos, or feeling repulsed by sex Emotions such as shame, guilt, depression, anxiety, or boredom in the relationship Situational factors such as an intoxicated partner, or a mother-in law being situated in the next room Fear of pregnancy or sexually transmitted diseases Low self-esteem or lack of confidence
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Physical Causes of Frigidity


Pain or discomfort during intercourse (dyspareunia) Vaginal dryness Lack of adequate foreplay Poor male sexual performance Exhaustion or fatigue Insomnia Effects of prescription medications Effects of alcohol or substance abuse Changes related to menopause or hormonal imbalance Damage to nerves due to surgery or trauma Infection or gynecological problems

Diagnosing and helping for Frigidity If lack of sexual desire has become a problem in your relationship, there are many treatment options to explore depending on the underlying causes and specific symptoms. A communication problem is often at fault for lack of sexual desire, so try discussing your partner's feelings. If the problem is an emotional one, bring it out into the open, or consider making an appointment with a psychologist for personal or couples counseling. It is possible for low libido or frigidity to be caused by a physical problem. If this is suspected, seek a professional opinion by consulting a gynecologist, general practitioner or complimentary health profession

II.6.DYSPAREUNIA: (Painful Sex for Women) What is dyspareunia? Dyspareunia is painful sexual intercourse for women. The pain can be in the genital area or deep inside the pelvis. The pain is often described as sharp, burning or similar to menstrual cramps.

42

What are some of the causes of dyspareunia? Any part of the genitals can cause pain during sex. Some conditions affect the skin around the vagina. The pain from these conditions is usually felt when a tampon or penis is inserted into the vagina, but pain can also occur even when sitting or wearing pants. Inflammation or infection may be the cause (such as a yeast infection, urinary tract infection or inflammation of the vagina). Injury to the vagina and the surrounding area can also cause pain. If a diaphragm or cervical cap (which is types of birth control) does not fit correctly, sex may also be painful. Vaginismus is a spasm of the muscles around the vagina. In some women, the pain of the spasms is so severe that penile penetration is impossible. Vaginal dryness can also cause painful sex. This dryness may be caused by menopause and changes in estrogen levels, or from a lack of foreplay before intercourse. Pain during intercourse may feel like it is coming from deep in the pelvis. Women often report the feeling that "something is being bumped into." The uterus may hurt if there are fibroid growths; the uterus is tilted or if the uterus prolapses (falls) into the vagina. Certain conditions or infections of the ovaries may also cause pain, especially in certain sexual positions. Past surgeries may leave scar tissue that can cause pain. Because the bladder and intestines are close to the vagina, they may also cause pain during sex. Endometriosis and pelvic inflammatory disease may also cause pain. Episiotomy bad sutured and or with a bad scar causes also pain and when the introitus has become too small for normal penetration (often worsened by scarring). We know that the mind and the body work together. This is also seen with sexual problems. Often the problem that first caused the pain may go away, but you have learned to expect the pain. This can lead to further problems because you may be tense during sex or you may be unable to become aroused. The problem can then become a cycle and you are caught in the middle. Negative attitudes about sex, misinformation about sex and misinformation about the functions of the woman's body are often associated with some types of pain. Is painful sex all in your head? No! But it is important to discuss feelings and difficulties with your partner and your doctor.

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How the exam is performed? During the exam, your doctor may apply a cotton-tipped swab to the area to see if the area around the vagina is painful. A gentle exam of the vagina and cervix is done with a speculum, similar to the way you get a Pap smear. For some women, this part of the exam may be painful. Your doctor may use a smaller speculum to decrease the discomfort. Or, your doctor may delay the exam until the pain has decreased. It is important to let your doctor know if the exam becomes too painful. Discuss this with your doctor ahead of time. Many women find it useful to hold a mirror during the exam to see the appearance of their genital structures. During the final part of the exam, your doctor will feel your uterus and ovaries with one hand on the abdomen and one finger in your vagina. This is similar to exams performed during a pelvic exam. Any tests needed? If your symptoms and exam suggest an infection, tests may be needed done to check for yeast or bacteria. If there is no infection, your doctor may do some other tests, such as urine or allergy tests. Treatment Dyspareunia is treated by the taking following steps:

Carefully taking a history. Carefully examining the pelvis to duplicate as closely as possible the discomfort and to identify a site or source of the pelvic pain. Clearly explaining to the patient what has happened, including identifying the sites and causes of pain. Removing the source of pain when possible. Prescribing very large amounts of water-soluble sexual or
surgical lubricant

during

intercourse. Discourage petroleum jelly. Moisturizing skin lotion may be recommended as

44

an alternative lubricant, unless the patient is using a condom or other latex product. Lubricant should be liberally applied (2 tablespoons full) to both the phallus and the orifice. A folded bath towel under the receiving partner's hips helps prevent spillage on bedclothes.

Instructing the receiving partner to take the phallus of the penetrating partner in their hand and control insertion themselves, rather than letting the penetrating partner do it. Encouraging the couple to add pleasant, sexually exciting experiences to their regular interactions, such as bathing together (in which the primary goal is not cleanliness), mutual caressing without intercourse, and using sexual books and pictures. In couples where a woman is preparing to receive vaginal intercourse, such activities tend to increase both natural lubrication and vaginal dilation, both of which decrease friction and pain.

Recommending a change in coital position to one admitting less penetration. In women receiving vaginal penetration, this is recommended for those who have pain on deep penetration because of pelvic injury or disease:

In women receiving vaginal penetration: maximum vaginal penetration is achieved when the receiving woman lies on her back with her pelvis rolled up off the bed, compressing her thighs tightly against her chest with her calves over the penetrating partner's shoulders. Minimal penetration occurs when a receiving woman lies on her back with her legs extended flat on the bed and close together while her partner's legs straddle hers.

A device has also been described for limiting penetration. A manual physical therapy which treats pelvic and vaginal adhesions and microadhesions may decrease or eliminate intercourse pain.

II.7. GENITAL ULCERATIONS Definition A Genital ulcer is an ulcer located on the genital area, caused by a sexually transmitted disease such as
genital herpes ,

syphilis, chancroid, or thrush. Some other signs of having genital ulcers

include enlarged lymph nodes in the groin area, or vesicular lesions, which are small, elevated
45

sore or blister. The syndrome may be further classified into penile ulceration and vulval ulceration for males and females respectively. 1. Mnemonic: Chisel
1. Chancroid (painful) 2. Herpes Genitalis (painful) 3. Inguinale (Granuloma Inguinale) 4. Syphilis 5. Eruption secondary to drugs 6. Lymphogranuloma venereum

2. Causes: Sexually Transmitted Disease Genital Ulcers 1. Painful


1. Herpes Genitalis

1. Grouped vessicles or small ulcers, serous discharge 2. 60-70% of U.S. genital ulcers it is sexual transmitted disease caused by the herpes simples virus type 1. as signs and symptoms: sores, flu ,fever ,swollen glands Complications: - recurrent painful genital sores - psychological distress - fatal infection in babies - may play a role in spreading HIV Diagnosis: visual inspection, taking a sample from sore and tasting in laboratory, use of blood test (which detects antibodies) Treatment: generally there is no treatment that can cure herpes but antiviral medication can help
2. Chancroid

1. Open sore with gray, yellow ulcer base 2. 50-70% in third world
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It an important bacterial infection caused by haemophilus ducreyi which is spread by sexual contact
Symptoms: - Genital ulcers

- Painful open genital sores - Swollen groin lymph nodes - Painful urination
Treatment: antibiotics: - Azythromycin

- Erythromycin - Ciprofloxacin - Ceftriaxone


Complications: - abscess

- scarring
Prevention: - do not have sex with multiple sexual partners

- do not have sex with anyone who has genital sores - do not have sex with anyone who has penile discharge - do not use petroleum jelly in vagina - practice safe sex - use condom
3. Fixed Drug Eruption

1. Pruritic lesion or burning pain 2. Non-Painful 1. Granuloma inguinale


2. Lymphogranuloma venereum 47

3. Syphilis (Early)

1. 10-20% of genital ulcers 3. Causes: non-Sexually Transmitted Disease Genital Ulcers 1. Yeast
2. Scabies 3. Pyoderma

4. Genital Trauma 5. Excoriations


6. Fixed Drug Eruption 7. Behcet's Disease

UNIT III. INFECTIOUS DESEASES IN GYNECOLOGY III.1. VULVO-VAGINAL INFECTIONS Infections of the vagina and outer female genitals include conditions caused by bacteria, viruses, cancer, non-cancerous tumors and tissue growths, foreign bodies or fistulas (abnormal passages between organs or an organ and a body cavity that allow fluids to pass from one to the other). These infections include:

Bacterial vaginosis, which represents about 60% of all vaginal infections Yeast infections, which account for 30 to 35 percent of vaginal infections. Most are due to Candida albicans. Yeast appears in 15 to 20 percent of nonpregnant and 20 to 40 percent of pregnant women.

Trichomonas vaginitis (swelling, redness and tenderness of the vagina caused by trichomonas), which is a sexually transmitted disease. It is responsible for between five and 10% of vaginal infections.

Herpes simplex virus (HSV), which causes genital ulcers (sores). It is different from syphilis and chancroid. Human papillomavirus genital warts, which are the most common viral sexually transmitted disease. About six percent of women between the ages of 20 and 34 have this infection.

Symptoms
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Vulvovaginal infections affect primarily the moist walls of the vagina and, to a lesser degree, the vulva. Specific symptoms differ with the cause of the condition. For example:

Yeast infections cause itching and a white discharge that looks like cottage cheese. Trichomoniasis vaginitis exhibits no symptoms at all for about half the women who have the organism. The other half may experience a heavy vaginal discharge (frothy, yellowish green and alkaline) with a fishy odor. Other symptoms include pain when emptying the bladder (urinating) and when having sex. The walls of the vagina may be swollen and, in serious cases, strawberry colored.

Herpes simplex virus (HSV) has a five- to seven-day growing period before symptoms appear. This makes it easy to spread between sexual partners. When a woman first is infected, her symptoms may include feeling unwell, swollen lymph nodes in the groin and a fever that usually goes away in a week. Painful ulcers develop on the genitals and heal in about 21 days. The virus comes back from time to time. When it returns, a sense of numbness or tingling may be felt where the ulcer is developing. Recurrences tend to be milder and in one place. Ulcers heal in about 10 days. A person can infect others for about four days after the symptoms have gone away.

A watery discharge, especially if bloody, may indicate a malignancy. Other causes of bleeding include cervical polyps and vaginal atropy, shrinking or wasting of the vagina walls. These usually happen after menopause.

Bacterial vaginosis causes a fishy smelling discharge. Itching and irritation are also common.

Causes and Risk Factors Vaginal infections have a variety of causes, and risk factors vary with the specific cause of the infection. For example:

Using an intrauterine device may put a woman at greater risk of getting bacterial vaginosis or a yeast infection. Having multiple sex partners or having sex with a person who has certain bacteria, viruses or other organisms adds to the risk of vaginal problems, including bacterial vaginosis, herpes simplex, trichomonas vaginitis or genital warts.

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Women who are pregnant, diabetic, have recently used an antibiotic, regularly use corticosteroids, have AIDS or who have weakened immune systems are at greater risk of getting a yeast infection.

Diagnosis

Bacterial vaginosis. Diagnosis is made during a pelvic examination. The doctor will check for signs of a discharge and a fishy smell. The doctor may measure the level of acidity in the vaginal area and take samples to examine under the microscope.

Candidal vaginitis. Diagnosis is made through a pelvic exam and by measuring how acidic or alkaline the vagina is. The doctor will also check for yeast cells under the microscope. Trichomonas vaginitis. A pelvic exam will show inflamed areas in the cervix and vagina that have a strawberry appearance. Cells may also be taken so they can be examined under the microscope.

Treatment The type of treatment given depends on the cause of the condition. In some cases, treatment completely cures the condition. In others, it relieves symptoms and shortens the period of time the person is affected. For example, herpes simplex cannot currently be cured, but timely anti-viral drugs can help reduce its effect. For eg -treatment of trichomonas vaginitis is flagyl; for Candidal vaginitis is Nystatin ovule; herpes simplex is symptomatic with gentian violet paint and antibiotics for bacteries

Other treatments for Vulvovaginal infections may include:


Vaginal creams Treatment of a woman's sexual partner in certain types of conditions Genital warts may be treated by applying an acid solution. Other treatments are freezing, burning or using laser therapy on the warts.

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III.2 CERVICITIS Definition Cervicitis is an inflammation of cervix. The cervix is the lower part of the uterus extending about an inch into the vaginal canal. Cervicitis is probably the most common of all gynecological disorders. It affects almost half of all women at some point in their lives. Symptoms Often there are no symptoms and cervictis is discovered during a pap test or a biopsy done for another condition. When symptoms are present, the most common symptoms are:

pain during intercourse grayish or yellow vaginal discharge bleeding after intercourse abdominal pain

The symptoms of cervictis are often confused with the symptoms of vaginitis Causes The most common cause of cervictis is STDs and exposures to certain types of bacteria. Diagnosis By considering symptoms, take a physical exam, and take samples of cervical secretions (pap smear) and analyze it for signs of cervictis. Treatment The treatment will depend on the cause. If the cause is bacteria, an antibiotic may be prescribed. If the cause is an STD, treatment of the STD is needed.

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Prevention

Limit the number of sexual partners. Know the history of your partner. Consult a health worker immediately if your partner has been diagnosed with urethritis. The symptoms of urethritis are: pain or burning during urination, a thin discharge from the penis, or a stain on his underwear.

Have a complete physical exam annually. Treat vaginal infections immediately. Avoid chemical irritants in deodorized tampons, douches, or sprays.

III.3 ENDOMETRITIS Endometritis refers to inflammation of the endometrium, the inner lining of the uterus. Pathologists have traditionally classified endometritis as either acute or chronic Acute endometritis is characterized by the presence of microabscesses or neutrophils: within the endometrial glands, while chronic endometritis is distinguished by variable numbers of plasma cells within the endometrial stroma. The most common cause of endometritis is infection. Symptoms include lower abdominal pain, fever and abnormal vaginal bleeding or discharge. Caesarean section, prolonged rupture of membranes and long labor with multiple vaginal examinations are important risk factors. Treatment is usually with broad-spectrum antibiotics. Causes of Endometritis
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-Pelvic inflammatory disease -Childbirth -Miscarriage -Induced abortion Other underlying conditions related to Endometritis:

Chorioamnionitis Intermenstrual PV bleed Maternal mortality Puerperal pyrexia Puerperal shock

About underlying conditions: With a diagnosis of Endometritis, it is important to consider whether there is an underlying condition causing Endometritis. These are other medical conditions that may possibly cause Endometritis. For general information on this form of misdiagnosis. Acute Endometritis Acute Endometritis is characterized by infection. The most causative agents are Staphylococcus aureus and Streptococcus. The most common causes of infection are believed to be because of compromised abortions, delivery, medical instrumentation, and retention of placental fragments. Histologically, neutrophilic infiltration of the endometrial tissue is present during acute endometritis. The clinical presentation is typically high fever and purulent vaginal discharge. Menstruation after acute endometritis is excessive and in uncomplicated cases can resolve after 2 weeks with antibiotic treatment. Chronic Endometritis Chronic Endometritis is characterized by the presence of plasma cells in the stroma. The most common causes are chronic pelvic inflammatory disease (PID), tuberculosis, and chlamydia.

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Patients suffering from chronic endometritis often have an underlying cancer of the cervix or endometrium. Chronic granulomatous endometritis is most often tuberculosis in etiology. The granulomas are small, sparse, and without cassation. The granulomas take up to 2 weeks to develop and since the endometrium is shed every 4 weeks, the granulomas are poorly formed. In human medicine pyometra is regarded as a form of chronic endometritis seen in elderly women causing stenosis of the cervical os and accumulation of discharges and infection. Symptom in chronic endometritis is blood stained discharge but in pyometra the patient complaints of lower abdominal pain.

Symptoms of Endometritis -Lower abdominal pain -High Fever -Increased vaginal discharge -Yellow foul- and bad smelling vaginal discharge; the discharge can be purulent and if it is pyometra the uterus will be enlarged, soft and tender.

The list of signs and symptoms are:

Treatment list for Endometritis Antibiotics -Surgery

III.4 SALPINGITIS Definition Salpingitis is the inflammation of the fallopian tubes. The fallopian tubes extend from the uterus, one on each side, and both open near an ovary. When inflammation occurs, extra fluid secretion or pus collects inside the fallopian tube. Infection of one fallopian tube usually leads to infection of the other. This occurs because the bacteria migrate via the nearby lymph vessels. Salpingitis is one of the most common causes of female infertility. If salpingitis is not promptly treated, the infection may permanently damage the fallopian tube so that the eggs released each menstrual cycle can't meet up with sperm. Salpingitis is sometimes called pelvic inflammatory disease (PID)

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Types of Salpingitis There are two types of salpingitis: acute and chronic. In acute salpingitis, the fallopian tubes become red and swollen, and secrete extra fluid so that the inner walls of the tubes often stick together. Sometimes the fallopian tubes may stick to nearby structures such as the intestines. In rare cases fallopian tube ruptures and causes a dangerous infection of the abdominal cavity. Chronic salpingitis usually follows an acute attack. Chronic salpingitis is milder, longer lasting and may not produce many noticeable symptoms. Symptoms of Salpingitis In mild cases of salpingitis, symptoms may not be present. When symptoms are present, they usually appear after the menstrual period. The most common symptoms of salpingitis are:

Abnormal color in vaginal discharge Abnormal smell in vaginal discharge Spotting between periods Painful periods Pain during ovulation Uncomfortable or painful sexual intercourse Fever Abdominal pain on both sides Lower back pain Frequent urination Nausea and vomiting

Causes of Salpingitis

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In most cases, salpingitis is caused by a bacterial infection. The common types of bacteria that cause salpingitis are: Mycoplasma, Staphylococcus, and Streptococcus. However, it can also be caused by sexually transmitted diseases such as gonorrhea and chlamydia. Diagnosis By Pelvic examination, blood tests and a mucus swab Treatment options for Salpingitis Bed rest, adequate fluid intake and analgesics are the basic necessities in the treatment of acute salpingitis, but the selection of suitable antibiotics in adequate dosage is also essential. Should an intrauterine contraceptive device be in place it should be removed after antibiotics cover is achieved. Bacterial swabs are taken from the cervix and urethra and should be tested for Chlamydia and, although gonococcal salpingitis.

Complications of Salpingitis Some of the most common complications of salpingitis are:


Infection to nearby structures, such as the ovaries or uterus Infection of sex partners An abscess on the ovary Ectopic pregnancy Infertility

III.5.OVARITIS/Oophoritis
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Definition Oophoritis is an inflammation condition of one or both ovaries. Ovaritis may involve the substance of the organ (oophoritis) or its surface (perioophoritis), and may be acute or chronic. Oophoritis usually occurring with salpingitis or other infections. Causes The fallopian tubes and ovaries are normally protected by the acidic vagina, the mucous plug of the cervix, and cilia in the uterus and fallopian tubes. But there are five situations, during which infection can more easily penetrate those delicate organs: During menstruation, the vagina is alkaline, the plug is gone, and only a healthy flow protects the fallopian tubes and ovaries from infection. Sexual activity, during a period, can introduce bacteria. During and just after childbirth. Following an abortion. It has been well-documented that abortion clinics tend to operate on a mass-production basis instead of the careful and sterile conditions one would find in a hospital operating room. Use of an IUD is also a significant cause of infection. General enervation or local congestion, due to a variety of causesranging from poor diet, overwork, constipation, pelvic infections, etc. Once salpingitis or oophoritis occurs, there is a 70% likelihood of sterility. Treatment/Management Antibiotics are usually given, but they only work on a short-term basis; and, frequently, a chronic case of salpingitis follows. While it is being treated, scar tissue and other blockage can occur on the tubes. Bed rest, adequate fluid and analgesics. Surgery if necessary (1) ACUTE FORM GENERAL CARE; Rest in bed; hot vaginal irrigation, twice daily; hot pelvic pack; Hot Leg Pack or Hot Footbath twice daily, followed by cold friction. If suppuration of tubes occurs, operation is usually necessary. During the first few days, ice bag over inflamed part, interrupted at intervals of 1-3 hours by Fomentation for 15 minutes or hot and cold pelvic compress for 30 minutes; heat to limbs.
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(2) CHRONIC FORM BASIC APPLICATIONS; Hot vaginal irrigation twice daily; hot rectal irrigation once daily, if exudation in pelvis is extensive; pelvis massage. General tonic applications; general massage; sunbaths; out-of-door exposure with proper protection, carefully avoiding chill; nourishing and blood-building diet. If suppuration is present, give drainage. Removal of the diseased appendages is sometimes required, but in most cases this may be avoided by the proper application of water treatments at the outset.

III.6. MASTITIS Definition Mastitis is a condition that causes the breast tissue to become inflamed. It usually occurs in women who are breastfeeding, so it is often referred to as lactation mastitis. Mastitis usually affects only one breast, causing it to become painful, red and swollen. Some women may also experience flu-like symptoms, which can include fever, chills or aches. Types of mastitis There are two main types of mastitis:

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non-infectious mastitis, which is typically caused by breast milk remaining within the breast tissue (milk stasis), and is due to a blocked milk duct or problems with breastfeeding, and

Infectious mastitis, which is caused by bacteria.

Left untreated, non-infectious mastitis can progress to infectious mastitis. This may be due to bacteria infecting the milk that remains in the breast tissue. Infectious mastitis requires prompt treatment in order to prevent more serious complications such as an abscess in the breast. Symptoms Mastitis usually affects only one breast and the symptoms can develop quickly. Symptoms of mastitis include:

the appearance of a red area on part of the breast that may feel hot and painful to touch, the breast can then start to appear lumpy and red, and these will be round lumps which move freely and are either firm or soft, and a burning pain in the breast that may be continuous or only occur when you are breastfeeding. Discomfort, soreness, tenderness, lumpiness, and possible cysts in the breast.

Some women will also experience flu-like symptoms such as:


aches, fever, shivering and chills, feeling tired, feeling anxious or stressed, and a general sense of feeling unwell.

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The symptoms are the most prominent before the monthly, and almost entirely absent during pregnancy. Causes This is the most common breast problem that women have; over 50% of adult females have it. This is most frequent in women of child-bearing age, and primarily occurs between the ages of 30 and 50. When there is too much fluid in the breast, instead of moving it out of the breast, the lymph system stores it in small spaces, here and there. Eventually, fibrous tissue surrounds them and thickens, forming cysts. These cysts frequently swell just before the monthly, causing pain. These cysts may change in size; but, although tender, they move freely. In contrast, a cancerous growth generally does not move freely, is usually not tender, and does not leave. It is important to regularly examine each breast for lumps, and determine what kind they are. It is best to do this weekly. It is known that the risk of breast cancer is three times as great in women with cysts. Breast cysts rarely appear after the age of 50, when estrogen levels are less. Hormonal imbalance, abnormal production of breast milk (caused by high levels of estrogen), and an underactive thyroid can induce cysts. Treatment/Management Drink enough water, so it is easier for the blood and lymphatic system to care for the milk glands. Regular breastfeeding/express breast milk Apply ice bag on the on the inflamed area Anti inflammatories,analgesics and antibiotics strict hygiene(wash hands before putting the baby on the breast)

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The importance of continuing to breastfeed Though the symptoms of mastitis may discourage you from continuing to breastfeed it is important to continue. Regular breastfeeding will help remove any "blocked" breast milk from your breast, should help resolve the symptoms faster and help prevent mastitis from becoming more serious. Though the milk from the affected breast can be a little saltier than normal, it is perfectly safe for your baby to drink. Any bacteria that may be present in the milk will be harmlessly absorbed by your baby's digestive system and cause no problems.

IV. INFERTILITY INFERTILIY OF COUPLE IV.1. Definitions Is when the couple has never conceived, despite of cohabitation and exposure to pregnancy (no contraception), for a period of 2 years. Is the inability to achieve spontaneous conception following 1 year of unprotected intercourse. Refers to absolute inability to conceive spontaneously .Infertility is the inability to become pregnant after 12 months of unprotected sex (intercourse). IV.2. Types of infertility Primary infertility

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Primary infertility is when a couple has never conceived, despite of cohabitation and exposure to pregnancy (no contraception), for a period of 2 years.

Secondary infertility

Is when a couple has previously conceived, but it is later unable to conceive again, despite of cohabitation and exposure to pregnancy (no contraception), for a period of 2 years. If the woman has breastfeed a previous infant or is on contraception then the exposure to pregnancy should be calculated from the end of lactating amenorrhea/contraception.

Pregnancy wastage when a woman is able to conceive but is unable to produce a live birth. Unproven infertility refers to problems perceived by individuals or couples as infertility when in fact; the member of a couple is virtually not at risk of conception. The problem can be biologic such as lactating mother who is anovilatory and couples who practicing contraception.Or Sub infertility indicates a reduction in the ability to conceive spontaneously.

IV.3. Causes The causes of infertility are the side oh a husband in 35-40% of cases, of the wife in 45-50% of cases, no cause for infertility in 10-20%.So it is a couple problem and it is important to investigate both husband and wife. Female causes Congenital: in a very few women the organs of reproduction has various defects of development that prevent conception. The defect might be complete lack of ovaries or poorly functioning ones. Or the uterus and vagina might be defective. In the history you might find that the woman has never menstruated or menstruations started later and was painful or very scanty. Examination might reveal a defective uterus or vagina.

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Hormonal: in some women, there is inadequate hormone secretion to stimulate ovulation or to sustain the released ovum. This could be due to congenital abnormalities as above, or because of damage of the ovaries by diseases such as tuberculosis, mumps or irradiations. In these two causes there might be failure of development of the secondary sex characteristics such as breast and the female shape. Injuries: mutilation of the genital organs can lead to a partial or complete inability to have normal intercourse because of the scars and the pain. Repeated and too radical D and C with removal of most of the endometrium may cause amenorrhea and also adhesions and occlusion of the uterine cavity. Tumours: fibroids and polyps can cause infertility or habitual abortions Tubal occlusion: this is the major cause of infertility. Tubal occlusion is due to pelvic inflammatory diseases, which in turn is usually caused by sexually transmitted diseases (chiefly gonorrhea) or sepsis after delivery or abortion. Gonorrhea can also cause occlusion of the males vas deferens and render him infertile. The interval between genital infection and the complaint of infertility is often a matter of years. There are also women who are asymptomatic carries of Neisseria gonorrhea. They may be infertile. Typhoid peritonitis or appendicitis can also lead to tubal occlusion.

Infections: infections of various types are major cause of infertility -infection of the ovaries by mumps -tuberculosis can damage the ovaries, fallopian tubes or the uterine endometrium -parasitic diseases, such as filariasis, cause infertility by damage to the fallopian tubes. High fever due to malaria can cause abortion. -chlamydia and other organisms are associated with salpingitis leading to tubal occlusion. Male causes

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Congenital

Developmental abnormalities of the male genitalia. The penis might be deformed in such a way that normal sexual intercourse and deposition of sperms in the vagina are impossible. Hormonal

The man might have low levels of male hormones. This in turn will lead to lack of adequate amounts of sperms or the sperms might be of low quality or defective:(Azoospermie (absence totale de spermatozoids dans ljaculat), Oligospermie

Tratozoospermie Asthnospermie =mobilit anormale Polyzoospermie Parvissmie<=frquence trop leve des rapports sexuels, Hyperspermie)

Diabetes mellitus can cause a man to be important and thus infertile.

Excess alcohol or tobacco

Excessive intake of these can reduce levels of testosterone hormones and render a man infertile. Cirrhosis of the liver has a similar effect. Impotence and premature ejaculation

These problems are usually due to psychological factors. General malnutrition

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Anemia and chronic ill health can cause infertility. IV.4. Investigations in infertile couple A complete history and physical examination of both partners is essential. General history Age of a couple How long the couple has been married Previous marriage and whether there were any children in these previous marriages. Occupation of the couple; whether one of them is often away; Frequency and timing of sexual intercourse Problems in sexual intercourse; Any serious general diseases;tuberculosis,diabetis mellitus or other endocrine disorder; Abuse of nicotine or alcohol by one or both partners.

Specific questions about the wife Menstruations history including menarche, regularity of periods, amount of bleeding, dysmenorrhea(primary or secondary) Venereal diseases or history of vaginal discharge or sores Earlier pregnancies with detail about deliveries or abortions especially fever or smelly discharge after the delivery or abortion. Specific questions about the husband General health History of venereal diseases or urethral discharge History of mumps as an adult Injury to the sexual organs or operations as for hernia repair

Examination of the wife General examination: any obvious male features, eg hairiness(hirsutism), diseases of lungs and heart

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Abdominal examination for masses and scars of previous operations Vaginal examinations for abnormalities of introitus, cervix and uterus, palpation of the adnexae for tumours of the ovary and fallopian tubes. Examination with speculum to inspect the cervix and the vagina for abnormalities such as a possible pathological discharge.

Examination of the husband General build and appearance Examination of genitalia for abnormalities of the penis eg hypospadias, a condition in which the urethra opens on the low aspect of the penis Size and consistency of testes Tests may include for example:

Blood hormone levels Cervical mucus to detect ovulation Clomid challenge test Endometrial biopsy ,Hysterosalpingography (HSG) Laparoscopy Luteinizing hormone urine test Pelvic exam Postcoital testing (PCT) Progestin challenge Semen analysis Serum progesterone Temperature first thing in the morning to check for ovulation (basal body temperature) Testicular biopsy

IV.5. Treatment Treatment depends on the cause of infertility and the important thing is to recognize and refer it to a specialist. It may involve: Education and counseling

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Medical procedures such as in vitro fertilization Medicines to treat infections and clotting disorders, or promote ovulation IV.6 Prevention Because sexually transmitted diseases (STDs) often cause infertility, practicing safer sex behaviors may minimize the risk. Gonorrhea and chlamydia are the two most common causes of STD-related infertility. STDs often don't have symptoms at first, until PID or salpingitis develops. These conditions scar the fallopian tubes and lead to decreased fertility, infertility, or an increased risk of ectopic pregnancy. Getting a mumps vaccine in men has been shown to prevent mumps and its complication, orchitis. The vaccine prevents mumps-related sterility. Some forms of birth control, such as the intrauterine device (IUD), carry a higher risk for future infertility. IUDs are not recommended for women who have not already had a child. If you are considering getting an IUD, carefully weigh the increased risk of infertility and the potential benefits with your partner and health care provider. Getting diagnosed and treated early for endometriosis may decrease the risk of infertility.

UNIT V.MENSTRUAL DISORDERS V.1.DYSMENORRHOEA Dysmenorrhea or pain associated with menstruation occurs in two main forms: Primary or spasmodic dysmenorrhea Secondary or congestive dysmenorrhea
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Primary dysmenorrhea This is a very common complaint, very often it occurs in girls a few years after puberty. The pain is felt in the pelvis and lower back and may radiate into the legs. The pain is colicky and sometimes severe, and it is accompanied by nausea, vomiting and fainting. It is commonest in nulliparous women. It is always associated with ovulatory cycles. Causes

The cause is probably ischemia due to strong contractions of the uterine muscle which occur during the first day of menstruation, childbirth often cures the condition, possibly because a uterus which has held a baby is more vascular and does not become ischemic so easily. Investigations

Take a history with special reference to the severity and duration of the pain. Do a physical examination to exclude pelvic tumours. In most cases no abnormalities is found. Treatment

Simple analgesics such as aspirin are enough in most cases. It is important to explain to the girl and her mother that this dysmenorrhea it is not caused by pelvic diseases and will not cause sterility. Do not give addictive drugs such as pethidine or morphine, however severe the pain might be. If pain is very severe and interfering with normal activities, refer the patient to a specialist who can put her to the pill for four or six months continuously. Secondary dysmenorrhea This type of pain begins 3 to 4 days (or sometimes up to a week) before menstruation and may either get better or get worse when bleeding starts. It is felt in the pelvis and back and is made worse by exercise. They may also be other symptoms such as menorrhagia, infertility and dyspareunia.

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This type of dysmenorrhea is always pathological caused. It may occur with uterine fibroids. The 2 main causes are pelvic inflammatory deaseses and endometriosis, and most women complaint of infertility. Treatment of the cause will usually relieve the dysmenorrhea, but we know that successful treatment of PID is difficult and so prevention should be emphasized V.2. IRREGURAL CYCLES It may be comforting to know that most An irregular cycle is frequently shorter or longer than this average, and may also include women don't have consistent 28-day menstrual cycles. A menstrual cycle can be considered regular if it averages between 26 and 35 days. An irregular menstrual pattern may be an indication of ovulation problems and can be a major factor in infertility. Irregular cycles may also release hormones inconsistently and may add to mood and pain problems. Irregular and long cycles are sometimes also associated with heavy cramping and bleeding. Irregular periods can be a sign of approaching menopause. But they can also arise from an increase in the number of cells in a section of the endometrium. Endometrial hyperplasias are caused when too much estrogen is produced by women who do not ovulate. To diagnose the problem, your doctor will probably perform a D & C, scraping cells from the endometrium and doing a biopsy. Mild hyperplasias are usually treated with monthly doses of progesterone. More serious hyperplasia requires long-term progesterone therapy or even removal of the uterus. Treatment depends on the cause.

V.3. POLYMENORRHOEA AND LONG CYCLE Polymenorrhoea or epimenorrhoea (short cycles) are periods occur at shorter intervals than usual; are under twenty-one days in length, are common at extremes of reproductive life, and imply higher estrogen production. Short cycles are commonly abnormal in ovulatory characteristics and often have increased in flow.
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Short cycles

Short cycles often signal low levels of estrogen and progesterone in the system, possibly resulting from an undersupply of certain precursors. Lacking these hormones, the endometrium cannot develop properly, and infertility may result. Short cycles also develop as some women approach menopause. They can also result from over- or under activity of the thyroid gland.

Long cycles

Long cycles (Oligomenorrhea) are not necessarily a problem. Many women with long cycles produce eggs and are fertile. Their ovaries are normal, and the eggs just take a long time to mature. By far the most common cause of an unexpectedly long cycle is simply pregnancy! Oligomenorrhea, flow at intervals longer than thirty-six (but less than 180) days, is more common than amenorrhea and also occurs at the extremes of reproductive life. However, 30 percent of women twenty to forty-nine years old had cycle intervals over sixty days. Women reporting a body mass index at age eighteen that was over twenty-four had increasing risks for oligomenorrhea with increasing weight. However, some women with regular periods two to five months apart may have ovarian cysts. Also, when a very long cycle is accompanied by a sudden increase in body hair, a decrease in breast size, and enlargement of the clitoris; and menstruation eventually stops altogether, the problem could be a growth or tumor of the adrenal gland. To make a diagnosis, the doctor will take urine, glucose tolerance, and other tests. A CAT scan or Magnetic Resonance Imaging (MRI) might also be ordered. Long cycles can also develop from over or underproduction of thyroid hormone. Here also you have to treat the cause. V.4. MENORRHAGIA This is when menstrual loss is heavier than usually (excessive menstrual bleeding). This is clinically important because of anaemia which is caused by excessive bleeding. Menorrhagia is a symptom and not a disease and its cause must be sought. Common causes are chronic pelvic inflammatory disease and uterine fibroids. Treatment of the cause will cure the heavy loss.

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V.5. AMENORRHOEA Amenorrhoea is normal (physiological) before ovarian activity begins at puberty and after it has ceased at menopause. Physiological amenorrhea also occurs during pregnancy and for some months after delivery when the woman is breastfeeding. Types of amenorrhea Primary amenorrhea means that menstruation has never occurred. Secondary amenorrhea means that the periods, once present, has stopped. A woman in the reproductive period who complaints of amenorrhea should be examined for signs of pregnancy. Causes of amenorrhea Causes of amenorrhea may be grouped under the following headings: Hormonal Poorly functioning ovaries or pituitary gland, suprarenal or thyroid disorders may cause amenorrhea. Diabetes mellitus can also be a cause. Nervous A change of occupation or environment often causes suppression of periods for a month or two, especially in young girls. Fear of or desires for pregnancy and sudden chocks or anxiety are others causes. The central nervous system has a powerful influence on menstruation. Constitutional Severe debilitating diseases such as tuberculosis and profound anaemia may interrupt the periods. Local cause

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After hysterectomy, bilateral removal of the ovaries or exposure to full dose of radiation, menstruation ceases permanently. Congenital abnormalities A congenital abnormality which causes what seems to be primary amenorrhea is an imperforated hymen. The vaginal orifice is closed by an intact membrane so that the menstrual blood formed is retained in the vagina. This condition is called haematocolpos. If it is not treated the uterus may become distended with blood: haematometra and haematosalpinx if also the fallopian tubes become distended with the blood. The condition is cured by incision of hymen which allows the blood to flow freely. Treatment of amenorrhea In each case of amenorrhea you must take a detailed history and do a clinical examination in order to rule out simple causes like pregnancy and an imperforate hymen. All patients who are not pregnant will need investigations and treatment. The treatment may take place at the hospital where sophisticated hormones studies and therapy, Xray and surgery may be done, depending on the cause of the disorder. Investigations and treatment of amenorrhea are the same as for Oligomenorrhea.

V.6. ENDOMETRIOSIS Endometriosis is a term used to describe the condition in which ectopic endometrium is found in situations other than the lining of the cavity of the uterus. The site at which endometriosis may occur: Most frequently in the ovaries, when it is usually bilateral; And may be associated with deposit in rectovaginal septum and uterosacral ligaments;

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Another common site is the wall of the uterus, where it lets of endometrial tissue are found surrounded by uterine muscle; this is known as adenomyosis; Small nodules of endometriosis may occur on the surface of the pelvic peritoneum, involving the wall of the bowel and bladder; The peritoneal coat of the fallopian tubes; Rarely in the umbilical region; In lower abdomen scars; The inguinal canal and in the vulva in relation to the round ligament.

Endometriosis never appears before puberty and it regresses after menopause. Etiology Endometriosis may arise in different ways and in different sites: Adenomyosis Adenomyosis may arise by down growth from the endometrium of the uterine cavity into the underlying myometrium, as a result of some unknown stimuli. Serial sections usually show direct continuity between endometrial tissue deep in the wall of the uterus and the normal endometrium. Retrograde menstruation theory Direct extension from the endometrium cannot possibly explain the occurrence of extra uterine endometriosis, and to account for this the implantation or cellular spill theory was introduced. This suggests that minute fragments of endometrium pass along the fallopian tubes during menstruation and spill into the pelvic part of the peritoneal cavity, becoming implanted on the surface of the ovary, in the rectovaginal pouch or in some other situation, and developing into endometriosis. Although the endometrium shed at menstruation is mainly necrotic, living fragments have been found at operation in the lumen of the tubes and in the peritoneal cavity. Direct transplantation of endometrial fragments into the tissues of the abdomen wall is thought to have occurred during operations on the uterus during pregnancy, such as hysterectomy, later giving rise to endometriosis in the abdominal scars. Serosal metaplasia

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An alternative theory is that of serosal metaplasia. The Mllerian ducts are originally derived from an unfolding of the embryonic coelom, and it is suggested that endometriosis may result from metaplasia of the peritoneal endothelial cells in the peritoneal cavity, possibly as a result of the loss of a suppression immunological mechanism. In extremely rare instances, endometriosis has been described in situations that could not be explained by either implantation or serosal metaplasia, such as the thigh and the pleura. It is possible that these tumours were synoviomata and not endometriomata. Clinical features Endometriosis may give rise to symptoms at any time during the childbearing period. Pain is the most common symptom, occur premenstrually and during menstruation; Deep dysmenorrhea occurs when the uterosacral ligaments or the rectovaginal pouch or septum are involved; Menorrhagia may occur, especially with uterine adenomyosis but also with extra uterine lesions; Moderate or severe endometriosis is associated with infertility

The pathology and clinical features of endometriosis vary with the anatomical site of the lesions as follows: Ovarian endometriosis This may occur as small, superficial dark red deposits, often associated with similar blood spots on various parts of pelvic peritoneum; alternatively it may occur apparently in substance of the ovary as the characteristic (chocolate cyst) Endometriosis of the rectovaginal septum Small modules of endometriosis are frequently found in the rectovaginal pouch, and they may invade the uterosacral folds and the rectovaginal septum, giving rise to an indurated mass with considerable fibrosis. The intestine

74

Endometriosis can occur in the bowel and particularly in the pelvic colon, either alone or with other lesions of endometriosis. Small hemorrhagic modules may be found on the peritoneal surface, and occasionally endometriosis involves the muscular wall, causing dense fibrosis and rarely intestinal obstruction. The bladder Endometriosis of the bladder is very rarest may cause frequency of micturition or haematuria at the time of the menstrual. Endometriosis in an abdominal scar This may follow an operation for endometriosis, myomectomy (if the uterine cavity is opened) and particularly hysterectomy in mid midtrimester pregnancy. Umbilical endometriosis Small modules are found. These increase in size and become tender in each menstrual cycle. Bleeding from umbilicus is very rare, but has been recorded. Treatment If symptomless endometriosis is an incidental discovery there is no need to insist on any treatment, although the patient should be re-examined periodically. If there are symptoms, a diagnosis of intrapertonial endometriosis has to be confirmed by laparoscopy or laparotomy. In most cases a choice has to be made between hormonal therapy and surgical treatment; that is why you have to refer the patient to a specialist.

UNIT V.MENSTRUAL DISORDERS V.1.DYSMENORRHOEA Dysmenorrhea or pain associated with menstruation occurs in two main forms: Primary or spasmodic dysmenorrhea Secondary or congestive dysmenorrhea

75

Primary dysmenorrhea This is a very common complaint, very often it occurs in girls a few years after puberty. The pain is felt in the pelvis and lower back and may radiate into the legs. The pain is colicky and sometimes severe, and it is accompanied by nausea, vomiting and fainting. It is commonest in nulliparous women. It is always associated with ovulatory cycles. Causes

The cause is probably ischemia due to strong contractions of the uterine muscle which occur during the first day of menstruation, childbirth often cures the condition, possibly because a uterus which has held a baby is more vascular and does not become ischemic so easily. Investigations

Take a history with special reference to the severity and duration of the pain. Do a physical examination to exclude pelvic tumours. In most cases no abnormalities is found. Treatment

Simple analgesics such as aspirin are enough in most cases. It is important to explain to the girl and her mother that this dysmenorrhea it is not caused by pelvic diseases and will not cause sterility. Do not give addictive drugs such as pethidine or morphine, however severe the pain might be. If pain is very severe and interfering with normal activities, refer the patient to a specialist who can put her to the pill for four or six months continuously. Secondary dysmenorrhea This type of pain begins 3 to 4 days (or sometimes up to a week) before menstruation and may either get better or get worse when bleeding starts. It is felt in the pelvis and back and is made worse by exercise. They may also be other symptoms such as menorrhagia, infertility and dyspareunia.

76

This type of dysmenorrhea is always pathological caused. It may occur with uterine fibroids. The 2 main causes are pelvic inflammatory deaseses and endometriosis, and most women complaint of infertility. Treatment of the cause will usually relieve the dysmenorrhea, but we know that successful treatment of PID is difficult and so prevention should be emphasized V.2. IRREGURAL CYCLES It may be comforting to know that most An irregular cycle is frequently shorter or longer than this average, and may also include women don't have consistent 28-day menstrual cycles. A menstrual cycle can be considered regular if it averages between 26 and 35 days. An irregular menstrual pattern may be an indication of ovulation problems and can be a major factor in infertility. Irregular cycles may also release hormones inconsistently and may add to mood and pain problems. Irregular and long cycles are sometimes also associated with heavy cramping and bleeding. Irregular periods can be a sign of approaching menopause. But they can also arise from an increase in the number of cells in a section of the endometrium. Endometrial hyperplasias are caused when too much estrogen is produced by women who do not ovulate. To diagnose the problem, your doctor will probably perform a D & C, scraping cells from the endometrium and doing a biopsy. Mild hyperplasias are usually treated with monthly doses of progesterone. More serious hyperplasia requires long-term progesterone therapy or even removal of the uterus. Treatment depends on the cause.

V.3. POLYMENORRHOEA AND LONG CYCLE Polymenorrhoea or epimenorrhoea (short cycles) are periods occur at shorter intervals than usual; are under twenty-one days in length, are common at extremes of reproductive life, and imply higher estrogen production. Short cycles are commonly abnormal in ovulatory characteristics and often have increased in flow.
77

Short cycles

Short cycles often signal low levels of estrogen and progesterone in the system, possibly resulting from an undersupply of certain precursors. Lacking these hormones, the endometrium cannot develop properly, and infertility may result. Short cycles also develop as some women approach menopause. They can also result from over- or under activity of the thyroid gland.

Long cycles

Long cycles (Oligomenorrhea) are not necessarily a problem. Many women with long cycles produce eggs and are fertile. Their ovaries are normal, and the eggs just take a long time to mature. By far the most common cause of an unexpectedly long cycle is simply pregnancy! Oligomenorrhea, flow at intervals longer than thirty-six (but less than 180) days, is more common than amenorrhea and also occurs at the extremes of reproductive life. However, 30 percent of women twenty to forty-nine years old had cycle intervals over sixty days. Women reporting a body mass index at age eighteen that was over twenty-four had increasing risks for oligomenorrhea with increasing weight. However, some women with regular periods two to five months apart may have ovarian cysts. Also, when a very long cycle is accompanied by a sudden increase in body hair, a decrease in breast size, and enlargement of the clitoris; and menstruation eventually stops altogether, the problem could be a growth or tumor of the adrenal gland. To make a diagnosis, the doctor will take urine, glucose tolerance, and other tests. A CAT scan or Magnetic Resonance Imaging (MRI) might also be ordered. Long cycles can also develop from over or underproduction of thyroid hormone. Here also you have to treat the cause. V.4. MENORRHAGIA This is when menstrual loss is heavier than usually (excessive menstrual bleeding). This is clinically important because of anaemia which is caused by excessive bleeding. Menorrhagia is a symptom and not a disease and its cause must be sought. Common causes are chronic pelvic inflammatory disease and uterine fibroids. Treatment of the cause will cure the heavy loss.

78

V.5. AMENORRHOEA Amenorrhoea is normal (physiological) before ovarian activity begins at puberty and after it has ceased at menopause. Physiological amenorrhea also occurs during pregnancy and for some months after delivery when the woman is breastfeeding. Types of amenorrhea Primary amenorrhea means that menstruation has never occurred. Secondary amenorrhea means that the periods, once present, has stopped. A woman in the reproductive period who complaints of amenorrhea should be examined for signs of pregnancy. Causes of amenorrhea Causes of amenorrhea may be grouped under the following headings: Hormonal Poorly functioning ovaries or pituitary gland, suprarenal or thyroid disorders may cause amenorrhea. Diabetes mellitus can also be a cause. Nervous A change of occupation or environment often causes suppression of periods for a month or two, especially in young girls. Fear of or desires for pregnancy and sudden chocks or anxiety are others causes. The central nervous system has a powerful influence on menstruation. Constitutional Severe debilitating diseases such as tuberculosis and profound anaemia may interrupt the periods. Local cause

79

After hysterectomy, bilateral removal of the ovaries or exposure to full dose of radiation, menstruation ceases permanently. Congenital abnormalities A congenital abnormality which causes what seems to be primary amenorrhea is an imperforated hymen. The vaginal orifice is closed by an intact membrane so that the menstrual blood formed is retained in the vagina. This condition is called haematocolpos. If it is not treated the uterus may become distended with blood: haematometra and haematosalpinx if also the fallopian tubes become distended with the blood. The condition is cured by incision of hymen which allows the blood to flow freely. Treatment of amenorrhea In each case of amenorrhea you must take a detailed history and do a clinical examination in order to rule out simple causes like pregnancy and an imperforate hymen. All patients who are not pregnant will need investigations and treatment. The treatment may take place at the hospital where sophisticated hormones studies and therapy, Xray and surgery may be done, depending on the cause of the disorder. Investigations and treatment of amenorrhea are the same as for Oligomenorrhea.

V.6. ENDOMETRIOSIS Endometriosis is a term used to describe the condition in which ectopic endometrium is found in situations other than the lining of the cavity of the uterus. The site at which endometriosis may occur: Most frequently in the ovaries, when it is usually bilateral; And may be associated with deposit in rectovaginal septum and uterosacral ligaments;

80

Another common site is the wall of the uterus, where it lets of endometrial tissue are found surrounded by uterine muscle; this is known as adenomyosis; Small nodules of endometriosis may occur on the surface of the pelvic peritoneum, involving the wall of the bowel and bladder; The peritoneal coat of the fallopian tubes; Rarely in the umbilical region; In lower abdomen scars; The inguinal canal and in the vulva in relation to the round ligament.

Endometriosis never appears before puberty and it regresses after menopause. Etiology Endometriosis may arise in different ways and in different sites: Adenomyosis Adenomyosis may arise by down growth from the endometrium of the uterine cavity into the underlying myometrium, as a result of some unknown stimuli. Serial sections usually show direct continuity between endometrial tissue deep in the wall of the uterus and the normal endometrium. Retrograde menstruation theory Direct extension from the endometrium cannot possibly explain the occurrence of extra uterine endometriosis, and to account for this the implantation or cellular spill theory was introduced. This suggests that minute fragments of endometrium pass along the fallopian tubes during menstruation and spill into the pelvic part of the peritoneal cavity, becoming implanted on the surface of the ovary, in the rectovaginal pouch or in some other situation, and developing into endometriosis. Although the endometrium shed at menstruation is mainly necrotic, living fragments have been found at operation in the lumen of the tubes and in the peritoneal cavity. Direct transplantation of endometrial fragments into the tissues of the abdomen wall is thought to have occurred during operations on the uterus during pregnancy, such as hysterectomy, later giving rise to endometriosis in the abdominal scars. Serosal metaplasia

81

An alternative theory is that of serosal metaplasia. The Mllerian ducts are originally derived from an unfolding of the embryonic coelom, and it is suggested that endometriosis may result from metaplasia of the peritoneal endothelial cells in the peritoneal cavity, possibly as a result of the loss of a suppression immunological mechanism. In extremely rare instances, endometriosis has been described in situations that could not be explained by either implantation or serosal metaplasia, such as the thigh and the pleura. It is possible that these tumours were synoviomata and not endometriomata. Clinical features Endometriosis may give rise to symptoms at any time during the childbearing period. Pain is the most common symptom, occur premenstrually and during menstruation; Deep dysmenorrhea occurs when the uterosacral ligaments or the rectovaginal pouch or septum are involved; Menorrhagia may occur, especially with uterine adenomyosis but also with extra uterine lesions; Moderate or severe endometriosis is associated with infertility

The pathology and clinical features of endometriosis vary with the anatomical site of the lesions as follows: Ovarian endometriosis This may occur as small, superficial dark red deposits, often associated with similar blood spots on various parts of pelvic peritoneum; alternatively it may occur apparently in substance of the ovary as the characteristic (chocolate cyst) Endometriosis of the rectovaginal septum Small modules of endometriosis are frequently found in the rectovaginal pouch, and they may invade the uterosacral folds and the rectovaginal septum, giving rise to an indurated mass with considerable fibrosis. The intestine

82

Endometriosis can occur in the bowel and particularly in the pelvic colon, either alone or with other lesions of endometriosis. Small hemorrhagic modules may be found on the peritoneal surface, and occasionally endometriosis involves the muscular wall, causing dense fibrosis and rarely intestinal obstruction. The bladder Endometriosis of the bladder is very rarest may cause frequency of micturition or haematuria at the time of the menstrual. Endometriosis in an abdominal scar This may follow an operation for endometriosis, myomectomy (if the uterine cavity is opened) and particularly hysterectomy in mid midtrimester pregnancy. Umbilical endometriosis Small modules are found. These increase in size and become tender in each menstrual cycle. Bleeding from umbilicus is very rare, but has been recorded. Treatment If symptomless endometriosis is an incidental discovery there is no need to insist on any treatment, although the patient should be re-examined periodically. If there are symptoms, a diagnosis of intrapertonial endometriosis has to be confirmed by laparoscopy or laparotomy. In most cases a choice has to be made between hormonal therapy and surgical treatment; that is why you have to refer the patient to a specialist.

UNIT V.MENSTRUAL DISORDERS V.1.DYSMENORRHOEA Dysmenorrhea or pain associated with menstruation occurs in two main forms: Primary or spasmodic dysmenorrhea Secondary or congestive dysmenorrhea

Primary dysmenorrhea

83

This is a very common complaint, very often it occurs in girls a few years after puberty. The pain is felt in the pelvis and lower back and may radiate into the legs. The pain is colicky and sometimes severe, and it is accompanied by nausea, vomiting and fainting. It is commonest in nulliparous women. It is always associated with ovulatory cycles. Causes

The cause is probably ischemia due to strong contractions of the uterine muscle which occur during the first day of menstruation, childbirth often cures the condition, possibly because a uterus which has held a baby is more vascular and does not become ischemic so easily. Investigations

Take a history with special reference to the severity and duration of the pain. Do a physical examination to exclude pelvic tumours. In most cases no abnormalities is found. Treatment

Simple analgesics such as aspirin are enough in most cases. It is important to explain to the girl and her mother that this dysmenorrhea it is not caused by pelvic diseases and will not cause sterility. Do not give addictive drugs such as pethidine or morphine, however severe the pain might be. If pain is very severe and interfering with normal activities, refer the patient to a specialist who can put her to the pill for four or six months continuously. Secondary dysmenorrhea This type of pain begins 3 to 4 days (or sometimes up to a week) before menstruation and may either get better or get worse when bleeding starts. It is felt in the pelvis and back and is made worse by exercise. They may also be other symptoms such as menorrhagia, infertility and dyspareunia. This type of dysmenorrhea is always pathological caused. It may occur with uterine fibroids. The 2 main causes are pelvic inflammatory deaseses and endometriosis, and most women complaint of infertility.
84

Treatment of the cause will usually relieve the dysmenorrhea, but we know that successful treatment of PID is difficult and so prevention should be emphasized V.2. IRREGURAL CYCLES It may be comforting to know that most An irregular cycle is frequently shorter or longer than this average, and may also include women don't have consistent 28-day menstrual cycles. A menstrual cycle can be considered regular if it averages between 26 and 35 days. An irregular menstrual pattern may be an indication of ovulation problems and can be a major factor in infertility. Irregular cycles may also release hormones inconsistently and may add to mood and pain problems. Irregular and long cycles are sometimes also associated with heavy cramping and bleeding. Irregular periods can be a sign of approaching menopause. But they can also arise from an increase in the number of cells in a section of the endometrium. Endometrial hyperplasias are caused when too much estrogen is produced by women who do not ovulate. To diagnose the problem, your doctor will probably perform a D & C, scraping cells from the endometrium and doing a biopsy. Mild hyperplasias are usually treated with monthly doses of progesterone. More serious hyperplasia requires long-term progesterone therapy or even removal of the uterus. Treatment depends on the cause.

V.3. POLYMENORRHOEA AND LONG CYCLE Polymenorrhoea or epimenorrhoea (short cycles) are periods occur at shorter intervals than usual; are under twenty-one days in length, are common at extremes of reproductive life, and imply higher estrogen production. Short cycles are commonly abnormal in ovulatory characteristics and often have increased in flow.

Short cycles

85

Short cycles often signal low levels of estrogen and progesterone in the system, possibly resulting from an undersupply of certain precursors. Lacking these hormones, the endometrium cannot develop properly, and infertility may result. Short cycles also develop as some women approach menopause. They can also result from over- or under activity of the thyroid gland.

Long cycles

Long cycles (Oligomenorrhea) are not necessarily a problem. Many women with long cycles produce eggs and are fertile. Their ovaries are normal, and the eggs just take a long time to mature. By far the most common cause of an unexpectedly long cycle is simply pregnancy! Oligomenorrhea, flow at intervals longer than thirty-six (but less than 180) days, is more common than amenorrhea and also occurs at the extremes of reproductive life. However, 30 percent of women twenty to forty-nine years old had cycle intervals over sixty days. Women reporting a body mass index at age eighteen that was over twenty-four had increasing risks for oligomenorrhea with increasing weight. However, some women with regular periods two to five months apart may have ovarian cysts. Also, when a very long cycle is accompanied by a sudden increase in body hair, a decrease in breast size, and enlargement of the clitoris; and menstruation eventually stops altogether, the problem could be a growth or tumor of the adrenal gland. To make a diagnosis, the doctor will take urine, glucose tolerance, and other tests. A CAT scan or Magnetic Resonance Imaging (MRI) might also be ordered. Long cycles can also develop from over or underproduction of thyroid hormone. Here also you have to treat the cause. V.4. MENORRHAGIA This is when menstrual loss is heavier than usually (excessive menstrual bleeding). This is clinically important because of anaemia which is caused by excessive bleeding. Menorrhagia is a symptom and not a disease and its cause must be sought. Common causes are chronic pelvic inflammatory disease and uterine fibroids. Treatment of the cause will cure the heavy loss. V.5. AMENORRHOEA

86

Amenorrhoea is normal (physiological) before ovarian activity begins at puberty and after it has ceased at menopause. Physiological amenorrhea also occurs during pregnancy and for some months after delivery when the woman is breastfeeding. Types of amenorrhea Primary amenorrhea means that menstruation has never occurred. Secondary amenorrhea means that the periods, once present, has stopped. A woman in the reproductive period who complaints of amenorrhea should be examined for signs of pregnancy. Causes of amenorrhea Causes of amenorrhea may be grouped under the following headings: Hormonal Poorly functioning ovaries or pituitary gland, suprarenal or thyroid disorders may cause amenorrhea. Diabetes mellitus can also be a cause. Nervous A change of occupation or environment often causes suppression of periods for a month or two, especially in young girls. Fear of or desires for pregnancy and sudden chocks or anxiety are others causes. The central nervous system has a powerful influence on menstruation. Constitutional Severe debilitating diseases such as tuberculosis and profound anaemia may interrupt the periods. Local cause After hysterectomy, bilateral removal of the ovaries or exposure to full dose of radiation, menstruation ceases permanently.

87

Congenital abnormalities A congenital abnormality which causes what seems to be primary amenorrhea is an imperforated hymen. The vaginal orifice is closed by an intact membrane so that the menstrual blood formed is retained in the vagina. This condition is called haematocolpos. If it is not treated the uterus may become distended with blood: haematometra and haematosalpinx if also the fallopian tubes become distended with the blood. The condition is cured by incision of hymen which allows the blood to flow freely. Treatment of amenorrhea In each case of amenorrhea you must take a detailed history and do a clinical examination in order to rule out simple causes like pregnancy and an imperforate hymen. All patients who are not pregnant will need investigations and treatment. The treatment may take place at the hospital where sophisticated hormones studies and therapy, Xray and surgery may be done, depending on the cause of the disorder. Investigations and treatment of amenorrhea are the same as for Oligomenorrhea.

V.6. ENDOMETRIOSIS Endometriosis is a term used to describe the condition in which ectopic endometrium is found in situations other than the lining of the cavity of the uterus. The site at which endometriosis may occur: Most frequently in the ovaries, when it is usually bilateral; And may be associated with deposit in rectovaginal septum and uterosacral ligaments; Another common site is the wall of the uterus, where it lets of endometrial tissue are found surrounded by uterine muscle; this is known as adenomyosis; Small nodules of endometriosis may occur on the surface of the pelvic peritoneum, involving the wall of the bowel and bladder;
88

The peritoneal coat of the fallopian tubes; Rarely in the umbilical region; In lower abdomen scars; The inguinal canal and in the vulva in relation to the round ligament.

Endometriosis never appears before puberty and it regresses after menopause. Etiology Endometriosis may arise in different ways and in different sites: Adenomyosis Adenomyosis may arise by down growth from the endometrium of the uterine cavity into the underlying myometrium, as a result of some unknown stimuli. Serial sections usually show direct continuity between endometrial tissue deep in the wall of the uterus and the normal endometrium. Retrograde menstruation theory Direct extension from the endometrium cannot possibly explain the occurrence of extra uterine endometriosis, and to account for this the implantation or cellular spill theory was introduced. This suggests that minute fragments of endometrium pass along the fallopian tubes during menstruation and spill into the pelvic part of the peritoneal cavity, becoming implanted on the surface of the ovary, in the rectovaginal pouch or in some other situation, and developing into endometriosis. Although the endometrium shed at menstruation is mainly necrotic, living fragments have been found at operation in the lumen of the tubes and in the peritoneal cavity. Direct transplantation of endometrial fragments into the tissues of the abdomen wall is thought to have occurred during operations on the uterus during pregnancy, such as hysterectomy, later giving rise to endometriosis in the abdominal scars. Serosal metaplasia An alternative theory is that of serosal metaplasia. The Mllerian ducts are originally derived from an unfolding of the embryonic coelom, and it is suggested that endometriosis may result from metaplasia of the peritoneal endothelial cells in the peritoneal cavity, possibly as a result of the loss of a suppression immunological mechanism.

89

In extremely rare instances, endometriosis has been described in situations that could not be explained by either implantation or serosal metaplasia, such as the thigh and the pleura. It is possible that these tumours were synoviomata and not endometriomata. Clinical features Endometriosis may give rise to symptoms at any time during the childbearing period. Pain is the most common symptom, occur premenstrually and during menstruation; Deep dysmenorrhea occurs when the uterosacral ligaments or the rectovaginal pouch or septum are involved; Menorrhagia may occur, especially with uterine adenomyosis but also with extra uterine lesions; Moderate or severe endometriosis is associated with infertility

The pathology and clinical features of endometriosis vary with the anatomical site of the lesions as follows: Ovarian endometriosis This may occur as small, superficial dark red deposits, often associated with similar blood spots on various parts of pelvic peritoneum; alternatively it may occur apparently in substance of the ovary as the characteristic (chocolate cyst) Endometriosis of the rectovaginal septum Small modules of endometriosis are frequently found in the rectovaginal pouch, and they may invade the uterosacral folds and the rectovaginal septum, giving rise to an indurated mass with considerable fibrosis. The intestine Endometriosis can occur in the bowel and particularly in the pelvic colon, either alone or with other lesions of endometriosis. Small hemorrhagic modules may be found on the peritoneal surface, and occasionally endometriosis involves the muscular wall, causing dense fibrosis and rarely intestinal obstruction. The bladder

90

Endometriosis of the bladder is very rarest may cause frequency of micturition or haematuria at the time of the menstrual. Endometriosis in an abdominal scar This may follow an operation for endometriosis, myomectomy (if the uterine cavity is opened) and particularly hysterectomy in mid midtrimester pregnancy. Umbilical endometriosis Small modules are found. These increase in size and become tender in each menstrual cycle. Bleeding from umbilicus is very rare, but has been recorded. Treatment If symptomless endometriosis is an incidental discovery there is no need to insist on any treatment, although the patient should be re-examined periodically. If there are symptoms, a diagnosis of intrapertonial endometriosis has to be confirmed by laparoscopy or laparotomy. In most cases a choice has to be made between hormonal therapy and surgical treatment; that is why you have to refer the patient to a specialist.

UNITVI.MENOPAUSE Menopause disorders VI.1Menopause definition Menopause is the end of menstruation. The word comes from the Greek mens, meaning monthly, and pausis, meaning cessation. Menopause is part of a woman's natural aging process when her ovaries produce lower levels of the hormones estrogen and progesterone and when she is no longer able to become pregnant.
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Unlike a womans first menstruation, which starts on a single day, the changes leading up to menopause happen over several years. The average age for menopause is 52. But menopause commonly happens anytime between the ages of 42 and 56. A woman can say she has begun her menopause when she has not had a period for a full year. VI.2.Perimenopause Refers to the several years before menopause when a woman may begin experiencing the first signs of her menopausal transition. But many people use the term menopause for both the perimenopausal years as well as the few years following menopause. VI.3.Menopause signs Menopause is a natural process that happens to every woman as she grows older, and is not a medical problem, disease or illness. Still, some women may have a hard time because of the changes in hormone levels during menopause. There are many possible signs of menopause and each woman feels them differently. Most women have no or few menopausal symptoms while some women have many moderate or severe symptoms. The clearest signs of the start of menopause are irregular periods (when periods come closer together or further apart), and when blood flow becomes lighter or heavier. Other signs may include some of the following:

weight gain; hot flashes; insomnia; night sweats; vaginal dryness; joint pain; fatigue; short-term memory problems;
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bowel upset; dry eyes; itchy skin; mood swings; and urinary tract infections.

Most of the time, these symptoms will lessen or go away after a woman has finished menopause. Do all women experience menopause in the same way? Menopause experiences are different among individual women, and also among women in different cultures and in different parts of the world. Research has shown that womens experience of menopause can be related to many things, including genetics, diet, lifestyle and social and cultural attitudes toward older women. What is "induced" menopause? "Induced", "sudden" or "surgical" menopause happens when a woman goes through an immediate and premature menopause. This occurs when her ovaries no longer produce the hormones estrogen, progesterone and testosterone. This may be caused by:

surgery to remove your ovaries; chemotherapy; radiation treatment; or ovarian malfunction.

Women going through induced menopause may have more severe menopausal symptoms, and are usually treated with hormone therapy. How should a woman prepare for menopause?

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Menopause is one of womens many important natural life-stages. For some, it is a challenging period of difficult physical and emotional changes. For others, it is a time of personal growth and renewal. And for many women, it is both at the same time. They don't call it "Menopausal Zest" for nothing! Here are some suggestions to help you enjoy your menopausal years to their fullest:

Learn about menopause through recent books, articles and other reading materials. Talk to friends and relatives who have already gone through menopause. Join a menopause or midlife support-group in your area. Have a nutritious diet and enjoy regular exercise. Manage your stress by balancing your work and social life. Talk with your health care practitioner about your personal health concerns. Know that you have choices and can take charge of your health. VI.4. Hormone therapy and menopause

What is hormone therapy (HT)? Hormone therapy (HT) is also known as hormone replacement therapy or HRT. It is a hormone treatment prescribed by a doctor. Some women take HT to offset the lower levels of estrogen and progesterone that happen naturally at the beginning of menopause. HT is either:

estrogen taken alone, sometimes called estrogen therapy (ET) or estrogen replacement therapy (ERT); progesterone (natural or synthetic);or combination estrogen plus progesterone.

HT may be taken as:


a pill; a patch; a cream or gel; an implant; an injection; or a vaginal ring.

What are the benefits of hormone therapy? Hormone therapy may improve menopausal symptoms such as:

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hot flashes; vaginal dryness; and night sweats.

There is no solid scientific evidence to show that HT can prevent:


urinary incontinence; memory loss; wrinkles; aging; or heart disease.

What are the risks associated with hormone therapy? There are side-effects associated with hormone therapy, with some women reporting:

headaches and/or migraines; breast tenderness; bloating; irritability; and vaginal bleeding.

There is also a risk of blood clots that starts immediately when taking HT.

Will hormone therapy reduce the risk of osteoporosis (thinning of the bones)? Research shows that estrogen therapy delays bone loss only while a woman is taking estrogen (and not after). Because of this, estrogen may be prescribed to help reduce the risk of osteoporosis. Many medical organizations have noted that the risks of HT may outweigh this benefit, and so suggest other, non-HT medications to reduce the risk of, and to treat osteoporosis. Who should take hormone therapy? There is no right or wrong answer since each woman has her own medical history and individual needs. However, those who may benefit most from HT include women:
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with severe vasomotor symptoms, such as hot flashes and night sweats; at high risk of bone fracture and osteoporosis who may not be able to take, or who may not respond to other, non-hormonal medications now available; or who have experienced an early 'induced' menopause caused by:
o o o o

surgery to remove their ovaries; chemotherapy; radiation treatment; or ovarian malfunction.

Women who should not consider standard HT, unless they discuss their specific risks with their physician, include women with:

breast cancer or at high risk for breast cancer; a history of liver disease; a history of blood clots; and a history of heart disease.

Do woman has to take hormone therapy when she reaches menopause? Hormone therapy is only one of many options for women going through menopause. Many women do not have severe menopausal symptoms and choose to go through menopause naturally. Other women experience several menopausal symptoms and choose to manage their symptoms through:

diet; exercise; botanical and herbal supplements; 'natural' hormone supplements (from plant sources); massage therapy; and hormone therapy.

What a woman decides to do will depend on her needs and medical history. A woman considering HT or other therapies should weigh the health benefits and risks in consultation with her medical practitioner.

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VI.5.Menopause and Heart Disease Does menopause increase a risk for heart disease? Heart disease, also known as coronary disease, is the leading cause of death for Canadian women. Increased risk for coronary disease is primarily associated with the process of aging, yet there is also a relationship between heart health and a woman's midlife transition through menopause. Before menopause a woman's heart and blood vessels seem to have some protection due to her hormones. But when a woman experiences menopause, her levels of estrogen decrease significantly, and as a result, her risk for heart disease increases. A woman has a reduced rate of heart disease before menopause compared with men her own age. After menopause, however, a woman's rate of heart disease increases considerably, until by the age of 65, her risk is equal to that of her male peers. Will hormone therapy prevent heart disease? For many years researchers believed that hormone therapy (HT) was beneficial for heart health. Medical practitioners routinely prescribed hormone therapy to women as a preventative measure for heart disease. However, several new important studies, such as the Women's Health Initiative study, have cast significant doubt on this practice. Recent research has found conclusively that there is no coronary health benefit for women with a history of heart disease, who take estrogen alone, or estrogen plus a progestin. The studies suggest that there is even the possibility of an increased risk for heart disease for women on hormone therapy. Research has also found that women without a previous history of heart disease may also face an increased risk for heart disease when taking hormone therapy. What are the current guidelines for hormone therapy and heart disease?

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The Heart and Stroke Foundation of Canada has issued new recommendations as a result of the latest study data:

Hormone therapy should not be prescribed to women who already have a history of heart disease. Hormone therapy should not be prescribed solely in order to reduce the risk of developing heart disease. Other non-medicinal measures can be undertaken to reduce the risk of heart disease, such as stopping smoking, becoming more active and reducing blood pressure and cholesterol levels.

The recommendation is that HT should not be used for the prevention of heart disease.

UNIT VII. STATIC DISORDERS VII.1.Retroverted and anteverted uterus A retroverted uterus (tilted uterus, tipped uterus) is a uterus that is tilted backwards instead of forwards. This is in contrast to the slightly "anteverted" uterus that most women have, which is tipped forward toward the bladder, with the anterior end slightly concave. One in three to five women (depending on the source) has a retroverted uterus, which is tipped backwards towards the spine. Related terms The following table distinguishes among some of the terms used for the position of the uterus:

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A retroverted uterus should be distinguished from the following:

Distinction

More common

Less common

Position tipped

"anteverted": tipped forward

"retroverted": tipped backwards

Position fundus

of

"anteflexed": the fundus is pointing forward "retroflexed": the fundus is pointing relative to the cervix. Anterior of uterus is backwards. Anterior of uterus is concave. convex.

Additional terms include:


retrocessed uterus: both the superior and inferior ends of the uterus are pushed posteriorly severely anteflexed uterus: the uterus is in the same position as "normal" and bends in the same direction (concave is anterior) but the bend is much pronounced vertical uterus: the fundus (top of the uterus) is straight up.

Position Under normal circumstances the uterus is both "anteflexed" and "anteverted." Developmental The bilateral Mllerian ducts form during early fetal life. In females these ducts give rise to the Fallopian tubes and the uterus. In humans the lower segments of the two ducts fuse to form a single uterus, however, in cases of uterine malformations this development may be disturbed. The different uterine forms in various mammals are due to various degrees of fusion of the two Mllerian ducts. The uterus (Latin word for womb) is a major female hormone-responsive reproductive sex organ of most mammals, including humans. It is within the uterus that the fetus develops during

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gestation. The term uterus is used consistently within the medical and related professions; the Germanic term, womb is more common in everyday usage. The plural of uterus is uteruses or uteri. One end, the cervix, opens into the vagina; the other is connected on both sides to the Fallopian tubes. Causes In most cases, a retroverted uterus is congenital, but some cases are caused by pelvic surgery, pelvic adhesions, endometriosis, fibroids, pelvic inflammatory disease, or the labor of childbirth. Diagnosis A retroverted uterus is usually diagnosed during a routine pelvic examination. It usually does not pose any medical problems, though it can be associated with dyspareunia (pain during sexual intercourse) and dysmenorrhea (pain during menstruation).

Fertility & Pregnancy Uterine position has no effect on fertility. A tipped uterus will usually right itself during the 10th to 12th week of pregnancy. If a uterus does not right itself, it may be labeled persistent. Treatment Treatment options are rarely needed, and include exercises, a pessary, manual repositioning, and surgery. VII.2. Genital prolapse Genital prolapse occurs when there is damage to, or weakness of, the structure which support the pelvic organs, so that some of these descend from their normal positions and finally herniate through the vaginal opening. Certain terms should first be defined:

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Cystocele Is the prolapse of the bladder and anterior vaginal wall. Descend of urethra and bladder neck may occur separately or may accompany a cystocele. When sagging of the urethra occurs alone is known as an urethrocele. Rectocele Prolapse of the rectum and posterior vaginal wall. It is usually accompanied by some defisciency of the penial body caused by parturition. Uterine prolapse Prolapse of the uterus, is accompanied by descent and inversion of the vaginal vault. Three degrees of uterine prolapse are described: the uterus becomes relatively retroverted and descends in the axis of the vagina, although the cervix does not reach the introitus. The cervix appears at the vaginal orifice but only protrudes on staining The vaginal wall are everted to such a degree that the uterus lies outside the vulva, this complete form of uterine prolapse is known as procedentia. Cystocele or rectocele may occur both without uterus descent, but uterine prolapse is accompanied by descent of the bladder because of the close attachment of the bladder to the anterior aspect of the supravaginal cervix. Descent of the rectum does not necessarily accompany uterine prolapse because the prolapsing vaginal wall easily becomes separated from the rectum. Enterocele Is the hernia of the pouch of Douglas through the posterior vaginal fornix. Elongation of this rectovaginal pouch inevitably accompanies uterine prolapsed, and small intestine may be found in the peritoneal sac behind the uterus in case of procidentia. Enterocele may also occurs without uterine prolapsed, and cause a bulge of the upper part of posterior vaginal wall. Vault prolapse, a type of enterocele may occur after abdominal or vaginal hysterectomy.

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Causes of prolapse Childbirth: a result of damage to the supporting structures during childbirth; Very occasionally, the uterovaginal prolapse is sees in a nulliparous woman after the menopause, when a congenital weakness of the supporting structures is thought to be present; 1. Obstetric factors: Obstetric factors may be particularly important in the development of prolapse. The fetal head during delivery can damage the supporting structures of the pelvic organs; A woman who push down before a full dilatation of the cervix; Use of forceps or vacuum extractor in first stage of labour, the cerix may be damaged and the transverse cervical ligaments may be overstretched; Obstetric injury: tearing or overstretching the perineal body, which remove the support of the posterior vaginal wall, and therefore indirectly that of anterior wall and bladder.

Prolonged labor; especially a long 2nd stage of labour or a delivery of a large fetus increases the risk of damage.

2. Postmenopausal atrophy Most cases of procedentia are seen in elderly women in whom the uterus and its supports are atrophic; atrophy of the ligaments it is associated with diminished oestrogen secretion, and there is a lowered muscle tone with increasing age. 3. Intra-abdominal pressure Chronic constipation, persistent cough, heavy work or intra-abdominal mass may be contributory factors in cases of prolapse. 4. Postoperative prolapsed Abdominal hysterectomy involves the division of the supporting ligaments of the uterus and prolapsed of the rectovaginal pouch or enterocele sometimes follows vaginal hysterectomy or the

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Manchester operation for prolapsed, and may occur either because the operator has fail to recognize and repair a pre-existing defect or because of failure to close the gap between the uterosacral ligaments. Symptoms -local discomfort -backache -dyspareunia -urinary symptoms: pollakiuria usually inevitable if cystocele, incomplete empting the bladder , incontinence,.. -bowel symptoms: if rectocele because of difficult in empting bowel. -ulceration and bleeding Diagnosis -By inspecting the vulva with the patient lying on her back and staining down. -Sims speculum enables an assessment of anterior wall prolapsed to be made -rectocele and enterocele are obvious on inspection of posterior vaginal wall while the patient is straining, once the anterior wall of the vaginal has been retracted with a sponge-holding forceps. Treatment Prevention -It is important to prevent and limit injury to the pelvic floor and supporting structures during delivery; -pelvic floor exercises antenatal may be helpful -to limit frequent pregnancies and short intervals -good nutrition and to consult every time you have a problem. If you diagnose a prolapse, refer the patient because it may need surgery treatment if it is no longer slight, but if it is slight and there is no discomfort it does not require a treatment.

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