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DEPARTMENT OF obstetrics and gynecology.

SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD


PAP Smear

The Papanicolaou test (also called Pap smear, Pap test, cervical smear, or smear test)
is a method of cervical screening used to detect potentially pre-cancerous and
cancerous processes in the endocervical canal (transformation zone) of the female
reproductive system.
In taking a Pap smear, a speculum is used to open the vaginal canal and allow the
collection of cells from the outer opening of thecervix of the uterus and the
endocervix. The cells are examined under a microscope to look for abnormalities. The
test aims to detect potentially pre-cancerous changes (called cervical intraepithelial
neoplasia (CIN) or cervical dysplasia), which are usually caused by sexually
transmitted human papillomaviruses. The test remains an effective, widely used
method for early detection of pre-cancer and cervical cancer. The test may also detect
infections and abnormalities in the endocervix and endometrium.
Procedure
For best results, a Pap test should not occur when a woman is menstruating. However,
Pap smears can be performed during a woman's menstrual period, especially if the
physician is using a liquid-based test; if bleeding is extremely heavy, endometrial
cells can obscure cervical cells, and it is therefore inadvisable to have a Pap smear if
bleeding is excessive.
Obtaining a pap smear should not cause pain, but it can if the patient has certain untreated vaginal
problems such as cervical stenosis or vaginismus, or if the person performing it is too harsh, or
uses the wrong size speculum. The patient should speak up if they are in pain. Many women
experience spotting or mild diarrhea afterward.The sample is stained using the Papanicolaou
technique, in which tinctorial dyes and acids are selectively retained by cells. Unstained cells
cannot be seen with a light microscope. Papanicolaou chose stains that highlighted cytoplasmic
keratinization, which actually has almost nothing to do with the nuclear features used to make
diagnoses now.In some cases, a computer system may prescreen the slides, indicating those that
do not need examination by a person or highlighting areas for special attention. The sample is then
usually screened by a specially trained and qualified cytotechnologist using a light microscope.

Intrauterine Device

The current Intrauterine devices (IUD) are small devices, often 'T'-shaped, often
1
DR.KANAK SONI
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE

DEPARTMENT OF obstetrics and gynecology.


SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

containing either copper or levonorgestrel, which are inserted into the uterus. They are
one form of long-acting reversible contraception which are the most effective types of
reversible birth control. Failure rates with the copper IUD is about 0.8% while the
levonorgestrel IUD has a failure rates of 0.2% in the first year of use.Among types of
birth control, they along with birth control implants result in the greatest satisfaction
among users. As of 2007, IUDs are the most widely used form of reversible
contraception, with more than 180 million users worldwide.
Evidence supports effectiveness and safety in adolescents and those who have and
have not previously had children. IUDs do not affect breastfeeding and can be
inserted immediately after delivery. They may also be used immediately after
an abortion. Once removed, even after long term use, fertility returns to normal
immediately.
While copper IUDs may increase menstrual bleeding and result in more painful
cramps hormonal IUDs may reduce menstrual bleeding or stop menstruation
altogether. Cramping can be treated with NSAIDs. Other potential complications
include expulsion (25%) and rarely perforation of the uterus (less than 0.7%). A
previous model of the intrauterine device (the Dalkon shield ) was associated with an
increased risk of pelvic inflammatory disease, however the risk is not affected with
current models in those without sexually transmitted infections around the time of
insertion.
Mechanism
IUDs primarily work by preventing fertilization. The progestogen released from the
hormonal IUDs prevents ovulation from occurring so an egg is never released. The
hormone also thickens the cervical mucus so that sperm cannot reach the Fallopian
tubes. The copper IUDs contain no hormones, but the copper causes the uterus and
Fallopian tubes to produce a fluid that contains white blood cells, copper ions,
enzymes, and prostaglandins, a combination that is toxic to sperm. The very high
effectiveness of copper-releasing IUDs as emergency contraceptives implies they may
also act by the prevention of implantation.
TYPES
Nonhormonal copper IUD ParaGard
Hormonal IUD Mirena or Skyla

NON HORMONAL COPPER IUDS

2
DR.KANAK SONI
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE

DEPARTMENT OF obstetrics and gynecology.


SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

Copper IUDs primarily work by disrupting sperm mobility and damaging sperm so
that they are prevented from joining with an egg. Copper acts as a spermicide within
the uterus, increasing levels of copper ions, prostaglandins, and white blood cells
within the uterine and tubal fluids. The increased copper ions in the cervical mucus
inhibit the sperm's motility and viability, preventing sperm from traveling through the
cervical mucus or destroying it as it passes through. Copper IUDs have a first year
failure rate ranging from 0.1 to 2.2%.
Most copper IUDs have a plastic T-shaped frame that is wound around with pure
electrolytic copper wire and/or has copper collars (sleeves). The arms of the frame
hold the IUD in place near the top of the uterus. The Paragard T Cu 380a measures
32 mm (1.26") horizontally (top of the T), and 36 mm (1.42") vertically (leg of the T).
Copper IUDs containing noble metals are becoming increasingly popular because
they are more resistant to corrosion. In the "Gold T IUD", which is made in Spain and
Malaysia, there is a gold core, which further prevents the copper from fragmenting or
corroding. Goldring Medusa is a differently-shaped German version of the Gold T.
Another form of Au Cu IUD is called Goldlily which is made by the Hungarian
company, Radelkis. Goldlily consists of a layer of copper wires wrapped around an
original layer of gold wires, and it provides electrochemical protection in addition to
ionic protection.
Silver IUDs also exist. Radelkis also makes Silverlily, which is similar to Goldlily,
and GoldringMedusa is available in an AgCu version as well. Nova-T 380 contains a
strengthening silver core, but does not incorporate silver ions themselves to provide
electrochemical protection.
Other shapes of IUD include the so-called U-shaped IUDs, such as the Load and
Multiload, and the frameless IUD that holds several hollow cylindrical minuscule
copper beads. It is held in place by a suture (knot) to the fundus of the uterus. It is
mainly available in China, Europe, and Germany, although some clinics in Canada
can provide it.
Advantages of the copper IUD include its ability to provide emergency
contraception up to five days after unprotected sex. It is the most effective form of
emergency contraception available.[ It contains no hormones, so it can be used while
breastfeeding, and fertility returns quickly after removal. Copper IUDs are also
available in a wider range of sizes and shapes than hormonal IUDs.
Disadvantages include the possibility of heavier menstrual periods and more painful
cramps.

HORMONAL IUDS
3
DR.KANAK SONI
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE

DEPARTMENT OF obstetrics and gynecology.


SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

Hormonal IUDs (brand names Mirena and Skyla in the US; referred to as intrauterine
systems in the UK) work by releasing a small amount of levonorgestrel, a progestin.
The primary mechanism of action is thickening of cervical mucus, making it
impenetrable to sperm. They also inhibit ovulation in some users, decrease the ability
of sperm to penetrate the ovum, and thin the endometrial lining. Because they thin the
endometrial lining, they reduce or even prevent menstrual bleeding, and can be used
to treat menorrhagia (heavymenses), once pathologic causes of menorrhagia (such
as uterine polyps) have been ruled out.
The progestin released by hormonal IUDs primarily acts locally; use of Mirena results
in much lower systemic progestin levels than other very-low-dose progestogen only
contraceptives.
Adverse effects
Regardless of containing progestogen or copper, potential side effects of intrauterine
devices include expulsion, uterus perforation, pelvic inflammatory disease (especially
in the first 21 days after insertion), as well as irregular menstrual pattern. A small
probability of pregnancy remains after IUD insertion, and when it occurs there's a
greater risk of ectopic pregnancy.
Substantial pain that needs active management occurs in approximately 17%
of nulliparous women and approximately 11% of parous women. In such
cases, NSAID are evidenced to be effective. However, no prophylactic analgesic drug
have been found to effective for routine use for women undergoing IUD insertion.
Also, IUDs with progestogen confer an increased risk of ovarian cysts, and IUDs with
copper confer an increased risk of heavier periods.

4
DR.KANAK SONI
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE

DEPARTMENT OF obstetrics and gynecology.


SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

Artificial insemination

Artificial insemination is a technique that can help treat certain kinds of infertility in
both men and women. In this procedure, sperm are inserted directly into a woman's
cervix, Fallopian tubes, or uterus. This makes the trip shorter for the sperm and
bypasses any possible obstructions. Ideally, it makes pregnancy possible where it
wasn't before. Intrauterine insemination (IUI), in which the sperm is placed in the
uterus, is the most common form of artificial insemination.
Artificial insemination can be used for many kinds of fertility problems. It's a popular infertility
treatment for men who have very low sperm counts or sperm that aren't strong enough to swim
through the cervix and up into the Fallopian tubes. Artificial insemination is also sometimes an
option for women who have endometriosis or abnormalities of any of their reproductive organs.
PROCEDURE
When patient is ovulating, her partner will be asked to produce a sample of semen. The doctor will
suggest that partner should be abstain from sex for two to five days in advance to ensure a higher
sperm count. If you live close to the clinic, partner may be able to collect the semen at home by
masturbating. Otherwise, the clinic will provide a private room for this purpose. The sperm must
be "washed" in a laboratory within one hour of ejaculation.
The process of "washing" the sperm enhances the chance of fertilization and removes chemicals in
the semen that may cause discomfort for the woman. It consists of liquefying the sperm at room
temperature for 30 minutes. Then a harmless chemical is added to separate out the most active
sperm. Then a centrifuge is used to collect the best sperm.
The sperm are then placed in a thin tube called a catheter and introduced through the vagina and
cervix into the uterus. Artificial insemination is a short, relatively painless procedure that many
women describe as being similar to a Pap smear. Some women have cramping during the
procedure and light bleeding afterward. Immediately after the procedure, your doctor will
probably have you lie down for about 15 to 45 minutes to give the sperm a chance to get to work.
After that, you can resume your usual activities.
In some cases, your doctor will place you on fertility drugs, such as Clomid, to induce
superovulation (ovulation of multiple eggs) before you undergo artificial insemination.

Success rates for artificial insemination vary.


Factors that lessen your chance of success include:

Older age of the woman


Poor egg quality
Poor sperm quality
5
DR.KANAK SONI
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE

DEPARTMENT OF obstetrics and gynecology.


SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

Severe endometriosis
Severe damage to Fallopian tubes (usually from chronic infection)
Blockage of Fallopian tubes (IUI will usually not work in this case)

DILATATION AND CURETTAGE

Dilation and curettage (D&C) refers to the dilation(widening /opening)of


the cervix and surgical removal of part of the lining of the uterus and/or contents of
the uterus by scraping and scooping (curettage). It is a therapeutic gynecological
procedure as well as a rarely used method of first trimester abortion.
D&C normally refers to a procedure involving a curette, also called sharp curettage.
However, some sources use the term D&C to refer more generally to any procedure
that involves the processes of dilation and removal of uterine contents, which includes
the more common suction curettage procedures of manual and electric vacuum
aspiration.
Procedure
The first step in a D&C is to dilate the cervix, usually done a few hours before the surgery. The
woman is usually put under general anaesthesia before the procedure begins. A curette, a metal rod
with a handle on one end and a sharp loop on the other, is inserted into the uterus through the
dilated cervix. The curette is used to gently scrape the lining of the uterus and remove the tissue in
the uterus. This tissue is examined for completeness (in the case of abortion
or miscarriage treatment) or pathologically for abnormalities (in the case of treatment
for abnormal bleeding).

Clinical uses
D&Cs are commonly performed for the diagnosis of gynaecological conditions
leading to 'abnormal uterine bleeding'; to resolve abnormal uterine bleeding (too
much, too often or too heavy a menstrual flow); to remove the excess uterine lining in
women who have conditions such as polycystic ovary syndrome (which cause a
prolonged build-up of tissue with no natural period to remove it); to remove tissue in
the uterus that may be causing abnormal vaginal bleeding, including postpartum
retained placenta; to remove retained tissue (also known as retained POC or retained
products of conception) in the case of a missed or incomplete miscarriage; and as a
method of abortion that is now uncommon. In contrast, D&C remains 'standard care'
for missed and incomplete miscarriage in many countries despite the existence of
alternatives currently used for abortions.
Because medical and non-invasive methods of abortion now exist, and because D&C
requires heavy sedation or general anesthesia and has higher risks of complication, the
procedure has been declining as a method of abortion. The World Health
Organization recommends D&C as a method of surgical abortion only when
manual vacuum aspiration is unavailable. Most D&Cs are now carried out for
6
DR.KANAK SONI
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE

DEPARTMENT OF obstetrics and gynecology.


SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

miscarriage management and other indications such as diagnosis.


Hysteroscopy is a valid alternative to D&C for many surgical indications from
diagnosis of uterine pathology to the removal of fibroids and even retained products
of conception. It poses less risk because the doctor has a view inside the uterus during
surgery, unlike with blind D&C.
Medical management of miscarriage and medical abortion using drugs such as
misoprostol and mifepristone are safe, non-invasive and cheaper alternatives to D&C.
Complications

Complications may arise from either the introduction or spreading of infection,


adverse reaction to general anaesthesia required during the surgery or from
instrumentation itself, if the procedure is performed blindly (without the use of any
imaging technique such as ultrasound or hysteroscopy).
One risk of sharp curettage is uterine perforation. Although normally no treatment is
required for uterine perforation, a laparoscopy may be done to verify that bleeding has
stopped on its own. Infection of the uterus or fallopian tubes is also a possible
complication, especially if the woman has an untreated sexually transmitted infection.
Another risk is intrauterine adhesions, or Asherman's syndrome. One study found that
in women who had one or two sharp curettage procedures for miscarriage, 14-16%
developed some adhesions. Women who underwent three sharp curettage procedures
for miscarriage had a 32% risk of developing adhesions. The risk of Asherman's
syndrome was found to be 30.9% in women who had D&C following a missed
miscarriage, and 25% in those who had a D&C 14 weeks postpartum. Untreated
Asherman's syndrome, especially if severe, also increases the risk of complications in
future pregnancies, such as ectopic pregnancy, miscarriage, and abnormal placentation
(e.g.placenta previa and placenta accreta). According to recent case reports, use of
vacuum aspiration can also lead to intrauterine adhesions.

7
DR.KANAK SONI
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE

DEPARTMENT OF obstetrics and gynecology.


SDM COLLEGE OF MEDICAL SCIENCES AND HOSPITAL,DHARWAD

8
DR.KANAK SONI
2nd MD (NATUROPATHY)
SDM COLLEGE OF NATUROPATHY AND YOGIC SCIENCES,
UJIRE