Gynaecology

Abnormal Uterine bleeding

Acute Episode of heavy menstrual bleeding of sufficient quantity to require immediate attention
- - .

-
Chronic -
Bleeding abnormal in volume , regularity or timing For past 6 months .

:
Dysfunctional Uterine Bleeding : Abnormal Uterine bleeding that occurs in absence of any clinically detectable organic , systemic or

iatrogenic cause ( pregnancy and fibroids are excluded ) .

This term has been replaced by AUB completely now .

Causes of
. AUB : PALM -

COEIN Classification / AGO Classification

p polyp
-

C-
Coagulopathy
A- Adenomyosis o -

Ovulatory dysfunction
L
Leiomyoma
-
E -

Endometrial
M -

Malignancy & Hyperplasia I -

Iatrogenic
N -
Not classified

-
Aetiology of Men orrhagea :

General Causes pelvic causes Contraceptives Hormonal IDUB

Blood dyscrasia -
DID -
NCD .
Ovulatory -

irregular ripening
-

Coagulopatny -

pelvic adhesions -

Post tubal sterilisation -

irregular shedding Italian 's disease)

-

thyroid dysfunction -
Uterine fibroids -

progesterone only pills

-

Genital TB -

Endometrial Hyperplasia .
Anorulatory-metropalhiahaemorrhagi.ca/ Schroeder's disease
-

Adenomyosis
-

Feminizing tumor of ovary

-
Endometriosis
-

Pelvic congestion

.
Investigations

-
CBC
-
Endometrial tissue sampling by D4C
-

Bleeding time & -

Diagnostic laparoscopy
-

Thyroid function tests - sono Ipingography

pelvic angiography if other investigations fail detect cause
to
USG pelvis
-
-

Diagnostic Hysteroscopy >

may show vaniosity & Arteriovenous fistula .

.MX
menorrhagia
v v

Older women
Young patient
I v

Rule out cancer

u v

uterine pathology
Conception and
contraception
desired desired
✓ v

Normal Uterus Uterine pathology present

v .
v

Combined 0C
Etnamsylate (NSAID) pills
'
Transexamic acid Progesterone u

-
cantifibn.no/ytic)
-

Medroxy progesterone Acetate 10mg aid

-

× ydays
Medical therapy •

Norethisterone 5mg
-

-0C pills contraindicated over 40 years Appropriate

Mirena -

progesterone and others surgery

Releases LNG Rough day
-

GnRH analogues 13-4 months v

No
response

v v v

Effective fails Hysterectomy with

v
removal of ovaries ( 750 years)
continue R, for -
minimally invasive surgeries
6- A month or -

D4C
as required -

Endometrial ablation

QR)
follow up
.
Hysterectomy with conservation
of ovaries
 Dysmenorrhea
- It is defined as a menstruation painful enough to incapacitate day to
day aunties
.

Primary (spasmodic) Secondary (congestive)

.
In absence of any pelvic pathology
-
In presence of pelvic pathology

.
mostly confined to adolescent .

-
Etiology
. pain always ovulation cycles & is usually cured
occurs in

after pregnancy and vaginal delivery .

11 Endometriosis
2) DID
3) Ovarian cysts & tumors
- theories : a) Cervical stenosis
5) fibroids
1) Uterine myometn.at hyperactivity
6) Adenomyosis
,

Junctional zone 132) hyperplasia & hyperactivity

7) Polyps
,

Dys peristalsis
8) Intrauterine adhesions
9) Transverse vaginal septum
H Overactivity of sympathetic nerves ,
Hyperion; city of circular fibres
of isthumus

.
C1F :
3) RPG Fa in ovulatory cycles > Ischemia of myometrium

4) low pain threshold

11 Pain starts its days prior to periods and relieves with start
Psychosomatic factors anxiety
of bleeding
, ,

2) Pain is dull in nature

3) Other symptoms related to underlying pathology present
.
C1F :
1) Pain begins few hours or just before menses .

a) Pain lasts for few hours to 24 hrs .

Investigations :
US9
3) Spasmodic lower abdominal pain ; Hysteroscopy
may radiate to back & medial aspect of thigh CTIMRI

4) may be alw nausea vomiting cold sweats , ,

Routine investigations
Syncope in severe cases
5)
6) Clinical exam does not reveal any abnormalities .

MX treatment of
- :
underlying cause .

Investigations : USG -

Rule out pelvic pathologies

4 :

" medical :

. NSAIDs Given for: 1-3 days .

For 3-6 cycles
-

Mefehamic acid : 950

-500mg lid
-

Indomethacin 25mg tid

-
Na broken 275mg lid

- Antispasmodics
-

Hyaline compounds
-

Drotaverine

.
Glycerol trinitrate transdermal patches

.
0C pills .
Relieve paint
progesterone releasing IUD contraceptive benefits

- Trans cutaneous Electrical nerve stimulation

a) surgery -

Rarely required

Laparoscopic Uterine Nerve ablation ( LUNA)

-
Laparoscopic pre sacral heurectomyll.HN )
 PCOS
- Definition : Heterogeneous syndrome complex characterised by chronic anovulation and Hyperandrogen Ism ; frequently alw insulin resistance ,

resulting in menstrual irregularity , infertility and hirsutism .

. Incidence : 4- 12% of women in reproductive age .

C1F :
Generally in
.
seen young women .

. Diagnostic Criteria ! -
centralobesity
1) Oligo or Anovulation -

Oligomenorrhoea I Amenorrhoea
-

Infertility
a) Hyper androgen ism :
Biochemical or clinical -

Hirsutism
-

Acne
b) On US9 : At least 12 follicles ,
I -9mm size present within t or both ovaries -

Acanthus's nigricans
OR -

male pattern alopecia

ovarian volume 710Mt

.
Investigations :
Ovulation Induction agents :

1) Serum Hormone values : DU0M iphone citrate ( Doctor anovulatory infertility)

4 E2 50mg 1 day for 5 days ( Day 2-6 or 5-9 of cycle)
4 LH -
success rate for ovulation -801 .

4 Testosterone & And rostenedione

+ SHBG ( sex Hormone binding globulin) 2) Letrozole 2.5mg 1 day X 5 days 20mg on day 3
H a- hydroxy progesterone 7300 nglml
-

4 Prolactin 3) Tamoxifen 20 -40mg 1 day X 5

days
A serum fasting Insulin
4) Anastrozole
2) USG :

Enlarged ovaries ,
-

volume 710mm's 5) Gonadotropin s :

12 or more follicles , size 2 -9mm placed peripherally -

HMG & Recombinant FSH

( Necklace of pearls pattern) -

Injection hCG 5,000-10,000 IU Im

-

4 in echo gene city and volume of stroma

- 4 in endometrial thickness due to unopposed estrogen stimulation side Effects : D Multiple pregnancies
a) Ovarian Hyper stimulation syndrome 10USD
3) Thyroid function tests in obese women .

3) A risk of epithelial ovarian cancer

4) Laparoscopy -

BIL enlarged ovaries SX for Ovulation Induction :

Laparoscopic drilling
ovarian

( Reserved for therapeutic purpose) -

Only in cases of failure with medical therapy

No risk of OHSS Or multiple pregnancy
-

-
RI
-
counselling of patient about disease .

.
Lifestyle modification Balance diet : -

Insulin sensitizes :
Regular exercise -

stop smoking alcohol ,

1) Metformin -
start at 500mg once a day
Can be 4 upto 1000mg twice
.
Weight loss
-
a day .

.
specific 14 : a) Myoinositol -

Newer insulin sensitize

D Irregular periods I amenorrhoea :

0C pills 1 Cyclical progesterone

2) Hirsutism : -0C pills

-

Anti androgens

Antiandrogen s :

3) Infertility : Ovulation induction

1) spironolactone 25 -100mg twice day
-

a
-
Assisted reproductive technology ( ART)
a) Flutamide
Insulin sensitizes 3) Fina sterile
4) Hyper insulin emia :

a) Cyproterone acetate

-
Best RI is 0C pills as it
regularises cycles
and suppress acne and Hirsutism .
 Prolapse
Support of Uterus :

Upper tier (
middle Tier strongest support ) Inferior Tier
① Endo pelvic fascia ① Dericervical ring ① Levator ani muscle
② Round ligaments ② Endo pelvic fascia ② Perineal muscles forming
Remnants of gubernaallum perineal body
Endo pelvic fascia
-

.
is condensed at places
-

function to maintain anteverted position of Uterus

③ Urogenital diaphragm
to form ligaments :
③ Broad ligaments
d) Pubocervical ligament
Double layer of peritoneum attaching to side
symphysis
-

from pubic to anterior cervix

-

Acts as mesentery for uterus

④ Transverse cervical 1 Cardinal Imackerodt 's ligament
-

from cervix to lateral pelvic walls

. Broad & Round ligaments are considered False support .

) utero sacral ligaments

-

From periosteum of 523,4 vertebrae to poster lateral cervix

.
Genital Prolapse : Downward displacement of organ from its normal anatomical position .

.
Aetiology :
. Classification : .
POPQ staging :

① Atonicity
( Pelvic organ prolapse Quantitative)
A) Anterior vaginal wall
Congenital weakness of supports Cystocele
upper 213
-

stourethrocde
:

}
-

Menopause -
lower yg : urethra Ie
.
stage 0 : No prolapse

② Birth injuries
.
stage Ii All points 71cm above Hymen
B) posterior vaginal wall
:

Prolonged labor -

Upper 43 :
Enterocele . Stage I : lowest point within 1cm of Hymen
-

multiparty -
Lower 213 : Recto I btw -1 and + 1)
Large baby c) Uterine descent lowest point 71cm below hymen
stage III
-

: . :

perineal tear descent of cervix into vagina but not complete prolapse
-

pudenda 1 nerve injury descent of cervix upto introits stage II : complete prolapse vault aversion
-
-

. or
-

Operative delivery -
descent of cervix outside introits
③ Others : -

Providential Entire uterus outside introits

.

Raised intra abdominal pressure

-
Chronic bronchitis : Mx :

.NU/liparous: Abdominal sling Sx

. C1F :

.
pregnancy :
Ring pessary upto 16 weeks
1) Vaginal symptoms
-

Sensation of bulge or profusion

.
post Natal '

Ring pessary ¢ pelvic Floor exercises

-

Pressure & Heaviness surgery if required

-

Excessive whitish discharge (due to venous congestion )

Blood stained discharge due to deulbitous ulcer independent part .
Young woman : Conservative vaginal surgery (Fertility sparing )
.
-

( 140 years)
2) Urinary symptoms : 4 frequency , urgency
-

Ant .

vaginal wall prolapse Ant.CO/porrhaphy :

incomplete emptying -

Posterior vaginal wall prolapse : posterior Colporrhaphy

-
uterine prolapse : Manchester operation
3) Bowel symptoms :
straining during defecation
( in Redocele )
-

sling surgeries

4) Dyspareunia
.
Women 740 years family complete or :

vaginal Hysterectomy with Ant ¢ posterior

colporrhaphy ( pelvic floor repair)
Manchester ( Fothergill ) operation :
- Indications : young patients with 2nd I 3rd degree uterine prolapse sling surgeries :
① Shirodkar's sling Closed loop posterior sling : static , ,
- Procedure :
1) Anterior Colporrhaphy done -

Tape anchored to sacral promontory 4 posterior aspect

2) Cervix dilated of isthmus
3) Amputation of cervix
front of cervix
② Purandara 's CerviCOPEXU : Dynamic Closed loop anterior sling
4) Dlication of Macken rodt 's ligament in
,
,

5) Posterior Tape anchored to anti abdominal wall 4 ant aspect of

tip amputated cervix covered by vaginal flap
-

of
.

isthumus
6) using stormdorff sutures
7) Cold operineorrhaphy is done ② Khanna 's sling :
static open neutral
, , sting
-

Tape anchored to A9S & anterior aspect of islhumus .

. complications : ① Haemorrhage ⑤ Infertility

② Cervical incompetence ⑥ Premature rupture of membranes ④ Virkud 's composite sling : static + dynamic open ,
,

③ Cervical stenosis Anterior + posterior sling

④ Cervical dystonia
 '
Male infertility
failure to conceive after one year of regular unprotected sex .

.
primary : Never conceived
.
Secondary : previous pregnancy ,
but failure to conceive subsequently -

[
Irrespective of outcome of previous pregnancy ]

.
Aetiology : .
Investigations :

1) Genetic -

Abnormal y chromosome ,
Kline fetter 's syndrome 1) Routine : Blood sugar
CBC
2) Diordels of spermatogenesis TSH
-

Hormonal :
Hypothalamic pituitary , , Hypothyroidism Hyperproladinemia , Urine routine
-

Kallman n syndrome

Testicular Absent germ cells

a) Semen analysis
-
: -

Varicocele sample
- :
masturbation & collection in sterile container
-

Cryptochordism Collection condom ( silicone polyurethane )

,

-
orchitislmumps.TN Penile vibratory stimulation 4 electro ejaculation
-

Drugs ( cimelidine spironolactone ) 4 , Radiate ideal time -

After 3- 5 days of abstinence

3) Duct disorders :
congenital absence ,
trauma ,
inflammatory blockage
3) Hormonal evaluation : FSH ,
LH , Testosterone , prolactin
4) Disorders of sperm Ivesiculah fluid : -

Kartagener syndrome limmotile cilia)

-

Sperm acrosome defect

4) Fructose content in seminal fluid
oocyte fusion defect
-

Zonapelkida binding 4 Fusion defect 5) Testicular biopsy

5) sexual dysfunction : -

low coital frequency

-

Impotence 6) Trans rectal USG

-

premature
7) scrotal USG
6) Psychological
8) Vasogram -

for potency of vas .

7) Chronic illness
a) Sperm function
8) Substance abuse -

drugs smoking ,
, alcohol

D) chromosome and genetic analysis

.MX :

-
For Impotence Retrograde ejaculation
Lifestyle modification
.
. .
Hypergonadotropin ic
Psychosexual help .
Hypogonadotrophk Hypogonadism
Improve general health phenyl ephrine
-
-
-

sildehafil 50.100mg Hypogonadism :

(testicular failure)
Exercise weight loss ( improve tone of sphincter)
-

Control sugar
11 hr before
-

Inj HCGSOOOIU -

IUI

sexual activity )
-

Inj HM9 . -

IUI -
Donor
-

Correct thyroid disorders

-
Dulsatile GnRH -

IVFIICSI
-
Treat infections
-

Clomiphene citrate
-

Adoption
-

Advice to stop smoking alcohol ,

'
Medical Mx .
Surgeries :

Antioxidants -
Astaxanthin -

For vaniocele
-

zinc -

Vasovdsotomylvasoepididymostomy For obstruction of vaslepididymis .

-
coenzyme Q
-

Transurethral resection of ejaculatory duds -

improves semen aleality

-

multivitamins led E)
-

levocarnitine
.
Assisted Reproductive technology :
IUI , IVFIICSI

Semen Exam

Not mat v

✓ . Abnormal
IUI Failed IUI

3- E cycles v ✓ investigations
v
IVF ICSI
( with ovarian stimulation t v

with omiphene citrate) correction of abnormality

v

If Count It count
more than 05×106 v

10 motile motile fails

sperms sperms I
IVI -

donor

Adoption
 - Aetiology :
Female infertility Anovuldtion Ovarian failure causes
① Ovarian ② Tubal 4 ③ Uterine ④ Cervical ⑤ vaginal
peritoneal I -

Hypothalamic pituitary failure -

Galadosemia
it Anovulation 1) fibroids ikervicdl Stenosis
I. PCOS
tuba , obstruction due to -

chemo tradition
iil Diminished ovarian i )pID a) Polyps iilprolapse ilvaginal Atresia II. Ovarian failure -

thyroiditis Hypothyroidism)
Reservation mature
'
3) Sisnechiae iiilscantdmuw.li) Transverse
ii )tB
syndrome) ivkerviatis
E- Hyproladinemia -
Addison 's disease
ovarian Failure ( Asherman
" Endometriosis vaginal septum Cigarette smoking
iiilufealpha Defect a) uterine Hypoplasia ↳ Anti sperm
-

NTUbd this on
Infections
irllutenisedunruptored g)septalelpsicornuale antibody in
-

follicle V ) Adhesions uterus cervical mucus

-
Investigations
* collapsed follicle 4 Free fluid in touch of Douglas on TVs are

Diagnosing Ovulation Tests for Tubal DUSG Features of recent ovulation

-

- .

Indirect methods Detects fibroid ,

*
potency : -

1) Menstrual History 1) Rubin 's test polyps ,

uterine
ii ) Basal anomalies Clomiphene citrate Challenge Test :
body temp .

iiilcervi.ca/mucusstudy2IHysIerosalpingo- 1) Measure serum FSH on

cycle days .

graph YLHSGI 2) HS4

ivlvaginal cytology 2) Administer 100mg Clomiphenecitratelday on days 5-9
iffndometrial biopsy 3) Measure serum ASH on
day 10
( forth) '
g) saline infusion 3) SIS
I I

Elevated Back to normal

vilhlormone estimation
sonographycsis)
-

+ t
Sr 4) laparoscopy
progesterone Normal function
functioning
-

ovaries not
srestradiol 4) Hyskrosalpingo .

well
-

SRLH Contrast nography 5) Hysleroscopy

viiltransvaginal USG
( for follicular study ) 5) Laparoscopy

* Direct method 6) Falloscoby

Laparoscopy
g) salpingoscobll
-

Test for Ovarian Reserve

1) Day 's Basal FSH

2) Basal Estradiol
[760 pglml in early follicular
phase >
Reproductive aging
&
Hastened cykdev)
3) Anti.mu/lerianHormone
4) Inhibits Bt with
tin number of oocytes

5) Clomiphene citrate
Challenge Test

6) USG
-

Antral Follicle count

• Rt :

DAnovulalion.fuboblastysx.tt therapeutic itcervicalmucus General measures :

Ovulation Induction Adhesiolysis Hysleroscopy quality improvement

agents : -

Fimbrioplasty by oestrogen 1) Lifestyle modification -

weight loss
Clomiphen @ Citrate Salpingostomy stop smoking alcohol
-

-
-

150.250mg Iday ) -

Tubotubal anastomosis ii)N -

acetyl eystein
-

letrozole Ancestral ,
Iv 2) Control of sugar in DM
-

HMG.MG
-
corneal connotation improves sperm
penetration 3) Correction of thyroid disorders
-
Reversal of
4) stress relief therapy
d) Diminished reserve :
tubal ligation iii. steroids in
-

DHEA 25mg tid Case of anti sperm

-

IVF '
4 of endometriosis antibodies 5) Appropriate R,
of infections if present
-

NF with donor

oocyte

'
Unexplained infertility -

Intrauterine insemination Indications for therapeutic Hysleroscopy :

super ovulation -1

1) polyps G fibroids ( Hysleroscopicpolypectomylmyomectomy)

Fails
✓
a) Intrauterine adhesions
In vitro fertilisation
3) Lateral wall metroplasty for 1- shaped uterus
4) Septum resections
'
Normal ovaries & Absent Uterus
In case of
surrogacy
:
 Endometriosis
' Definition : It is defined as presence of normal functional endometrial mucosa (glands & stromal abnormally implanted in locations
other than endometrial cavity .

. sites :
.
Aetiology :
-
Endometriosis is a proliferative hormone dependent disease of childbearing period .

1) Pelvic Endometriosis
-

Extremely rare before menarche and disappears after menopause

.

2) Pouch of Douglas
Genetic susceptibility in Isi cases 3) Utero sacral ligament
-

seen .
.

4) Ovarian
-
theories
5) Chocolate cyst of ovary
:

6) Appendix pelvic lymph nodes

1)Sampson 's theory of Retrograde menstruation ( most accepted )
,

1) Metastatic Lungs scar endometriosis

a) Coelomic metaplasia Ivan off & Meyer
-

,
:

3) Haematogenous spread
a) Lymphatic spread that ban 's theory)
5) Direct implantation .
Investigations :

1) Laparoscopy :
Investigation of choice

Detects site of endometriosis & staging

. C1F :
Take biopsy
-

Asymptomatic surgically treat endometriosis by

-

Dysmenorrhoea ablation of removal

-

menorrhagia & premenstrual spotting findings :

Pelvic pain it chocolate cysts

bdominal pain and back Dain iit powder bum spots
= 4-Jeep dyspareunia :
mostly seen in edometriosis of pouch of douglas
iii) Matchstick burnt spots
in Blueberry lesion
-

Infertility v
) Red 1 Purple raspberry lesion
-

Dyschezia ( pain on defecation ) vi) sub ovarian adhesions

-
Pain on micturition & Teed frequency vii) sub peritoneal defects ( Allen Master syndrome)
-
Cyclical Haematite 'd lif Bladder involved )
21 USG trans vaginal )

3) CT IMRI

4) CA 125 -

Nonspecific marker

. Mx :

Asymptomatic symptomatic
medical : symptomatic relief from pain dysmenorrhoed
surgery
,

-
t size of lesions .

Observe 6-8 months

1) Minimal Invasive :
laparoscopy
1) Pseudo pregnancy regimen
V
it 0C pills 2 tabs X 6-9 months
Investigate for infertility Destruction by cautery 1 Laser ablation
-

ii ) oral progesterone
-

Medroxy progesterone acetate ( 10 mgtid ) Xo g months

-
-

Excision of cyst
-

Dihydrog estrone 110 mg Hay )X f- a month

-

Adhesions is

)
Iii Im progesterone -

presacralneurectomy.fr pain relief

medroxy progesterone 150mg
-
at 3 months interval
LUNA
in Levonorgestrel releasing IUD
-

a) Laparotomy
d) Pseudo menopause regimen :

Danazol 400mg in 4 divided

-

doses X 6- a months
( Rarely used )
-

Hysterectomy with bk salpinooophoredomy

-

Excision of scar endometriosis

-

Gastrinone 25mg twice a week × 6- a months

g) medical castration :
GnRH analogue CMK )
leuprolid@3.ls mg Im monthly X 6 month
-

Nata reline
200mg intra nasal daily X 6 months

a) Dienogest oral semisynthetic active steroidal progesterone

:
 Fibroid
✓ v

Uterine cervical
1 t
v
Iv u
-

Anterior
sub mucous subgenus Interstitial -

posterior
Intramural -

Central
-

sessile ( most common ) -

lateral
-

pedunullated

Effects on pregnancy
:

'
Incidence :
20% - Abortions
.
malpresentations
.
Etiology . C1F : . preterm labor
-

Asymptomatic .
IUGR
Estrogen dependant tumor -

menorrhagia
.
prolonged Iobstructed labor
-

Multiparty -

metorrhagia -
APHEIPPH
-

Infertility ( fibroid causes infertile 4 Infertile women

-

Dysmenorrhoea
to develop fibroids )
are prone Infertility
-

Obesity -

Lump in abdomen
-

Deletions of chromosome 7 -

pressure symptoms -

dysuria or urinary retention

-

On examination ,
firm to hard enlarged uterus 42-14 wks or more )

* smoking is protective -

cervix moves with movement of mass felt per abdomen .

'
Investigations :

.
Blood group ,
CBC ,
Blood sugar , ECG ,
chest x
ray etc
.

-
USGCIOC) -
concentric solid
, , hypo echoic mass
-

Hyperechoic → Calcification ,
Anechoict Necrosis

'
Doppler USG : Determine vanity
-

differentiate fibroid from adenomyosis .

( Blood flow surrounds fibroid ,

but diffuses through adenomyosis) .

'

Saline infusion nography

. MR1 1CT

.
Hyskroscopy -

Diagnostic as well as therapeutic .

laparoscopy
-

. RI

Fibroid
✓ v

Asymptomatic symptomatic

w v

Regular supervision Surgery surgery

↳ months interval )
-

sizes Rwks
-

Pedunullatd ✓ v v

Old
✓
•
-

causing hydrometer young Uterine artery embolisation

Size size tses Family complete
stationary
-

Symptoms
t appear
-

t u
r u

follow up surgery tnyomedomy Hysterectomy preoperative therapeutic

-
Myomectomy :
Removal of fibroid leaving uterus behind .

① vaginal ② Hysleroscopic ③ Laparoscopic

+ +

For sub mucous fubmucous fibroids not

-

For a) Peduncle lated fibroid

fibroids removable easily by vaginal Route b) sub serous ( not 710cm ,

not 74in number)

Implications :

① Cervical trauma ④ Uterine adhesions

② thermal injury ⑤ Infection
③ Bleeding ⑥ Failure
 Pelvic pain
Acute pelvic pain
Causes :

Obstetric Gynaecological others :

Abortions septic abortion Dysmenorrhoea Acute cystitis

-

-
-

Ectopic pregnancy -

mittelschmerz -

Urinary retention
-
Red degeneration of fibroid -

DID -
Appendicitis
-

Twisted ovarian cyst -

Endometriosis -
Abdominal TB
-

Acute Hydraamnios -

Ovarian Hyperstimulation syndrome -

UT1
-
Molar pregnancy -
Ovarian tumors
-

Abrupt'o placenta @

Chronic pelvic pain

Investigations :
Aetiology -

US4
-

Doppler USG For pelvic congestion

1) Gynaecological causes :
mostly Organic -

urine tests
Endometriosis -

colonoscopy
i Ovaries -

Adhesions -

Radiography of joints
-

Residual Ovarian syndrome

-

CECT
-

Tumors
-

Intravenous pyelography
)
Iii Tubal -

Chronic P1D
-
MRI

parameter 'tis
-

Hysterosoopy
Adhesions
-

Diagnostic laparoscopy
Conscious Pain mapping Laparoscopy under LA t
in Uterine fibroids
-

interaction with patient on touching

Adenomyosis various organs
fixed retro rated uterus
pyometra
. Mx
4 Pelvic TB and adhesions

medical : ① NSAIDs in Endometriosis

Drugs & doses
-

a) Functional causes : ② progesterone therapy

-

Congestive dysmenorrhoea ③ SSRI fluoxetine 10 -60mg 1 day

mittelschmerz
-

sertraline
song Hay
-

- Cpps
-

pelvic varicose veins -

Adjuvant therapy : ① Acupuncture

② Short wave diathermy
g) Non gynaecological causes !
-

surgeries :

Intestinal TB
-
Diverticulitis ① Laparoscopic utero sacral Nerve ablation ( LUNA)
Bladder dysfunction
-

Irritable bowel syndrome > side effects : prolapse ,

Intestinal obstruction ( chronic)

②
-

presacral Neuredomy
-

Ca Rectum
-

ureteric colic
-
Nerve entrapment
-

static magnetic therapy for a week or Transcutaneous nerve

stimulation has been helpful in some cases .

Joint pains
-

for varicosity of pelvic veins : Embolisation

Sderotnerapy 151 ethanol amine. mdleate)
 Cervical cancer
Risk factors : symptoms
① Young age at 1st intercourse 416 years)
② Multiple sex partners -
Abnormal vaginal bleeding
③ cigarette smoking vaginal discomfort
-

④ Race -

malodorous vaginal discharge

⑨ High parity -

pelvic pain
⑥ HPV infection -

Dysuria .
A frequency , urgency
⑦ HN rectum invaded)
constipation ( if
-

⑧ Immunosuppression pelvic wall involved edema Hydronephrosis

:
leg pain
-

, ,

⑨ Low socioeconomic status -

Cachexia
Anaemia
-

'
Investigations
.MX
- Pre clinical stage
Pap smear ( Exfoliate cytology) ① stage IA1 young patient therapeutic cauterisation
-

: :

HPV DNA test

simple Extra facial Hysterectomy
-

old patient :
-

Colposcopy and DNA testing

-

Diagnostic cone Biopsy

② Stage IA2 IB , ,
IA :
Wertheim 's Hysterectomy
Clinical stage & Late ca (aka Meigs Obayashi Hysterectomy)
- :

Punch Biopsy from growth or ulcer on cervix

-
CBC ③ Stage IB -

I : Not operable
RFT 4 left &
R, by Radiotherapy ( External beam RT to pelvis
-

Hysteroscopy
Brachytherapy )
-

Colposcopy -

Addition of Cisplatin 40mg weekly improves radio sensitivity

cytoscopy ¢ proctoscopy
.

USG
Chest ray to rule out pulmonary mats
x
-

-
Abdominal 91mm to rule out liver mets 89 stage I -

I are all Radio sensitive .

-
Radionuclide scanning
indication of post op RT:

FIGO staging 12018) :

① Positive LN for metastasis
② Positivereseated margin
I carcinoma strictly confined to cervix
. :

③ Evidence of lymph oracular invasion

. IA -

Can be diagnosed only microscopically Max depth of invasion ( 5mm

⑥ Poorly differentiated tumor
,

IA1 : Invasion 13mm

IA2 : Invasion 3- 5 mm in depth

- IB :
Depth of invasion 75mm Neo adjuvant chemotherapy :
Greatest dimension
sgifgelffnfcm.in
IB1

¥§gi; ① paclitaxel 90mg -11ns Ifosfamide 1000mg -1

.

Size 74cm Masha 400mg weekly for 3 cycles .

-
II :
Carcinoma invades beyond uterus but does not extend to lower 43 of vagina ② cisplatin 50mg
weekly
,

or to pelvic wall
. IA : limited to upper 213 vagina without parametric involvement .

IA1 : size gem

-
IA2 : size 7,4cm

- IB : Involvement of parametric m but not upto pelvic wall .

. II

II A : Involves lower 113 of vagina but not pelvic wall

IIB : Extension to pelvic wall
or
cause )
Hydronephrosis IN on functioning kidney ( not due to
any other known

IIc :
Involvement of pelvic or 14 paraorlic lymph nodes .

Pelvic LN metastasis only

III ;
-

Para aortic LN metastasis

- II
IIA : spread to adjacent pelvic organs
IB : spread to distant organs .
 Endometrial Cancer
Postmenopausal Bleed DIDS
Risk Factors : Estrogen dependent cancer
- Uterus :
① PCOS ( Anovulationt Hyperestrogen Ism) C1F -

Atrophic endometrium
② Granulosa cell tumor of ovary ( estrogen secreting)
postmenopausal bleeding senile endometntis
③ Early menarche and late menopause
I -
HRT
④ Age , so years perimenopausalpolymenorrhag.io -

Endometrial Hyperplasia
⑤ Multiparty -

Offensive watery discharge -

Endometrial cancer
⑥ Tamoxifen therapy
⑦ Unopposed estrogen therapy in HRT
-

Simpson 's pain -

Endometrial polyp
-
Uterine sarcoma
⑧ Atypical endometrial Hyperplasia
-
fibroids
⑨ Lynch a syndrome .

.
Cervix
-

Cancer
Erosion
Investigations :
-

Cerviatis
① Fractional curettage ⑦ Pre op evaluation .
-

polyps
② DEI C - CBC ,
FBS ,
RFT LFT
,
.
Vagina
③ Endometrial biopsy -

chest x ray -

Atrophy
④ Hysterosoopy -

EC9 -

Cancer
⑤ Transvagindl Ultrasound
thickened Endometrium
-
.
Ovary -

Tumors Cancer ,

Hyperechoic endometrium with

-

irregular outline
-

rsedrasalan.ly on Doppler
.
Fallopian tube ca( very rare)

⑥ CTIMRI ( if needed)

. My :

-
Staging :

Total Abdominal Hysterectomy with BIL

salpingo-oopherectomy
Tumor confined to uterus
: .tn →

IA No 142 myometn.at invasion Radiotherapy vaginal cuff radiation

9%3%8%1
-
: or :

External beam radiation

IB the myometn.at invasion
-

- :

modified Radical
tBKsalpingo-oopheredomyt.tt
Cervical stromal invasion but not beyond uterus
: IN dissection
Hysterectomy
External RTC 4500-500044)
>
-1 Beam

. I
-

TIA : Invades aerosol or adnexa

-

IIB :
Vaginal lparametn.at invasion
- IIC
> IICI : pelvic LN involved
>
IC2
:
Para aortic LN involved

De bulking followed by Radiotherapy

. I s
surgery
( External Beam)
-
IIA : Invasion of bladder 1 bowel mucosa

IB : Distant metastasis

.
Chemotherapy and Hormonal therapy is used in

Advanced or recurrent cases .

Chemotherapy Agents Hormonal therapy

-

Cisplatin -

progestins
-
Carbo plain -

GnRH analogues
-

Cyclophosphamide -

Aromatase inhibitors
-
paclitaxel
-

Adriamycin